Bell Convalescent Hospital

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan with interventions addressing a resident's identified risk for falls for one of one sampled resident (Resident 1). This failure had the potential to place Resident 1 at an increased risk for falls, injury, and failure to receive necessary care and services. FindingsDuring a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included dementia (a progressive state of decline in mental abilities), history of falling, and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the left hand. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ice machine was cleaned and sanitized properly. This deficient practice had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 91 of 91 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage properly when the dumpster lid was overflowing with bags of waste on two consecutive days. This deficient practice had the potential to increase the likelihood of pest and vermin infestation contributing to unsanitary conditions on the facility premises.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan with interventions for three of eight sampled residents (Resident 18, Resident 36, and Resident 48), addressing the use and refusal of dentures and hand tremors (involuntary, rhythmic, and alternating muscle contractions causing shaking in the hands or fingers). These deficient practices ha the potential to negatively affect Resident 18 and 36's mental, physical, and psychosocial well-being and had the potential to delay the delivery of necessary care and services. These deficient practice also had the potential for Resident 48 to exhibit impaired oral intake, aspiration (choking) and poor hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all Restorative Nursing Aides (RNA) received training and demonstrated competency in performing Range of Motion (ROM) exercises for one of three sampled residents (Resident 38). This failure had the potential to place Resident 38 at risk for inconsistent or improper restorative care leading to decline in ROM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration and accurate accountability of all controlled medications (medications with a high potential for abuse) for three of three residents (Resident 89, Resident 12, and Resident 27) by failing to: 1. Notify Resident 89's doctor as ordered when the resident's blood sugar was 436 milligrams per deciliter (mg/dL, which measures the amount of sugar in a specific amount of blood) on 1/22/2026, which was over the parameter of 400 mg/dL requiring doctor notification. This failure increased the risk of Resident 89 experiencing harmful effects from high blood sugar, which could lead to nerve damage, kidney disease, heart disease, stroke (a sudden loss of brain function due to a blocked or burst blood vessel), and vision loss. 2. [...]

Inspectors wroteBased on observation and interview, the facility failed to dispose of non-controlled medications in the presence of a witness in accordance with the facility's policy titled, Disposal of Medications. This deficient practice increased the risk for lack of accountability for disposal of non-controlled medications throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the cook (Cook 1) followed the Korean menu recipes and failed to ensure the zucchini recipe ingredients were not altered. These deficient practices had the potential to alter nutrition, provide the appropriate therapeutic texture, and introduce allergens to resident meal trays.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the correct food texture-modified diet (alters the consistency of food and liquids to make swallowing safer and easier for people with chewing or swallowing difficulties) for two of eight sampled residents (Resident 44 and 77). This deficient practice has the potential for Resident 44 and 77 to have problems chewing and swallowing and increased the risk for Residents to choke while eating.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's personal belongings were inventoried and tracked upon discharge and readmission for one out of one sampled residents (Resident 48). This deficient practice resulted in the facility's inability to account for Resident 48's hearing aids and dentures.

Inspectors wroteBased on interview and record review, the facility failed to ensure a PRN (as needed) order for Lorazepam (psychotropic medication- drug that affects mental processes, moods, and behaviors) indicated a stop date for one of six sampled residents (Resident 16). This deficient practice placed Resident 16 at risk for continued use of unnecessary psychotropic medication without timely physician reassessment and had the potential for Resident 16 to be chemically restrained by the administration of unnecessary psychotropic medication, and/or suffer extrapyramidal symptoms (a group of movement disorders that can occur because of certain medications, particularly antipsychotics) due to prolonged use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS, a resident assessment tool) assessment for one of six sampled residents' (Resident 18) oral and/or dental status. This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 18's missing natural teeth and had the potential to negatively affect the resident care plan and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services met professional standards when a medication for one of five sampled residents (Resident 63) was not handled according to instructions. This deficient practice had the potential to result in adverse side effects, absorption of medication, and birth defects for the nurse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 36), who had hand tremors, was assisted during mealtimes. This deficient practice had the potential to cause a negative impact on Resident 36's overall health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain good grooming and personal hygiene for two of 12 sampled residents (Resident 33 and Resident 3) by failing to keep their nails clean and neat. This deficient practice had the potential to result in a negative impact on Residents 33 and 3's quality of life and self-esteem and had the potential for development of infection.

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders, ensure medication parameters were followed, and orthostatic hypotension (sudden, sustained drop in blood pressure that occurs when standing up from a sitting or lying position) monitoring was performed for three of 12 sampled residents (Resident 84, Resident 2, and Resident 6). These deficient practices placed Residents 84 and 2 at risk for serious medication related complications, including potential overdose, underdose, or adverse effects due to unmonitored response to treatment, and placed Resident 6 at risk for undetected episodes of hypotension, falls, and injury for not being monitored.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 38) was provided active-assist range of motion [(AAROM), a physical therapy term for exercises where the patient moves a body part independently but a therapist or device assists further] as indicated in the physician's (MD, medical doctor) order. This failure had the potential for Resident 38 to exhibit range of motion (ROM, full movement potential of a joint) decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services related to urinary Foley catheter (a flexible tube inserted through the urethra [a hollow tube that lets urine leave the body] into the bladder to drain urine into a collection bag) management were provided for one of two sampled residents (Resident 11) by failing to:a. Irrigate (wash out) Resident 11's Foley catheter as needed as indicated by the physician orders.b. To Notify the Resident 11's physician of urine sediment (matter that settles to the bottom of a liquid), cloudiness and urinary pain. These deficient practices resulted in urinary catheter obstruction, and had the potential for increased infection, discomfort and decline in Resident 11's health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure a pain scale (an assessment tool used to rate pain level) was used when administering Tramadol (a narcotic medication used to treat moderate to severe pain) for one of one sample resident (Resident 33). This deficient practice had the potential to result in the resident having inadequate treatment, miscommunication between nurses and physicians, and poorly controlled pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for dialysis treatment (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) on Sundays, Tuesdays, and Fridays, and failed to ensure staff assessed the dialysisaccess site (surgically created access allowing blood removal and return during dialysis) each shift for two of two sampled residents (Residents 90 and 102). These deficient practices placed Resident 102 at risk for undetected dialysis access site complications, including swelling, pain, bleeding, bruising, and access malfunction, and placed Resident 90 at an increased risk of missed or delayed dialysis treatments, potentially resulting in serious adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician face-to-face visits were conducted at least once every 30 days for the first 90 days following admission for two of six sampled residents (Residents 16 and 33). This deficient practice had the potential to result in undetected changes in Residents 16 and 33's medical, physical, mental, and psychosocial conditions, and potentially delay the provision of medically necessary care, treatment, and services.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three of sampled residents (Resident 12, 33, and 36) by not ensuring licensed staff documented:1. Resident 12's medication administration and pain reassessment in a timely manner.2. Resident 33's pain reassessment in a timely manner.3. Resident 36's hand tremors. These deficient practices resulted in incomplete resident medical care information and placed residents at risk for confusion in the provision of care and services. Findings 1. During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to implement and maintain an effective infection prevention and control program by failing to ensure the dialysis binder (used as a dialysis communication record and transported with the resident to and from dialysis appointments) used for one of one residents (Resident 90) was clean and free from visible contamination. This deficient practice increased the potential for the transmission of infectious agents and placed Resident 90, other residents, and staff, at risk for infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP) completed ten hours of continuing education in Infection Prevention and Control on an annual basis. This deficient practice had the potential for the IP to be unaware and be unable to educate the facility's staff of updated information regarding Infection Prevention and Control practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 3), was weighed on admission and weekly for four (4) weeks, as indicated in its policy and procedure (P&P) titled, Weight Assessment and Interventions. This failure resulted in the facility not having resident's baseline weight on admission and placed Resident 3 at risk for unidentified weight loss and possible complications, like skin breakdown, other illnesses and possible hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Resident 17 and Resident 44) were free from avoidable accidents and accident hazards when the facility: 1. Did not conduct an Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) assessment following Resident 17's fall on 6/14/2024. 2. Did not develop or implement person-centered interventions to prevent Resident 17 from having repeated falls on 6/21/2024 and 8/3/2024. 3. Did not conduct an IDT in a timely manner, after Resident 44 fell on 5/19/2024, to prevent further falls. 4. Did not develop new, person-centered, fall prevention interventions following Resident 44's fall on 5/19/2024 and subsequent falls on 8/22/2024 and 9/14/2024. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to review and act on the Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) conducted for all facility residents from 8/19/2024 to 8/20/2024. This deficient practice resulted in delays to adjustments to multiple residents' medications and/or plans of care due to lack of physician notification of the consultant pharmacist's recommendations.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the inside gasket of the kitchen's ice machine was free of yellow and white build up components. This deficient practice placed all the residents who consumes ice in the facility, at risk for foodborne illnesses (diseases caused by consuming food or drinks that are contaminated with harmful bacteria, viruses, parasites, or chemicals).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the garbage storage area was maintained in a sanitary condition, by failing to ensure: 1. There were no trash bags and cardboard boxes on the ground. 2. The outside trash dumpster lid was closed. These deficient practices had the potential to result in pests' inside the facility and pest-related diseases (like [NAME] virus [spread by mosquitoes], lyme disease [a bacterial infection spread by the bite of an infected blacklegged tick], and rabies [a preventable viral disease of mammals usually transmitted through the bite of an infected animal]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for three out of three sampled residents (Resident 38, 62, 84) by failing to: 1. Change the nasal cannula (NC, a plastic medical device to provide supplemental oxygen therapy to resident who had lower oxygen levels; device went directly into the nostrils) tubing every seven days. 2. Ensure Resident 38 and 84's indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing did not touch the floor. 3. Ensure Resident 84's indwelling urinary catheter tubing and drainage bag was free of sediments (gritty particles that settle at the bottom of a liquid). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective, ongoing pest control program was maintained in the facility. This deficient practice resulted in unresolved infestation of german cockroaches (a small, fast-moving, nocturnal cockroach that is a common household pest in the United States) and had the potential to affect the health and living conditions of the 91 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent for psychotropic medications (drugs that affect a person's mental state) from one of five sampled residents (Resident 45) responsible party (RP), informed consent was obtained from Resident 45's family member (FM) 2, who was not Resident 45's RP. This deficient practice resulted in Resident 45 receiving sertraline (a medication used to treat depression) and aripiprazole (a medication used to treat mental disorders, including depression) without her knowledge or explicit consent. This deficient practice also placed Resident 45 at risk for experiencing unwanted adverse effects of the medication, including increased risk of suicidal thoughts and other mental status changes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of one of eight sampled resident's (Resident 23) by not placing the call within reach and not providing an appropriate call light device. This deficient practice prevented Resident 23 from communicating with staff and had the potential to delay appropriate care, treatment, and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation clarifying if a resident has an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) or not for two out of eight residents (Resident 6 and 35), when: 1. Facility did not complete the advance directive acknowledgement form (ADAF, part of an advance directive, a legal document that allowed a person to specify their medical care wishes and who should make decisions for them if they could not) for Resident 6. 2. Facility did not obtain the ADAF for Resident 35 within 24 hours of admission in accordance with the facility's Policy and Procedure (P&P) titled, Advance directives. [...]

Inspectors wroteBased on interview and record review, facility staff failed to report an allegation of resident-to-resident verbal abuse to the State Agency, for two of four sampled residents (Resident 3 and Resident 30), after directly observing the abuse incident on 12/29/2024. This failure resulted in delayed notification of the State Agency, and the subsequent timeliness of their investigations. The failure also increased the potential for additional resident-to-resident abuse incidents to occur.

Inspectors wroteBased on interview and record review, the facility did not ensure the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals with a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) assessment was accurate, and that determination for necessity of potential necessary services, was completed for one of one sampled resident (Resident 45). This deficient practice had the potential for Resident 45 to not receive the required services and care needed for their diagnosed mental disorders.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were developed for four of 21 sampled residents when the following occurred: 1. Resident 45 did not have a care plan addressing diagnoses of depression and psychosis. 2. Resident 58 did not have a fall risk care plan. 3. Resident 32 did not have a care plan for the use of a low air loss (LAL) mattress (a mattress designed to distribute body weight evenly and reduce pressure on specific areas of the body). 4. Resident 77 did not have a care plan for the use of a LAL mattress. These deficient practices placed Residents 45, 58, 32, and 77 at risk for avoidable complications due to staff not having defined and resident-specific interventions for provision of care.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plans for two of 21 sampled residents when the following occurred: 1. Resident 44's fall care plan was not revised following his first fall on 5/19/2024. 2. Resident 17's fall care plan was not revised following her first fall on 6/14/2024, and second fall on 6/21/2024. These deficient practices resulted in Resident 44 sustaining a second fall on 8/22/2024, and a third unwitnessed fall on 9/14/2024. The above deficient practice also resulted in Resident 17 sustaining a third unwitnessed fall on 8/3/2024.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality of care for one out of eight residents (Resident 62) by failing to document the following on Resident 62's Medication Administration Record (MAR): 1. The administration of pantoprazole (medicine treated conditions that caused too much stomach acid) on 10/4/2024, 10/14/2024, and 10/16/2024 at 6:30 a.m. 2. The administration of insulin lispro (a fast-acting, human-made insulin [a hormone that removed excess sugar from the blood, could be produced by the body or given artificially via medication]) on 10/4/2024, 10/14/2024, and 10/16/2024 at 6:30 a.m. 3. Coronavirus disease (COVID-19, an infectious disease caused by the SARS-CoV-2 virus) and vital signs (measurements of the body's most basic functions) monitoring on 10/3/2024, 10/13/2024, 10/15/2024, and 10/21/2024 during the night shift; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, a medical mattress that uses air to help prevent and treat pressure ulcers [localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence]) pressure levels were adjusted according to the resident's weight for two of six sampled residents (Resident 32 and Resident 77). This deficient practice had the potential to cause the development, worsening or reinjury of pressure ulcers to Resident 32 and 77.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 32), received the oxygen two (2) liters per minute (LPM) via nasal cannula (NC - a device used to deliver supplemental oxygen through the nose) as ordered by the physician. This deficient practice had the potential to result in oxygen desaturation (decreased amount of oxygen in the blood) which could lead to low levels of oxygen in the body tissue (hypoxia), difficulty breathing, rapid heart rate, and confusion, including hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) had failed) received services that were consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals, when the facility did not provide dialysis emergency kit (E-kit - contains supplies such as tape, clamp, and gauze to use in case the resident experienced bleeding from their dialysis access site) at the bedside, for three out of three residents (Resident 66, 36, and 63). These deficient practice placed the affected residents at risk for ineffective emergency treatment and complications of uncontrolled bleeding resulting in hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure unnecessary medications were not administered to two of five sampled residents (Resident 45 and Resident 62) when: 1. A gradual dose reduction (GDR, stepwise tapering of a medication to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Resident 45's sertraline (a medication used to treat depression) was not attempted. 2. Informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the use of Trazodone (a drug used to treat depression [a constant feeling of sadness and loss of interest]) ordered on 10/8/2024, was not obtained for Resident 62 prior to use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure left over food, for four out of four residents (Residents 69, 66, 73 and 63), were stored, in accordance with the facility's policy and procedure (P&P) titled, Foods brought by family/ visitors. These deficient practices placed Residents 69, 66, 73 and 63 at risk for food-borne illnesses (food poisoning, with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and could lead to other serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to conduct a rehabilitation screening and/or provide rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) and restorative nursing services (RNS, nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible) for one of 21 sampled residents (Resident 45). This deficient practice prevented the facility Case Manager (CM) from advocating for Resident 45 to receive rehabilitative therapy services and led to a delay in the provision of RNS to Resident 45. This created the potential for a decline in Resident 45's mobility and ability to perform activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily).

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive Care Plan for three out of four sampled residents (Residents 1, 3, and 4) who were diagnosed with Covid-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus). This failure had the potential to result in Residents 1, 3, and 4's needs not being met and unidentified interventions to address the resident's Covid-19 infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its infection prevention and control measures for Covid-19 (A highly contagious respiratory disease caused by the SARS-CoV-2 virus) by failing to: a. Ensure staff donned (put on) personal protective equipment ([PPE], equipment worn to prevent spread of infections or diseases such as a gown, face shield [cover/protection] and gloves) prior to entering a Covid-19 positive room (room [ROOM NUMBER]). b. Ensure staff doffed (removed) PPE prior to leaving Covid-19 positive Room (room [ROOM NUMBER]). c. Conduct close contact testing of exposed staff after one resident (Resident 1) tested positive for Covid-19 on 9/5/2024. d. Adequately screen facility visitors prior entering facility during a Covid-19 outbreak. e. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control was maintained when the following occurred: 1. Enhanced barrier precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] that employs targeted gown and glove use during high contact resident care activities) were not implemented for 15 of 16 residents who met EBP-implementation criteria (Residents 2, 3, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P), titled Administering Medications, which indicated medications were to be administered in accordance with prescriber orders and within one hour of their prescribed time for one of three sample residents (Resident 19). This deficient practice resulted in Resident 19 being administered Hydrocodone-Acetaminophen (Norco - a medication to relieve moderate to severe pain) 3 hours earlier than the prescribed time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer supplemental oxygen as ordered by the physician for one of two sampled residents (Resident 5). This deficient practice created the potential for Resident 5 to suffer from oxygen toxicity (lung damage that happens from breathing in too much extra [supplemental] oxygen, and can cause coughing, trouble breathing, and, in severe cases, death).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P), titled Pain Assessment to ensure effective pain management assessment was conducted for one of three sampled resident (Resident 19), by: 1. Licensed Vocational Nurse (LVN 5) failing to promptly address Resident 19's pain, when the resident verbalized, he was in pain. 2. LVN 5 failing to use a standard pain assessment scale to determine Resident 19's pain level. 3. LVN 5 failing to ensure the licensed nurse further assessed Resident 19's pain to determine the location, frequency, quality, intensity, and duration of pain. 4. LVN 5 failing to document Resident 19's administration of Hydrocodone-Acetaminophen (Norco - a medication to relieve moderate to severe pain). 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of four sampled residents (Resident 1 and Resident 3) were provided assistance with Activities of Daily Living (ADL- such as using the restroom, oral hygiene, walking), by leaving Residents 1 and 3 wet with urine for an extended period of time. This failure placed Resident 1 and 3's needs unmet and the potential for skin breakdown and infections.

Inspectors wroteBased on interview and record review, the facility failed to provide visual monitoring and prevent accident hazards, as indicated in the resident ' s care plan, for one of seven sampled residents (Resident 1), who had a high risk for fall. This deficient practice resulted in Resident 1 falling, sustaining facial trauma and a right arm fracture (broken bone) which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating to ensure an allegation of abuse was reported to the California Department of Public Health (CDPH) within two hours, for one of seven sampled residents (Resident 2). This deficient practice resulted to the delay in the abuse investigation by the CDPH and placed Resident 2 at risk for continuous abuse at the facility.

Inspectors wroteBased on observation, interviews and record review, the facility failed to: 1. Ensure staff refrained from washing their hands utilizing the sink meant for obtaining resident's drinking water. 2. Ensure sink area utilized to obtain resident's drinking water was cleaned and free of rust and dirt. These deficient practices had the potential for cross contamination (transfer of harmful bacteria from object or place to another) and cause residents to be ill.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for four of 24 sampled residents (Resident 70, 9, 49, and 68) by failing to: 1a. Ensure the correct dose of Methadone (a powerful drug used for pain relief and treatment of drug addiction) 50 milligrams ([mg]- a unit of measurement) twice a day was transcribed (copy from one place to another) per physician order. 1b. Follow up on the delivery of the Methadone with the pharmacy on 11/8/2023 when ordered by the Physician. 1c. Ensure accurate and complete documentation of the medications administered on the Electronic Medication Administration Record (EMAR, an electronic record of medications administered to a resident) and the Controlled Drug Administration Record. 1d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to uphold the resident rights for three of six sampled residents (Resident 34, Resident 54, and Resident 59) when the facility failed to: 1. Follow up on the application to appoint a Public Guardian to aid in Resident 34's Medi-Cal (a public health insurance program which provides needed health care services for low-income individuals) application, assist with Resident 34's financial obligations, and help guide Resident 34's care. 2. Provide a dignity bag for Resident 54's and Resident 59's indwelling catheter bag (a drainage bag connected to a catheter inserted into the bladder to drain urine). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of eight out of eleven sampled residents (Resident 6, 7, 12, 15, 34, 58, 59, and 74) by failing to: 1. Provide functioning call lights which enabled the light located outside of the residents' door to turn on when the call light was activated for Residents 6, 7, 15, 34, 58 and 74. 2. Ensure the call lights were within reach for Residents 12 and 59. These deficient practices had the potential to cause a delay in care and physical and psychosocial harm by not anticipating the needs of and accommodating Residents 6, 7, 12, 15, 34, 58, 59, and 74.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive resident-centered care plan for four of 30 sampled residents (Resident 38, 46, 49, and 66) by failing to: 1. Implement Resident 49's care intervention to administer antibiotics (medication to treat an infection) for a urinary tract infection (UTI, infection in any part of the urinary system that includes the kidneys and bladder). 2. Implement Resident 46's care intervention to infuse enteral feeding (a special liquid food mixture containing protein, carbohydrates, fats, vitamins, and minerals). 3. Implement Resident 38's care intervention to apply padding to the side rails and a floor mattress. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse (RN) was scheduled to work in the facility to administer intravenous (IV, in the vein) antibiotics (medication to treat an infection) for two of 12 sampled residents (Resident 49 and Resident 70). This failure resulted in Resident 49 missing two doses and Resident 70 missing one dose of IV antibiotics.

Inspectors wroteBased on observation, interview, and record review the facility failed to record the medication room and refrigerator temperature for one of two inspected medication rooms (Medication Room B.) This failure increased the potential for residents in the facility to receive medications that were ineffective or toxic due to the inadequate storage monitoring, and potentially experience medication adverse consequences resulting in negative impact to residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%) due to three (3) errors observed out of 26 total opportunities (error rate of 11.54%). The medication errors were as follows: 1. Resident 50 received a form of vitamin D3 (medication used as a dietary supplement to promote bone health) and fish oil (medication used as a dietary supplement to help reduce blood triglyceride [form of fat in the body] levels) that was different than the one ordered by Resident 50's physician. 2. Resident 50 did not receive diclofenac (medication used to treat pain) 1% (strength of the medication) gel as ordered by Resident 50's physician. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Remove and discard two expired inhalation (a form of a medication to be inhaled as a vapor or spray) treatments for Residents 26 and 72 in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart C.) 2. Label two inhalation treatment foil packs (package made of foil protecting the inhalation solution from light and degradation) for Resident 28 and 72, with an open date in accordance with the manufacturer's requirements in one of two inspected medication carts (Medication Cart C.) 3. Store one lorazepam (a medication used to treat anxiety) oral solution bottle for Resident 43 in the refrigerator in accordance with the manufacturer's requirements in one of two inspected medication carts (Medication Cart Station C.) 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food under sanitary conditions in one (1) of 1 kitchen, by failing to: 1. Ensure the food items in the refrigerator were dated. 2. Ensure there were no expired food items in the refrigerator. 3. Ensure the food items in the freezer were dated. 4. Ensure the refrigerator did not have meat thawing for an extended time. These deficient practices had the potential to result in the transmission of infectious agents that could lead to illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four Residents (Resident 9, 64, and 84) understood the arbitration (is a way of resolving a dispute without filing a lawsuit and going to court) agreement when entering a binding contract (an agreement between two or more parties that creates certain obligations that must be adhered to by law) by failing to: 1. Present the arbitration agreement in a language Residents 64 and 84 can understand or preferred language. 2. Ensure Resident 9, 64, and 84 understand the arbitration agreement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures were implemented and maintained for three of 30 sampled residents (Resident 10, 38, and 49) by failing to: 1. Ensure Resident 49 was placed on contact isolation (resident is placed away from others when a resident has an infectious disease that could be spread by touching either the resident or objects handled by the resident; medical staff and visitors required to wear gowns and gloves when entering the room) until his antibiotic (medication to treat an infection) therapy was completed. 2. Label oxygen (a colorless, odorless reactive gas, and the life-supporting component of the air) tubing with the date of initiation for Resident 10 and Resident 38. These failures had the potential to affect all residents and cause avoidable spread of infection to residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of ten residents (Resident 9) was informed of their right to formally complain to the State Agency (Department of Public Health) about the care they were receiving. This failure had the potential to result in Resident 9 being unable to voice her concerns and to advocate for herself and other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure ten of ten residents (Resident 5, 9, 23, 45, 55, 56, 60, 73, 78, and 90), that attended the resident council group meeting, were aware of the availability and location of the facility's latest survey results. This failure had the potential to result in the residents and their representatives to not be fully informed of the facility's deficient practices and how they were corrected.

Inspectors wroteBased on observation, interview, and record review, the facility's Social Services Director (SSD) and nursing staff failed to ensure a resident received proper attention for hearing loss to the right ear for one of 24 sampled residents (Resident 18). The SSD and nursing staff failed to refer Resident 18 to allied professional services to assist with Resident 18's hearing needs, failed to provide a communication board, and failed to place a hearing impaired sign to indicate which ear Resident 18 could better communicate per the resident's care plan and physician order. These deficient practices resulted in a delay of services, and exposed Resident 18 to embarrassment of having staff repeat themselves when communicating.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure padded siderails and a floor mattress were utilized for one of three sampled residents (Resident 38). This failure had the potential to result in injuries during a seizure (a disorder in which nerve cell activity in the brain is disturbed) by Resident 38 potentially hitting the resident's head or other body parts on the exposed siderails or falling onto the bare floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enteral feeding (a special liquid food mixture containing protein, carbohydrates, fats, vitamins, and minerals) was administered as ordered for one of four sampled residents (Resident 46). This failure had the potential to result in Resident 46 to not meet their nutritional requirements, placing the resident at risk for avoidable weight loss, malnutrition, and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the tube feeding (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) water bag used for flushing (technique used to prevent blockage or clogging of the feeding tube) was labeled with the date for one of three sampled resident (Resident 59) receiving tube feeding. This deficient practice placed Resident 59 at risk for an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for two of four residents (Resident 10 and Resident 140) by failing to: 1. Ensure the humidifier (water used to increase the moisture while providing oxygen therapy) bottle was filled with sterile water when oxygen therapy was provided for Resident 10. 2. Ensure oxygen therapy was administered to Resident 140 with a physician's order. These failures had the potential to result in dryness of Resident 10's mouth and nostrils, and the potential for Resident 140 to receive oxygen therapy unnecessarily.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete annual performance evaluations for one of three sampled Certified Nurse Attendants' ([CNA] 3). This failure had the potential to allow CNA 3 to perform CNA 3's duties without being held accountable for CNA 3's performance when providing quality care for all the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of six sampled residents (Resident 70) was free from unnecessary medications when the facility continued to administer Hydroxyzine ([also known as Atarax] drug used to treat anxiety [feeling of fear, dread, and uneasiness], nausea, vomiting, allergies, and itching) after the physician discontinued the order on 10/30/2023. This failure had the potential to result in Resident 70 receiving unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 70 was free from a significant medication error for one out of eight sampled residents (Resident 70) by failing to: 1. Ensure the right dose of Methadone (a powerful drug used for pain relief and treatment of drug addiction) was transcribed to the electronic Medication Administration Record ([eMAR]- an electronic record of medications administered to a resident) per physician order. 2. Accurately document the administration of Methadone 5 mg ([mg]- unit of measurement) on the Controlled Drug Administration Record and eMAR between 11/8/23 and 11/14/23. 3. Ensure the availability of Methadone 5 mg for Resident 70. [...]

Inspectors wroteBased on interview and record review, the facility's Social Services Director (SSD) failed to ensure one of 24 sampled residents' (Resident 18) dental needs were identified and the resident received dental services. The facility also failed to ensure a referral for dental services was completed for Resident 18. This deficient practice resulted in a delay of dental services and complaints of discomfort while chewing.

Inspectors wroteBased on observation and record review, the facility failed to provide the appropriate textured diet for two out of three residents (Resident 29 and Resident 66). This deficient practice placed Resident 29 and Resident 66 at risk for choking.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow their infection prevention and control program by failing to: 1. Isolate (separation of a sick resident with a contagious disease from a resident who was not sick) one of two sampled residents (Resident 1) who tested positive for coronavirus disease ([COVID-19], a highly contagious respiratory infection caused by a virus that can easily spread from person to person) in a timely manner; 2. Ensure Registered Nurse (RN 1) donned (put on) Personal Protective Equipment use of personal protective equipment ([PPE] specialized clothing or equipment worn to minimize exposure to serious illnesses) before going to a COVID-19 isolation room; and 3. Report the facility COVID-19 outbreak to licensing and certification. [...]