Berkley East Healthcare Center

Inspectors wroteBased on record review and interviews the facility failed to follow the physician's order to perform physical therapy (PT- is a healthcare specialty that evaluates and treats movement dysfunctions, pain, and physical limitations) five times a week for 60 days for one of three sampled residents (Resident 1). This deficient practice had the potential to cause a decline in functioning for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedures (P&P) titled Self-Administration for Medications revised 1/2026 for three of three residents sampled (Residents 24, 48 and 91) by failing to ensure there was documented assessment for self-administration before:1. Allowing Resident 91 to self-administer 2 (two) medications.2. Leaving unidentified medications at Resident 48's bedside.3. Leaving a medicine cup with thick, smooth and rich white substance on Resident 24's nightstand. This deficient practice had the potential for:1. Incorrect medication of administration that may or may not result in medication error, and / or negative outcome to resident's health condition.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Resident 127 with a communication tool that was accessible in the resident's language, easily readable, and within reach according to the resident's Care Plan, dated 2/28/2026, the Care Plan on communication deficit related to hearing impairments, and facility's policy and procedures (P&P) titled Communication-Cognitive Deficit, reviewed 1/2026. This failure had the potential to result in Resident 127's inability to communicate with staff his needs, preferences, and requests.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Minimum Data Set (MDS - resident assessment tool) was accurately documented according to their policy and procedure (P&P) titled Certifying Accuracy of the Resident Assessment reviewed 1/2026 for two of two sampled residents (Residents 66 and 127). This deficient practice resulted in Resident 66 and Resident 127's medical records being inaccurate and missing vital information of services being rendered to the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the interdisciplinary team (IDT team, a collaborative group of professionals-including doctors, nurses, social workers, and therapists-who work together to create and implement a unified, patient-centered care plan) assess and evaluate the ability to self-administration medications for one (1) of 3 residents sampled for medication administration observations (Resident 91). This deficient practice had the potential to cause incorrect or unsafe medication administration that may or may not cause a negative outcome to resident's health condition.

Inspectors wroteBased on observation, and interview, the facility failed to observe and maintain their infection control measures according to their Policy and Procedure (P&P), titled Infection Prevention & Control Program Policy, reviewed 10/2026, for one of one sampled residents (Resident 24) when Resident 24's nebulizer (a small electric machine that turns liquid medication into fine mist) mask was on Resident 24's night stand not stored in a plastic bag according to their P&P titled Administering Medication through a small Volume (Handheld) Nebulizer, reviewed 1/2026. This deficient practice had the potential to cause infection and/or hospitalization for Resident 24.

Inspectors wroteBased on observation, interview and record review, the facility's staff and practitioner failed to ensure medications were not left at the bed side unattended for two out of two sampled residents (Residents 24 and 48) according to the facility's policy and procedures (P&P) titled Medication Storage In The Facility with a reviewed date of 1/2026. This deficient practice had the potential for confused residents and residents with wandering behavior to gain access and ingest the medications which could result in anaphylaxis reaction (undesirable), choking, unnecessary hospitalization and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of two sampled residents (Resident 127) according to the facility's policy and procedures (P&P) titled, Call Lights: Accessibility and Timely Response, revised on 10/2025. This deficient practice had the potential to result in staff delay in meeting Resident 127's needs for hydration, toileting, and activities of daily living.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 did not violate the resident's rights to be treated with respect and dignity and did not subject the resident to humiliation (the feeling of being ashamed or losing respect for yourself) for one of eleven sampled residents (Resident 1) by failing to ensure: 1. CNA 1 did not record a video of Resident 1 without Resident 1 and/or Resident 1 Responsible Party 1's (RP 1) consent.2. CNA 1 did not post a video of Resident 1 on social media. These deficient practices violated Resident 1's right to be treated with respect and dignity and the potential to subject Resident 1 to humiliation (the act of being made to feel ashamed, embarrassed, or worthless, often publicly). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient preparation and orientation for one of four sampled residents, (Resident) 1 with a safe and orderly discharge planning by failing to: 1. Follow-up on the Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) Care Conference meeting regarding Resident 1 ' s discharge planning during admission. 2. Ensure Resident 1 ' s are provided with necessary care and services upon discharge to home. These deficient practices resulted in incomplete and ineffective discharge planning that may lead to lack of necessary care, accident and possible injury after discharge.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of five sampled residents (Resident 1) by failing to develop an individualized Care Plan (CP) for Resident 1 ' s behavior of removing his own wound dressing. This deficient practice had the potential to have a negative impact on residents ' health and safety, as well as the quality of care and services received. Cross Reference F686.

Inspectors wroteBased on interviews and record review, the facility failed to: 1. Obtain a wound consultation in the management of wound and maintain skin integrity for one of five sampled residents (Resident 1). 2. Ensure Resident 1 ' s Treatment Administration Record (TAR) were documented accurately per facility ' s policy and procedure (P&P) titled, Charting and Documentation. 3. Ensure Resident 1 ' s wound dressings are monitored and kept clean and dry per physician ' s order. These deficient practices had the potential to delay the provision of necessary care and services and deterioration of residents ' current wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) remained free of recurrent falls by failing to provide supervision of Resident 1 who is a high fall risk. This deficient practice resulted in Resident 1 had an unwitnessed fall on 2/5/2025, and 3/19/2025 while trying to ambulate to bathroom.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect and safeguard the residents personal and medical records according to the facility's policy and procedures (P&P), titled, confidentiality of information and personal privacy, reviewed 1/2024 for 11 of 13 sampled residents (Residents 11, 31, 44, 59, 65, 78, 142, 242, 343, 345, and 346). This deficient practice violated the resident's rights for privacy.

Inspectors wroteBased on observations, interview, and record review, the facility failed to: 1. Ensure the facility received and reviewed daily activity and discrepancy reports of the Cubex system (a computerized system that stores, dispenses, and tracks medications in healthcare setting), which was inconsistent with the facility policy for at least 11 months. 2. Ensure non-controlled drug dispositions (the process of returning or destroying unused medications) were performed and recorded by two licensed nurses as per policy for at least 8 months. 3. Ensure outdated medication are discarded and not stored in a medication cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 12/16/24 when: 1.25 residents on mechanical soft diet (for resident who experience chewing or swallowing limitations) received Cajun country rice with sliced turkey instead of the Cajun country rice with ground turkey per menu and spreadsheet (food production guide includes food portion and serving guide). One resident on Dysphagia diet (for people with difficulty swallowing- food is moist, mechanical altered easily mashed, or pureed requires little chewing) received baked fish instead of ground fish, received regular Cajun Country rice instead of pureed rice per food production guides (food portion and serving guide). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe food handling practices when: 1. One of one ice scooper was not cleaned and sanitized daily in accordance with the facility policy and procedure (P&P) titled, Ice Procedures. The ice scooper was not stored in a sanitary condition, the ice scooper had red color stains on it and was sticky. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in101 out of 102 residents who received ice from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label Resident 141's enteral feeding (aka tube feeding - the delivery of nutrients through a feeding tube directly into the stomach) for one of 22 sampled residents. This deficient practice had the potential to cause complications associated with enteral feeding, including infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for the use of Continuous Positive Airway Pressure (machine helps treat sleep apnea [a sleep disorder that causes breathing to repeatedly stop and start during sleep]. CPAP machine delivers continuous air through your mouth and/or nose to keep your airways)/Bilevel Positive Airway Pressure (BIPAP a noninvasive breathing device that helps people who have trouble breathing) upon admission for one of six sampled residents, Resident 191. This deficient practice had the potential to place Resident 191 at risk for respiratory distress and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a hemodialysis (HD -a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit was at the bedside for one of ten sampled residents (Resident 26). This deficient practice had the potential to delay life saving interventions during accidental bleeding.

Inspectors wroteBased on interview and record review failed to: 1. Ensure staff was competent on how to use a Continuous Positive Airway Pressure (machine helps treat sleep apnea [a sleep disorder that causes breathing to repeatedly stop and start during sleep]. CPAP machine delivers continuous air through your mouth and/or nose to keep your airways)/Bilevel Positive Airway Pressure (BIPAP a noninvasive breathing device that helps people who have trouble breathing) . 2. Ensure staff completed their annual skills competencies. These failures can cause or have the potential to cause a resident to go into respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to properly receive proper verificiation of informed consent (a principle in medical ethics and medical law that a patient should have sufficient information before making their own free decisions about their medical care) form prior to administering psychotropic medication Lexapro (an antidepressant medication) and Seroquel (an antipsychotic medication) for one of five sampled residents (Resident 77). This deficient practice had the potential for Resident 77 to receive medications without being properly informed of the medications' risks and adverse side effects that could lead to serious illness, hospitalization, or death.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure the label matched the correct quantity of a controlled medication (medications that the use and possession of are controlled by the federal government) received by the facility for a former resident. This deficient practice had the potential for loss or diversion (transfer of a controlled medication from a lawful to an unlawful channel of distribution or use) of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the reach in freezer was maintained in a good operating condition. The freezer had ice buildup inside the ceiling and walls. There was ice buildup on the door and the parameters of the door. Ice buildup on the door gasket and ice outside of the freezer door sealing the door and causing difficulty to open the freezer door. The freezer was operational in a manner that had the potential to affect food quality. This deficient practice results in the inappropriate storage of food and had the potential to affect 101 out of 102 residents, who eat food from the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was free from potential of misappropriation of her property (jewelry), by not reimbursing Resident 1's ring included on the inventory list upon admission to the facility. This deficeint practice had the potential for Resident 1 to be anxious and upset about her missing ring.

Inspectors wroteBased on interview and record review, and per facility policy and procedures (P&P) titled Bed-Holds and Returns reviewed 1/2024, the facility failed to inform in writing one of four sampled residents (Resident 1) of the bed-hold and return policy when the resident was transferred to General Acute Care Hospital 1 (GACH 1) on 8/13/2024. This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility not of the resident's or responsible party's preference.

Inspectors wroteBased on interview and record review, the facility failed to readmit one of four sampled residents (Resident 1) to the facility following hospitalization at General Acute Care Hospital 1 (GACH 1) on 8/13/2024 according to the facility's policy and procedure (P&P) titled, Transfer or Discharge, Facility-initiated. As a result, Resident 1 remained in GACH 1 and had the potential to cause psychosocial harm.

Inspectors wroteBased on interview, and record review, the facility failed to revise a care plan for weight loss for two of four sampled residents (Resident 1 and 2), who had actual significant weight loss. This deficient practice had the potential to place Resident 1 and 2 at risk for recurrent weight loss.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality of care and services for one of three sampled residents (Resident 1) by failing to: 1. Ensure proper documentation was done when Resident 1 had a change of condition (COC/CIC). On 8/15/2024 at around 7:25 p.m., Licensed Vocational Nurse 2 (LVN2) notified Resident 1's physician (MD) via text message that Resident 1's family was concerned that Resident 1 was becoming confused and with hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there). 2. Ensure a urinalysis (UA-urine test) was done per physician's order (MD order). These deficient practices had the potential to negatively impact the delivery of care services provided to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure a BIPAP (bilevel positive airway pressure- a noninvasive machine that pushes air into the lungs via a mask to assist with breathing) was available from 6/21/2024 to 6/25/2024 for one of two sampled oxygen dependent (required 24-hour oxygen administration), residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for shortness of breath.

Inspectors wroteBased on interview, and record review, the facility failed to document Quality Control (QC-routine tests that verify the reliability of the machine) results on multiple days for the Glucometer (machine used to check blood sugars) as per policy. Additionally, based on observation, interview, and record review the facility failed to dispose of medications as per policy. These deficient practices had the potential to place residents at risk for inaccurate results when checking blood sugars for diabetic residents and had the potential to place staff at risk of diversion (when a medication is redirected from its intended destination for personal use, sale, or distribution to others) which could in turn place residents at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy on infection control to prevent the spread of coronavirus 2019 (COVID-19, a respiratory (organs involved in breathing) disease that is highly contagious thought to spread mainly from person to person through respiratory droplets produced when an infected person coughs, sneezes, or talks) and other diseases as evidenced by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1), Licensed Vocational Nurse 1(LVN 1) and Central Supply staff (CS) performed hand hygiene by washing hands using soap and water or use alcohol-based hand rub (ABHR) after contact with residents and their environment. 2. Ensure visitors were screened before entry into the facility. These deficient practices had the potential to spread infection to the residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the emergency generator started and transferred power to supply the facility within 10 seconds after interruption of normal power on 6/13/2024 at 8:28 PM As a result, the facility lacked power for over 30 minutes on 6/13/2024 for 88 of 88 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality for two of five sampled residents (Residents 2) by failing to ensure that Resident 2 ' s albuterol sulfate (used to prevent and treat wheezing and shortness of breath caused by breathing problems) medication was not left unattended. This deficient practice had the potential to result in residents in unintended complications related to the management of medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 3), who was assessed as a high risk was not left unattended in the bathroom unsupervised. This deficient practice resulted in Resident 3 falling while in the bathroom on 5/9/2024 at 6:45 p.m. and sustained a mild displaced comminuted subcapital (is a difficult hip injury that can have serious complications) fracture (a break in a bone) of the right femoral neck (right hip fracture). Resident 3 was transferred to General Acute Care Hospital (GACH) on 5/10/2024. Resident 3 underwent a closed reduction percutaneous fixation (a procedure to set [reduce] a broken bone without cutting the skin open) of the right femoral neck fracture resulting from a right non-displaced femoral neck fracture.

Inspectors wroteBased on interview and record review the facility failed to accurately perform a neuro check (assessing mental status and level of consciousness, pupil response, motor strength, sensation, and walking) after a fall for one of five sampled residents, (Resident 3). This deficient practice had the potential to result in a delay to transport Resident 3 to the general acute care hospital (GACH) where he was diagnosed with a mild displaced mildly comminuted subcapital fracture of the right femoral neck (right hip fracture).

Inspectors wroteBased on interview, and record review the facility failed to provide enough certified nursing aids (CNA) ' s to provide assistance with toileting for one of five sampled Residents, (Resident 3). This deficient practiced caused Resident 3 to fall while unattended in the bathroom; subsequently develop leg pain that required transport to the general acute care hospital (GACH) where he was diagnosed with a mild displaced mildly comminuted sub capital fracture of the right femoral neck (right hip fracture).

Inspectors wroteBased on observation, interview, and record review the facility failed to administer antihypertensive (medications to lower blood pressure) medications timely for one of four sampled residents, Resident 4. This deficient practice placed Resident 4 at risk of having elevated blood pressure which can lead to severe Headache, hemorrhagic stroke (bleeding in the brain) or death.

Inspectors wroteBased on interview, and record review the facility failed to apply a non-rebreather oxygen mask (NRBM- It is a face mask oxygen delivery device that fits over your mouth and nose. An elastic band stretches around your head to keep mask on. The mask connects to a small bag filled with oxygen (reservoir bag), and the bag is attached to an oxygen tank. Oxygen should be set on 10-15 lpm (liters per minute) to administer a higher concentration of oxygen in an emergent situation) correctly in an emergent situation for one of three sampled residents, Resident 1. This deficient practice could have caused Resident 1 to remain short of breath due to not enough oxygen delivery.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that licensed nurses had the skills and knowledge apply a non-rebreather oxygen mask (NRBM- It is a face mask oxygen delivery device that fits over your mouth and nose. An elastic band stretches around your head to keep mask on. The mask connects to a small bag filled with oxygen (reservoir bag), and the bag is attached to an oxygen tank. Oxygen should be set on 10-15 lpm (liters per minute) to administer a higher concentration of oxygen in an emergent situation) correctly in an emergent situation for one of three sampled residents, Resident 1. This deficient practice could have caused Resident 1 to remain short of breath due to not enough oxygen delivery and potentially places other residents having severe shortness of breath at risk.

Inspectors wroteBased on interview and record review the facility failed to develop a care plan for discharge planning for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk of needs not been met and delay in necessary intervention during discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five sampled residents, (Resident 1) received treatment and care accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to ensure Resident 1 was routinely checked and monitored to maintain safety and well-being per facility ' s policy and procedure (P&P) titled, Routine Resident Checks. This deficient practice resulted to failure in the delivery of necessary care and services for Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that Licensed Vocational Nurse 3 (LVN 3) have the specific competencies and skill sets necessary to care for one of one sampled resident (Resident 1) by failing to properly monitor and assessed Resident 1 per facility ' s policy and procedure titled, Routine Checks. This deficient practice resulted in a negative effect to Resident 1 ' s plan of care and delivery of necessary care and services. Cross Reference F684.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of nine sampled residents (Resident 1) by failing to develop a comprehensive care plan for Resident 1's diagnosis of Parkinson's disease (a disorder in the brain that affects movement, often including tremors). This deficient practice had the potential to result negative impact on residents' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received adequate and continuous supervision and monitoring to prevent falls and injury for one of two sampled residents (Resident 1) who was a high risk of fall by failing to: 1. Ensure Resident 1 was closely supervised when he was left alone in his room while sitting on a wheelchair. According to Certified Nursing Assistant 2 (CNA 2), she did not monitor Resident 1 while Certified Nursing Assistant 1 (CNA 1) went for her lunch break. 2. Failing to use two people to transfer Resident 1 from bed to wheelchair, using a Hoyer lift (sling lift, an mechanical assistive device that allows residents to be transferred between a bed and a chair, by the use of electrical or hydraulic power) as indicated in the facility ' s policy and procedure. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the pneumonia (PNA-infection that inflames air sacs in one or both lungs and can be life-threatening to anyone but particularly to infants, children, and people over [AGE] years old) vaccine was offered to one of five sampled residents (Resident 1). This deficient practice placed Resident 1 at a higher risk of possibly acquiring and transmitting pneumonia infection to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's clinical records were updated regarding Physician Orders for Life-Sustaining Treatment (POLST - is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) for two out of two sampled residents (Resident 1 and Resident 2) by failing to maintain a completed form of the resident's POLST in the resident's medical record. This deficient practice had the potential to cause conflict with resident's wishes regarding health care.

Inspectors wroteBased on interview, and record review, the facility failed to develop a baseline care plan for one of six sampled residents (Resident 1), addressing Resident 1 ' s identified risk of aspiration and physician ' s diet orders. This deficient practice had the potential for delayed provision of necessary care and services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 ( LVN 1) immediately initiated Cardiopulmonary Resuscitation (CPR- a medical procedure involving repeated compression of a patient's chest, performed to restore the blood circulation, and breathing of a person who has suffered cardiac arrest) for one of the three sampled residents (Resident 1) and did not leave Resident 1 unattended when LVN 1 found Resident 1 unresponsive (Unconscious, and possibly dead or dying) on 12/3/23 at 7:30 p.m. As a result, Resident 1 did not receive the necessary emergency life-saving services immediately. The paramedics (Healthcare professionals trained in the medical model, whose main role is to respond to emergency calls for medical help outside of a hospital) arrived at the facility on 12/3/23 at 7:39 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for one of three sampled residents (Resident 1) by failing to develop an individualized/person-centered care plan with goals and interventions upon readmission for being at risk for aspiration. This deficient practice had the potential for Resident 1 to aspirate (when something enters your airway or lungs by accident) during meals for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide services in compliance with the applicable Federal, State, and local laws, regulations, and codes and with accepted professional standards and principles for two of two sampled residents (Residents 1 and 4) by failing to: 1. Ensure timely reporting and notification of death to appropriate agencies for Residents 1 and 4. Resident 1 expired on [DATE] and Resident 4 expired on [DATE]. 2. Ensure reporting of any positive COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) resident ' s death to the Los Angeles County Department of Public Health (LAC-DPH). Resident 4 tested positive on [DATE]. 3. Ensure reporting of Resident 1's unwitnessed fall with complain of pain, left temporal (area behind the ear) area bump, left forearm hematoma (large bruise; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to promptly inform the physician (MD) for one of four sampled residents (Resident 3's) STAT (immediately, urgent or rush) laboratory results. This deficient practice had the potential to result in possible delayed provision of necessary care and services to Resident 3. Resident 3 expired in the facility on [DATE]. Cross Referenced F726.

Inspectors wroteBased on interview and record review, the facility failed to ensure an interdisciplinary team (IDT-a coordinated group of experts from several healthcare fields that actively coordinate treatment goals for the patient)meeting was done since admission for one of two sampled resident (Resident 3). This deficient practice had the potential for Resident 3 not receiving appropriate care/ treatment and/ or services to be provided by the facility such as offering palliative care (interdisciplinary medical caregiving approach aimed at optimizing quality of life to patients who have serious or life-threatening disease or illness) and when Resident 3 had a fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician (MD) progress notes for one of four sampled residents (Resident 3) was up to date when Resident 3's MD assessed and visited Resident 3 on [DATE]. This deficient practice had the potential to delay necessary services, poor continuity of care and follow up for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff had specific skills necessary to care for one of three sampled resident (Resident 3 ' s) needs by failing to: 1. Ensure prompt notification of Resident 3 ' s lab result to the physician (MD). 2. Ensure proper documentation pertaining Resident 3 ' s death was recorded in the nurse progress notes. 3. Ensure a change of condition documentation was completed when Resident 3 ' s physician ordered STAT (immediately, urgent or rush) lab works and dextrose 5 percent (%) in water (D5W) at 50 cubic centimeter per hour (cc/hr) for one liter intravenously (IV-administering fluid medication through a needle or tube inserted into a vein) for Resident 3 ' s episode of poor oral intake. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodations to meet resident needs for one of 27 sampled residents (Resident 387) by failing to assess the resident for call light accommodation needs and provide an appropriate call device that Resident 387 could use independently and without risk for injury or harm. 1. On 11/25/2023 at 6:22 PM Resident 387 was observed to have a silver bell with a black handle tightly tied to resident's left middle finger with a white gauze causing an indentation (area of skin that looks pushed in close to the bone of the finger) and redness, pain, and swelling to the resident's left middle finger. 2. On 11/25/2023 at 7:57 PM, the same bell was observed tied to Resident 387's left index finger. 3. On 11/26/2023 at 8:40AM, the same bell was observed tied to Resident 387's left index finger. [...]

Inspectors wroteBased on observation, interview and record review, the facility's interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together) failed to ensure medications were not left at the bedside without a physician's order and Medication Self-Administration Assessment was completed for four of 27 sampled residents (Resident 85, 89, 107 and 330). These deficient practices had the potential to result in unsafe medication application and delayed necessary health intervention.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive care plan to meet the care/services needs based on the resident's individual assessed needs for five of 25 sampled residents (Residents 85, 89, 107, 127 and 330) by failing to: 1. Implement a comprehensive care plan for bed side rails for Residents 85, 107 and 127 2. Implement a comprehensive care plan for contact isolation precaution and on antiviral therapy (a class of medication used for treating viral infection [are illnesses you get from tiny organisms that use your cells to make more copies of themselves]) for Resident 280 3. Implement a comprehensive care plan for oxygen therapy for Resident 330 . These deficient practices had the potential to result in negative impact on the health, safety and quality of care and services provided for Residents 85, 107 and 127.

Inspectors wroteBased on interview and record review, the facility failed to provide effective pain management to maintain the highest practical level of well-being for two of 27 sampled residents (Residents 230 and 383) by failing to: 1. Assess, recognize, develop, and implement an individualized pain management care plan for Resident 230. 2. Ensure accurate documentation for Oxycodone hydrochloride (narcotic [a drug or other substance that affects mood or behavior and is consumed for nonmedical purposes, especially one sold illegally] pain medication) 10 milligram (mg - unit of measurement) give one tablet by mouth every four hours as needed for severe pain. in Resident 230's electronic Medication Administration record (eMAR). 3. Ensure Resident 230 was offered nonpharmacological (therapies that do not involve medications) interventions for pain management. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post daily the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift in a visible and prominent place for residents and visitors. This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to: 1. Ensure discontinued medications were removed from the medication cart and returned to back to the resident for one of three sampled discharged residents (Resident 121). Resident 121 was discharged to home on [DATE] without Resident 121's own clonazepam (medication that can treat seizures, panic disorder, and anxiety) 0.5 milligram (mg - unit of measurement) . 2. Ensure Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) matched/corresponded with the Medication Administration Records (MAR) for two of five sampled residents (Residents 65 and 230) by failing to: a. [...]

Inspectors wroteBased on observation, interview, and record review, for two out of four sampled medication carts (medication cart 3 and medication cart 4) the facility failed: 1. To label an open date on Resident 5's ipratropium-albuterol inhalation solution (medications to help relieve shortness of breath) and Pulmicort (medication that helps with breathing by decreasing swelling in the lungs) inhalation located in medication cart 3 solution that that could expire according to manufacture guidelines. 2. To label an open date on Resident 86's albuterol inhaler (medication that help relieve shortness of breath) located in medication cart 3 that could expire according to manufacture guidelines. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper food handling practices by: 1. Failing to label an open bag of wheat bread with the date it was opened and use by date inside one of one walk in Refrigerator 1. 2. Failing to seal the open box of turkey skinless links, veggie patties, green beans in the one of one Freezer (Freezer 1) and label with the open and use by date. 3. Failing to ensure an open almond milk and grape juice in Refrigerator 3 was dated with open and use by date inside one of two Refrigerator (Refrigerator 1). 4a. Failing to ensure food and drinks brought in from outside the facility kitchen had a date food was prepared and open and use by date. 4b. Failing to ensure one of three Residents' Refrigerator (Residents' fridge 3) temperature was checked every day. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control measure and prevention program by failing to: 1. Ensure two of six sampled facility staff (Housekeeper 1 [HK1] and Housekeeper 2 [HK2]) wore proper fit tested N95 (filtering facepiece respirator) mask when entering a COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) isolation room. 2. Ensure one of three sampled Residents' refrigerator (Residents' fridge #3) temperature log was checked and documented. 3. Ensure proper signages for droplet/contact (precautions used for diseases that can be transmitted during contact with the patient or patient's environment) transmission-based precaution (TBP) were placed on the room entrance of two of five sampled rooms. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. Pneumonia (PNA-infection that inflames air sacs in one or both lungs and can be life-threatening to anyone but particularly to infants, children, and people over [AGE] years old) vaccine was offered to four of 19 sampled residents (Resident 4, 28, 44, and 62). 2. Influenza (Flu-common viral infection that can be deadly, especially in high-risk groups) vaccine was offered to five of 19 sampled residents (Resident 4, 38, 44, 62, 280). These deficient practices placed Residents 4, 28, 38, 44, 62, and 280 at a higher risk of possibly acquiring and transmitting influenza and pneumonia infection to other residents and staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) vaccination was offered/ re-offered and/or administered to eight of 19 sampled residents (Resident 4, 28, 38, 41, 44, 48, 60, 280). This deficient practice might have the potential for not preventing Resident 4, 41, and 48, who were tested positive for COVID 19, from COVID-19 infection, and placed other residents and staff at risk for COVID-19 infection.

Inspectors wroteBased on observation, interview and policy review, the facility failed to maintain patient care equipment in safe working condition when: - One sit-down bicycle was missing foot straps. - One sit-down bicycle's monitor screen was not working. - One stand-up bicycle was missing foot straps. These deficient practices had a potential to cause incidental accidents to the residents while using the equipment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that promote or enhanced resident's dignity and respect for two of five sampled residents (Resident 12 and 232) by failing to: 1. Ensure adhering to facility's care plan, policy, and procedure (P&P) regarding non-English-speaking residents for one of three sampled residents (Resident 12). This deficient practice violated Resident 12's right to have effective mode of communication and to communicate her needs to facility staff as desired. 2. Ensure one of three sampled residents (Resident 232) was informed of confirmed COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) cases in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided with room change notification for one of three sampled residents (Resident 430). This deficient practice violated resident 430's right to room change notification.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed or offered an advanced directive (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) in a timely manner for four out of four sampled residents (Resident 85, Resident 89, Resident 127, and Resident 430). This deficient practice had the potential to cause conflict with resident's wishes regarding health care (Resident 85, Resident 89, Resident 127, and Resident 430).

Inspectors wroteBased on interview and record review, the facility failed to follow its policies and procedure by failing to notify the physician immediately upon identification of COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) positive result for one of three sampled residents (Resident 48). This deficient practice resulted in a delay of necessary treatment for COVID-19 and could result in a decline in medical condition for Resident 48.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three randomly selected residents (Residents 26 and 121) were provided with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (skilled nursing facility Advanced Beneficiary Notice [SNF-ABN]) complete appeal process. This deficient practice had the potential to result in Residents 26 and 121 and their responsible parties not being able to exercise their right to decide if they wished to continue receiving the skilled services that may not be paid for by Medicare and to assume financial responsibility.

Inspectors wroteBased on interview and record review, the facility failed to complete a change in condition (COC - a deterioration in health, mental, or psychosocial status) assessment for one of three sampled residents (Resident 390). On 11/24/2023, Resident 390 intravenous (IV - a within a vein) line (a soft, flexible tube placed inside a vein, usually in the hand or arm) on the left forearm, infiltrated (when fluid or medication accidentally leaks into the surrounding tissues outside a vein). As a result, Resident 49 experienced swelling, redness and pain of the left forearm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality by failing to ensure trazodone (medication used to treat depression and may help to improve mood, appetite, and energy level as well as decrease anxiety and insomnia [difficulty falling or staying asleep]) was not left unattended at the bedside for one of five sampled residents (Residents 107) This deficient practice had the potential to result in residents in unintended complications related to the management of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 27 sampled residents (Residents 387 and 330) received treatment, care, and services in accordance with professional standards of practice by failing to: 1. Assess, identify risk factors, and provide Resident 387 with a call device the resident could use independently and without risk for injury or harm. 1.1 On 11/25/2023 at 6:22 p.m., Resident 387 was observed to have a silver bell with a black handle tightly tied to resident's left middle finger with a white gauze causing an indentation (area of skin that looks pushed in close to the bone of the finger) and redness, pain, and swelling to the resident's finger. 1.2. On 11/25/2023 at 7:57 p.m., the same bell was observed tied to Resident 387's left index finger. 1.3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the Peripherally Inserted Central Catheter PICC- a long, flexible catheter (thin tube) that's put into a vein in your upper arm and goes all the way up to a vein near the heart or just inside the heart) line dressing was changed every seven days for Resident 387. 2. Ensure peripheral intravenous (IV-a small, flexible tube placed into a small vein used to administer medications and fluids) for Resident 223 by failing to: 2.1. Replace IV site no more frequently than every 72 to 96 hours. 2.2. Date and initial when IV dressing is changed. 2.3. Document and assess and monitor the IV site after IV for infection. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care that was consistent with professional standards of practice to meet the goal ensure for two of five sampled residents (Residents 113 and 330) by: 1. Failing to ensure Resident 113's oxygen nasal cannula tubing and oxygen humidifier had a date when the humidifier and tubing were changed. 2. Failing to ensure to obtain a physician order for Resident 330's oxygen therapy. This deficient practice had the potential to result in complications including infections related to oxygen therapy for Residents 113 and 330.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper use of bed rails (a barrier attached to the side of the bed) for three out of five sampled residents (Residents 85, 107 and 127) as indicated in the facility's policy and procedure titled Proper Use of Side Rails. These deficient practices had the potential to result in inappropriate use of bed siderails and placed the residents at risk for serious injury or harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure 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 associated with medication) for two of five sampled residents (Residents 49 and 113) was free from unnecessary drug. This deficient practice resulted in unnecessary use of antibiotics and at risk for side effects of antibiotics for Resident 113 and had the potential to place Resident 49's receiving unnecessary medication and possibly hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to implement its' policy and procedures (P & P) titled, Psychotropic Medication Use,, by failing to indicate the behavioral symptoms and follow up with the recommendation for a gradual dose reduction for Seroquel (This medication is used to treat certain mental/mood conditions, such as bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration] or depression) for one of six sampled residents (Resident 17). These deficiencies had the potential to result in the use of unnecessary medication and expose Resident 17 to adverse side effects related to higher or prolong use of antipsychotic drugs (medication taken to exert an effect on the chemical makeup of the brain and nervous system).

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 60), were free from significant medication errors by: 1. Failing to ensure Resident 60's benazepril hydrochloride (medications to treat high blood pressure (BP) [the force of the blood pushing on the blood vessel walls is too high]) was administered in accordance with the physician's order with parameters (low and high limits set by the physician telling the nurse when a medication can and cannot be given) to hold (do not give) the medication if Resident 60's systolic blood pressure (SBP-measures the pressure in your arteries [pathway that carries blood away from the heart] when your heart beats) was less than 110 millimeters of mercury (mmHg). 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to promptly notify the physician of one of two sampled residents (Resident 113) about abnormal hemoglobin (blood cells that is responsible for delivery of oxygen to the tissues), hematocrit (measures the percentage of the red blood cells in the blood) and potassium (electrolyte) levels. On 11/20/2023 Resident 113 had a documented hemoglobin level of 8.3 grams per deciliter (gm/dL, ranges from 13.2 to 16.6 gm/dL), a documented Hematocrit level of 27.5 percent (%-ranges from 38.3% to 48.6%), and a documented potassium level of 3.3 millimoles per liter (mmol/L, ranges from 3.6 to 5.2mmol/L). [...]

Inspectors wroteBased on interview and record review, the facility failed to assist with arranging transportation services to a follow up Orthopedic (a doctor that is specialized in the musculoskeletal [muscles and bones] system) appointment for one of three sampled residents (Resident 12). This deficient practice resulted in Resident 12 missing a scheduled physician's appointment with the potential to negatively affect Reident 12's health and wellbeing.

Inspectors wroteBased on interview, and record review, the facility failed to maintain accurate medical record in accordance with accepted professional standards and practices for three of 19 sampled residents (Residents 4, 41, and 90) by failing to ensure complete and accurate pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid), influenza (Flu-common viral infection that can be deadly, especially in high-risk groups) and COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) vaccination consents were properly completed. This deficient practice had the potential to negatively impact the delivery of services given to Residents 4, 41, and 90.

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship (actions designed to use antibiotic medications effectively while reducing the possibility of being prescribed an unnecessary medication) program by failing to conduct infection surveillance and complete the infection control reporting form when signs and symptoms of infection were identified and antibiotics were initiated for one of five sampled residents (Residents 113). This deficient practice had the potential for Resident 113 to develop antibiotic resistance (not effective to treat infection) resulting from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist Nurse (IPN), who is responsible for the facility's Infection Prevention Control Program (IPCP), adequately maintained the facility's vaccination program and properly monitored the facility's antibiotic stewardship program (ASP). This deficient practice had the potential to increase the spread of infection and possible transmission of communicable diseases between residents, staff and the community. Cross Reference F880, F881, F883 and F887

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for one of five sampled residents (Resident 1) by failing to ensure the shower chair was cleaned before and after use. This deficient practice had the potential to negatively impact the quality of life and increased risk for physical discomfort for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality for two of five sampled residents (Residents 1 and Resident 4) by failing to: 1. Ensure that Resident 1 ' s Lidoderm patch (eases pain by numbing the nerves and making them less sensitive to pain) medications were not left unattended. 2. Ensure Resident 4 ' s potassium chloride tablet (a medication used in the management and treatment of hypokalemia [low potassium level]) was not left unattended. These deficient practices had the potential to result in residents in unintended complications related to the management of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe and functional shower room for 1 out of 5 shower rooms in the facility, by having a broken shower door knob. This deficient practice had the potential to negatively impact the psychosocial wellbeing of the residents or result in delayed provision of services.

Inspectors wroteBased on observation, interview, and record review, the facility failed staff responded to residents call light timely for three of five sampled residents (Residents 2, 4, and 5) in accordance with the facility's policy and procedures (P&P) n accordance with the facility's undated P&P titled, Answering the Call Light. The facility was aware Resident 2 was a high risk for fall and had disorders of bone density and structure (Osteoporosis is a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). Residents 4 and 5 were dependent on staff for activities of daily living (ADL) As a result, 1. On 9/24/2023, Resident 2 pressed the call light waited for 50 minutes from for facility staff to respond to call light. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of four sampled residents (Resident 10) with an indwelling catheter (urinary catheter-a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services consistent with professional standard of care by failing to: 1. Ensure Resident 10 ' s urinary catheter drainage bag was not touching the floor. 2. Ensure Resident 10 ' s urinay catheter drainage bag was covered with privacy bag. These deficient practices had the potential to cause urinary issues such as infection and had the potential to violate Resident 10 ' s rights to be treated with dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Ensure the quality control testing for the Assure glucometer machine (device that measures how much sugar is in the blood sample) are performed correctly according to the manufacturer guidelines for 11 out of 11 glucometer machines. This deficient practice has the potential to result in residents with unintended complications related to the management of their blood glucose. b. Ensure the medication disposition record log for discarding and destroying medications are complete with date when it was discarded for one of three medication disposition log (Medication room [ROOM NUMBER]) according to their policy. This deficient practice has the potential to result in drug diversions. c. Ensure a Restorative Nursing Assistant (RNA) meeting was done on a monthly basis. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify resident upon changes to the charges for items and services that the facility offers in writing at least 30 days of implementation of the change according to their policy for one of five sampled residents, Resident 1. This deficient practice had the potential to result in Resident 1 and her responsible parties not being able to exercise their rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure protection of resident ' s medical record for three of three sampled residents (Resident 11, 12 and 14) when Resident 11, 12 and 14 ' s information was not removed from the medication containers. This deficient practice had the potential to result on violating Resident 11, 12 and 14 ' s right to privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy by failing to report a sexual abuse within 2 hours of occurrence to law enforcement, the State Agency and Ombudsman for one of five sampled residents (Resident 3). This deficient practice resulted in a delay of an onsite investigation by the law enforcement and the State Agency to ensure the rights and safety of the resident involved.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary treatment and service to three of seven sampled residents (Resident 7, 9 and 10) consistent with the resident ' s needs and professional standard of care by failing to ensure Resident 7, 9, and 10 ' s low air loss mattresses (LAL-a mattress designed to prevent and treat pressure wounds) were in appropriate setting per manufacturer ' s guideline. This deficient practice can place Resident 7, 9 and 10 at risk of poor wound healing of the current pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and possibly development of a new pressure injury.

Inspectors wroteBased on interview and record review, the facility failed to: a. Report missing ring to the Administrator timely, and b. Initiate and Investigate allegation of a missing ring thoroughly and timely as per facility policy for one of three sampled residents, (Resident 1). This deficient practice could have place other residents at risk of possible theft due to prolonged and incomplete investigation.

Inspectors wroteBased on interview and record review the facility failed to report possible misappropriation of property for one of three sampled residents, (Resident 1), to the California Department of Public Health (CDPH) per policy. This deficient practice resulted in a delay in the investigation of the allegation of the misappropriation of property for Resident 1. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect the rights of one of four sampled residents (Resident 1) to be free from physical abuse (any intentional act not limited to slapping, pinching, choking, kicking, shoving) by caregiver 1 (CG1) in accordance with the facility's undated policy and procedures titled Prohibition Of Abuse, Neglect and/or Misappropriation of Resident Property and Mandating Reporting by failing to: 1. Ensure CG1 did not hit and slap Resident 1 on the leg on 10/11/2023 at 6 a.m. Resident 1's diagnoses included dementia (progressive, persistent loss of intellectual functioning, especially with impairment (significant disturbance in an individual's cognition, emotional regulation, or behavior) of memory and abstract thinking). 2. [...]

Inspectors wroteCross Reference F600 Based on interview, and record review, for 35 of 35 caregivers, the facility failed: 1. To make reasonable efforts to ensure contracted workers received training in elder and dependent adult abuse protocols and abuse prevention in accordance with the facility's undated Prohibition of Abuse, Neglect and/or Misappropriation of Resident Property and Mandated Reporting, Orientation Program for Newly Hired Employees, Transfers, Volunteers revised on 5/2019, and Caregiver, Non-Staff Reviewed on 1/2023, 2. To provide orientation program for all contracted caregivers in accordance with the facility's policy and procedures titled Orientation Program for Newly Hired Employees, Transfers, Volunteers, revised on 5/2019, by failing to: a. Ensure all caregivers attended a 10-hour orientation program within their first five (5) days of hire. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (A device used by a patient to signal his or her need for assistance from professional staff) for one of four sampled residents (Resident 2) was answered in a timely manner. This deficient practice had the potential for Resident 2's needs not being met.

Inspectors wroteBased on interview, and record review, the facility failed to 1. ensure the Director of Nursing (DON) have the specific competency and skill set necessary to ensure the facility's policy of elopement (leaving the facility unsupervised and without staff knowledge) was implemented by failing to investigate and report the unusual occurrence to the State Survey Agency within 24 hours after Resident 1 left the facility unsupervised and without staff knowledge for one of five sampled residents (Resident 1). 2. ensure that Licensed Vocational Nurse (LVN 5) and Licensed Vocational Nurse 6 (LVN 6) have the specific competencies and skill sets necessary to care for one of five sampled residents (Resident 2) by failing to properly document in the Medication Administration Record (MAR) when medications were refused and withheld. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the State Survey Agency a written report of the findings of the investigation of an unusual occurrence of elopement (leaving the facility unsupervised and without staff knowledge) after 5 working days of Resident 1's leaving the facility unsupervised and without staff knowledge for one out of five sampled residents (Residents 1). This deficient practice had a potential for an ongoing reoccurrence of elopement.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy of elopement (leaving the facility unsupervised and without staff knowledge) by failing to investigate and report the unusual occurrence to the State Survey Agency within 24 hours after Resident 1 left the facility unsupervised and without staff knowledge for one of five sampled residents (Resident 1). This deficient resulted in a delay of an onsite inspection by the Department of Public Health and had potential for an ongoing reoccurrence of elopement. Cross reference F609.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for two of five sampled residents (Residents 2 and 3) by failing to: 1. Implement the care plan for Resident 3's self-administration of Vyndamax (used to treat a certain type of heart failure) medication when Licensed Vocational Nurse 1 (LVN 1) confirmed that Resident 3 takes his own medication, and the medication was left at bedside. 2. Implement the care plan for Resident 2's refusal of taking Biktarvy (prescriptions medicine used to treat human immunodeficiency virus [HIV 1 - a virus that attacks the body's immune system] in adults and children) medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a care plan for at risk of elopement (leaving the facility unsupervised and without staff knowledge) for one of five sampled residents (Resident 1), who left the facility unsupervised and did not notify the staff and without physician's order. This deficient practice placed Resident 1's at risk for recurrent elopement.

Inspectors wroteBased on observation, interview, and record review, facility failed to meet professional standards of quality for two of five sampled residents (Resident 2 and 3) by failing to: 1. Implement the facility ' s policy and procedure titled, Medication Administration (General) , to assess each resident ' s mental and physical abilities, to determine whether a resident is capable of self-administering medications. 2. Clarity with the physician for order of Resident 3 ' s Vyndamax (used to treat a certain type of heart failure) medication left at bedside. 3. Failing to ensure a timely assessment for self-administration of Vyndamax medication for Resident 3. [...]

Inspectors wroteCross reference to F657 Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was properly supervised to prevent elopement (leaving the facility unsupervised and without staff knowledge) by failing to: 1. Ensure to evaluate and analyze hazard(s) and risk(s) of elopement when Resident 1 was observed walking around his room and made attempt of leaving as he was observed walking in the hallway and attempting to take the elevator. 2. Implement the comprehensive care plan for risk of elopement related to Resident 1 verbalizing of wanting to go home and expressing to his (Resident 1) daughter of not wanting to stay in the facility. These deficient practices resulted in Resident 1 eloping on 9/23/2023, took the bus unsupervised and without notifying the staffs. [...]