Berkley Post-Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure unopened insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) pens (a pre-filled device used to inject insulin) were stored in the refrigerator and not in the medication cart per manufacture's guidelines for one of one sampled medication cart (Medication Cart 1). 2. Discard one expired insulin injection pen after opening on 2/27/2026 according to the manufacturer's guidelines. These deficient practices had the potential to place residents at risk for ineffective medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by: 1. Failing to ensure the kitchen's red sanitation buckets were at the proper concentration for three of three sampled red sanitation buckets. 2. Failing to implement the facility's quaternary ammonium (a class of positively charged chemical compounds used extensively as disinfectants or sanitizers) log policy as evidenced by failing to provide documented evidence of a quaternary ammonium log. These deficient practices had the potential to place 117 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility diet spreadsheet by failing to serve the residents' chef's vegetable of choice as indicated on the facility spreadsheet to be served for lunch on 5/7/2026 for two of three sampled residents (Resident 2 and Resident 3). This deficiency had the potential for Resident 2 and Resident 3 to not receive the nutrition needed and the potential for unintended wight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure that nursing staff have the specific competency and skills set necessary to care for residents' needs, as identified through residents' assessments and plan of care for three of three sampled staff (Certified Nursing Assistant 1 [CNA 1], CNA 2, and CNA 3) reviewed for competency skills check or performance evaluations for colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) care. This deficient practice had the potential to place residents with a colostomy at risk of not receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were not standing over a resident while assisting with feeding for one of three sampled residents (Resident 3). This deficient practice had the potential to affect the resident's self-esteem, self-worth, and sense of independence.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy on meal service by failing to ensure kitchen staff recorded food temperatures for three meal times on 4/11/2026 (Lunch), 4/12/2026 (Dinner), and 4/15/2026 (Lunch). This deficient practice had the potential to place 117 of 119 in-house residents at risk for foodborne illness (any illness resulting from eating contaminated/spoiled foods).

Inspectors wroteBased on interview and record review, the facility failed to provide routine biologicals and pharmacy services including administering all drugs per physician's order in accordance with good nursing principles and practices by failing to administer Atorvastatin (medication to help lower cholesterol) and Semglee (glargine insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication]) on 1/6/2026 at 9:00 p.m. per physician's order for one of three sampled residents. (Resident 1)This deficient practice had the potential to result in health complications due to inconsistent medication levels, leading to decreased therapeutic benefit.

Inspectors wroteBased on interview and record review, the facility failed to conduct a resident's nutritional assessment within seven (7) days upon readmission for one of four sampled residents (Resident 1), as per the facility's policy and procedure (P&P). This deficient practice had the potential to place the resident at risk for undetected nutritional status and at risk for medical complications related to impaired nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained dignity and respect for three of seven residents (Residents 62, 120, and 83) observed during medication pass by failing to ensure:1. Licensed Vocational Nurse (LVN) 4 pulled the curtain closed when checking Resident 62's blood sugar and during administration of insulin (a natural hormone that turns food into energy and manages your blood sugar level) via injection.2. Registered Nurse (RN) 4 pulled the curtain closed or shut the door to the hallway while administering oral medications to Resident 120.3. Registered Nurse (RN) 4 fully pulled the curtain closed while checking Resident 83's blood pressure and administering oral medications and eyedrops. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (CP-a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) by failing to:a. 1. Develop a care plan addressing the communication needs of one resident of one (Resident 2) residents reviewed under the communication and sensory care area. a.2. Develop a care plan addressing the risks associated with the use of Seroquel (medication used to treat various mental health conditions) which carries a Black Box Warning (warnings that are intended to provide critical information about a drug's potential risks) for one of four (Resident 2) reviewed under the dementia care area.b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions (treatments or therapies that do not involve the use of medications) prior to administering as needed (prn) opioid ([narcotic- used to treat moderate to severe pain) pain medication to a resident for one of four sampled residents (Resident 147). This deficient practice had the potential to place the resident at an increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the use of opioids.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure the licensed nurse documented the administration of Tramadol (a controlled substance with the potential for addiction- can treat moderate to severe pain) in the Medication Administration Record (a vital document in healthcare that accurately tracks and records all medications administered to a patient) right after the medication was administered to one of three residents (Resident 16) reviewed under the Medication Storage and Labeling task.2. Ensure the licensed nurse documented the administration of Norco (a controlled substance with the potential for addiction- used to relieve pain severe) right after the medication was administered for one of three (Resident 67) residents investigated under the Medication Storage and Labeling task. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were properly stored and labeled in accordance with professional standards in two of three inspected medication carts by:1. Failing to label a box of Artificial Tears (eye drops that moisten dry eyes) with a resident's name but instead used a last name, during the investigation of Medication Cart 1, Station 1.2. Medication Cart 1, Station 2 had four loose, unlabeled pills left in the medication cart. These deficient practices had the potential for a resident to receive medication not intended for that resident or incorrect, contaminated, or expired medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of residents when the Swedish meat ball portions were four (4) ounces (oz, a unit of measurement) instead of three (3) oz portions. This failure had the potential to decrease nutrient intake of protein resulting in unplanned weight loss to 78 of 122 residents on regular texture (texture of food with no restrictions and modifications) diet and ineffective diet therapy of 38 of 122 residents on consistent carbohydrate (CCHO, diet consisting of the same amount of carbohydrate each meal), renal diet (diet consisting of food with limited amount of protein, sodium, potassium and phosphorus) getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserve temperature when raspberry parfait was at 52 degrees Fahrenheit ( F, a degree of temperature) and puree raspberry parfait was at 59 F.This deficient practice placed 121 of 122 facility residents on regular (texture of food with no modifications and restrictions) and modified texture diet at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen equipment and kitchen areas were not cleaned and sanitized.a. Reach in freezer bottom shelves had boxes particles and dirt debris.b. The ice cream reach-in freezer had dirt and dust debris.c. The bread refrigerator had dried juice and milk sticky food spill.d. Reach in refrigerator vent had dust buildup.e. Walk in refrigerator vent had dust buildup.f. Ice buildup in the walk-in freezer door.g. [NAME] particles on the dry storage room floorh. Can opener container have had dust and dirt buildup.i. The condiment container had salt, pepper, sugar, artificial sweetener and dust debris.j. Hood and hood light where the staff cook food had dust and dirt particles.k. Mixer had dust and was not cleaned after use. l. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when two (2) of 2 dumpsters (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) were not covered while not actively being used and there were soiled gloves and food juices on the floor. This failure had potential to attract birds, flies, insects, pests and possibly spread infection to 121 of 122 facility residents.

Inspectors wroteBased on interview and record review, the facility failed to:a. Ensure pain assessments were accurately documented for two out of three residents investigated under the pain care area (Residents 11 and 111) when the site of pain was not correctly documented as a part of the pain assessment. This failure resulted in Residents 11 and 111 having incorrectly and incompletely documented pain assessments.b. Clarify hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) orders were clear and accurate for one of five sample residents (Resident 12). This deficient practice placed Resident 12 at risk for unnecessary dialysis treatment and potential for electrolyte imbalance. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure facility staff donned (put on) and doffed (took off) an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) when entering and exiting a resident's room who was on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes) for one of seven sampled residents (Resident 6). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible to two of four sampled residents (Resident 148 and Resident 18) reviewed under the accidents care area by:a. Failing to ensure Resident 148 was provided with a tab alarm (refers to a type of fall prevention device that utilizes a pull-string or cord to activate an alarm when a patient attempts to move, such as getting out of bed or a chair) while in bed as ordered by the physician. b. Failing to ensure Resident 18's side rails were the correct size as ordered by the physician. These deficient practices had the potential to result in increased risk of injuries for Resident 148 and Resident 18.

Inspectors wroteBased on interview and record review, the facility failed to prevent significant medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by giving hydralazine HLC (blood pressure medication) outside of the prescribed parameters (a fixed limit/range by the doctor to either give or hold a medication) for one of five sample Residents (Resident 12). This deficient practice placed Resident 12 at risk for potential hypovolemic shock (a critical condition resulting from a significant decrease in blood volume, leading to inadequate blood flow to the body's organs) or other adverse effects (unwanted, unintended result).

Inspectors wroteBased on interview and record review that facility failed to implement their policy on homelike environment by failing to provide documented evidence that the facility checked residents ' room temperatures daily from 1/26/2025-1/28/2025. This deficient practice had the potential to keep residents from being provided a homelike environment and having comfortable room temperatures.

Inspectors wroteBased on observation, interview and record review, the facility failed to remove two unidentified and unlabeled medication tablets found in one of five medication carts (Nursing Station 1 Medication Cart Two [2]). This deficient practice had the potential for the residents to receive medications with improper efficacy due to improper storage condition of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were kept safe from injury and accident hazards for three of six sampled residents (Resident 163, Resident 164, and Resident 29) by failing to: 1. Ensure residents' medications, who had no self-administration assessment, were not left unattended at the bedside for Resident 163 and Resident 164. This deficient practice had the potential for other residents to enter the room and take another resident's medication and could experience adverse side effects (undesired harmful effect resulting from a medication or other intervention). 2. Ensure Resident 29 had bedside floor mats (cushioned foam mats which reduce the risk of injury from a fall) placed next to the resident's bed as indicated in the care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (PRN) opioid medication (powerful pain-reducing medications) on multiple days for two of 27 sampled residents (Residents 11 and 83). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from opioid pain medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control policy and procedure by failing to: 1. Ensure two visitors were for two of four days screened for signs and symptoms of Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection). This deficient practice had the potential to spread COVID-19 to residents in the facility. 2. Ensure Dietary Aide 1 (DA 1) washed their hands after touching a trash can lid. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 110 of 114 residents who received food from the kitchen. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a facility staff knocked and asked permission prior to entering a resident's room for one of five sampled residents (Resident 413). This deficient practice violated the resident's rights to be treated with respect and dignity which had the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) fully closed a resident's privacy curtain while providing care for one of 27 sampled residents (Resident 96). This deficient practice violated the resident's right to privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled resident rooms (Room A) occupied by four residents (Resident 100, Resident 167, Resident 168, and Resident 363) was within the temperature range of 71 degrees Fahrenheit (F, a unit of measure for temperature) to 81 F. This deficient practice had the potential to create an uncomfortable environment and for the residents to become dehydrated (condition occurring when a harmful reduction in the amount of water in the body).

Inspectors wroteBased on interview and record review, the facility failed to develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by one of three sampled residents (Resident 364). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a water pitcher was not left at bedside for one of one sampled resident (Resident 317) who was on strict fluid restrictions. This failure placed Resident 317 at an increased risk for injury and or hospitalization related to hypo-osmolality (a condition where the levels of electrolytes [substances that have a natural positive or negative electrical charge when dissolved in water], proteins, and nutrients in the blood are lower than normal) and hyponatremia (a condition where the level of sodium in your blood is lower than normal).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was provided a scheduled toileting plan (or bladder [a sac-shaped muscular organ that stores the urine secreted by the kidneys] training, which can involve assisting a resident to the restroom at specific timed intervals) for one of two residents (Resident 4). This deficient practice has the potential for Resident 4 to not to achieve or restore normal bowel (a tube-shaped organ in the abdomen that helps the body digest food and absorb nutrients) and bladder function.

Inspectors wroteBased on interview and record review, the facility failed to complete a post-dialysis (the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of one sampled resident (Resident 102). This deficient practice placed Resident 102 at risk for complications of dialysis such as redness at the dialysis access site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions).

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality of care by failing to ensure a lidocaine patch (eases pain by numbing the nerves and making them less sensitive to pain) was removed after 12 hours from application as per physician's order for one of five sampled residents (Resident 413). This deficient practice had the potential in excessive dosing and a potential to cause adverse reaction (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses monitored for side effects while a resident received an anticoagulant medication (medications that prevent and treat blood clots in the heart and blood vessels) for two of 27 sampled residents (Resident 73 and Resident 364). This deficient practice had the potential to result in the residents experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the anticoagulant.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a vial of insulin (hormone that lowers the level of glucose [sugar] in the blood) that was past the discard date, was not stored in one of three medication carts (Medication Cart A) for one of one sampled resident (Resident 85). This deficient practice had the potential for an expired insulin to be administered to Resident 85 which could result in uncontrolled blood glucose (the primary sugar in the blood and the body's main source of energy).

Inspectors wroteBased on observation, interview, and record review, the facility staff (Cook 1) failed to check the temperature of all of the food items on the tray line (a system of food serving in which a tray is moved along an assembly line to ensure a resident gets their prescribed diet) during mealtime service on 8/21/2024 at 1:25 p.m. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 110 of 114 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' Quarterly Minimum Data Sets (MDS - a standardized assessment and care screening tool) were completed timely for six of 27 sampled residents (Residents 83, 42, 58, 46, 30, and 62). This deficient practice had the potential to negatively affect the provision of necessary care and services for these residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure Registered Nurse 1 (RN 1) transcribed a physician order accurately and administered the prescribed dose of lisinopril-hydrochlorothiazide (a combination of medication used to treat hypertension) as ordered by the physician for one of three sampled residents (Resident 1) between 3/30/2024 to 3/31/2024 and 4/1/2024 to 4/16/2024. Resident 1 was administered a total of 13 incorrect doses of lisinopril-hydrochlorothiazide. This deficient practice placed Resident 1 at risk for serious health complications as a result of being administered lisinopril-hydrochlorothiazide when the blood pressure (BP - pressure of circulating blood against the walls of blood vessels, normal range less than 120/80 millimeters of mercury [mmHg - unit of measure]) was less than 140/80 mmHg. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the Notice of Proposed Transfer or Discharge (NPTD) Form for facility-initiated transfer (the resident expects to return to the facility) or discharge (when return to the facility is not expected) was sent to a representative of the Office of the State Long-Term Care (LTC) Ombudsman Program (advocates for residents in nursing homes) before transfer, discharge or in emergency situations as soon as practicable for 14 of 23 sampled residents (Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 22, and 24). As a result, Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 22, and 24 were denied protection and advocacy in the event residents were inappropriately or involuntary transferred or discharged from the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) had a physician ' s order to administer supplemental oxygen (O2- a treatment that provides you with extra oxygen to breathe in) prior to providing the resident with oxygen. This deficient practice had the potential to result in complications from lack of sufficient oxygen level in the body and lead to shortness of breath (SOB), rapid breathing, confusion, and loss of consciousness and irregular heartbeats.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of two sampled residents (Resident 4) received prescribed pain management by failing to administer pain medication as ordered by the physician. This deficient practice had the potential to result in confusion on the delivery of care and services rendered and may lead to inadequate management of resident ' s pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Administration Record (MAR- the report that serves as a legal record of the drugs administered to a resident of a facility by a health care professional) and Controlled Drug Record (CDR - an accountability log signed by the nurse with the date and time each time a controlled substance [medications with a high potential for abuse] is administered to a resident) coincided and were accurately documented per facility policy for one of two sampled residents. (Resident 4). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident ' s responsible party was informed of and explained any changes in Medi-Cal (a public health insurance program that provides free or low-cost medical services) share of cost (the amount you agree to pay for health care before Medi-Cal starts to pay) for one of three sampled residents (Resident 1). This deficient practice had a potential to result in the resident ' s responsible party inability to make an informed decision regarding payments, incurring late fees, and having a delinquent account.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident ' s call light (device used by residents that when pressed informs facility staff that assistance is being requested) was placed within reach for one of five sampled residents (Resident 2). On 10/12/2023, observed Resident 2 ' s call light placed on the resident ' s bed and covered with the bed sheet, out of reach from Resident 2 who was sitting by the bed. This deficient practice had the potential to result in a delay with resident care, and residents not receiving assistance with activities of daily living (ADL- fundamental skills required to independently care for oneself, such as eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet).

Inspectors wroteBased on interview and record review, the facility failed to provide oral hygiene (cleaning the mouth, teeth, and tongue) to one of five sampled residents (Resident 3), who required extensive assistance from staff with activities of daily living (ADL- describes fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). This deficient practice had the potential to place Resident 3 at risk for diseases of the mouth, gums, and teeth.

Inspectors wroteBased on interview and record review, the facility failed to administer tramadol (medication to treat pain) as prescribed by the physician to one of five sampled residents (Resident 1) who had a diagnosis of right shoulder replacement survey. This deficient practice had the potential to result in ineffectively managed pain for the resident and could result in unrelieved pain.

Inspectors wroteBased on interview and record review, the facility failed to provide residents written material with information regarding formulating an Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), for three out of 14 sampled residents (Residents 504, 250 and 252) investigated for Advance Directives. These deficient practices violated the resident's right to be fully informed of the option to formulate an Advance Directive and had the potential to cause conflict due to a lack of communication regarding the resident's wishes about his medical treatment and delay care in an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow menu as written for residents on pureed diet (food that residents cannot normally chew) as evidenced by: 1. The residents on pureed diet received less food than residents on regular diet. 2. The residents on pureed diet received five ounces of the lasagna instead of eight ounces per menu. This deficient practice had the potential to result in weight loss due to inadequate caloric intake and delay recovery from illness or injury for 11 residents who were on puree diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Frozen foods and nutrition supplements thawing in the walk-in refrigerator with no thaw (frozen to liquid state) date or use by date. 2. Expired milk cartons in the walk-in refrigerator and expired boxes of food items in dry storage area was not properly disposed. 3. Unknown food items with no labels and date in the walk-in freezer and unknown items with no label and date in the residents' refrigerator. 4. One fruit cocktail can with side dented in the dry storage room was not properly disposed. 5. The can opener blade had dried black residue with the potential to harbor harmful bacteria that were not easily cleanable. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by: 1. Failing to clean and disinfect the glucometer (a small, portable machine that's used to measure how much glucose [a type of sugar] is in the blood) before and after using with one (Resident 18) of two sampled residents observed during medication administration. 2. Failing to clean and disinfect the blood pressure monitor (a device used to measure blood pressure, composed of an inflatable cuff to collapse and then release the artery under the cuff in a controlled manner) before and after use for one (Resident 14) of two sampled residents observed during medication administration. 3. Failing to ensure a resident's oxygen tubing was not on the floor for one (Resident 505) out of four sampled residents investigated for infection control. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a dignity bag (a cover for a catheter bag, used to protect one's dignity) to cover a resident's indwelling catheter (a tube inserted into the bladder allowing urine to drain from the bladder) drainage bag (bag used to collect urine) for one (Resident 84) out of one resident sampled for dignity. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect Resident 21's back brace (device used to support the lower back) from loss or theft, for one of one sampled residents. This deficient practice had the potential to result in limited functional movement and restricted participation in activities for Resident 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Registered Nurse 2 (RN 2) verified gastrostomy tube (g-tube - a tube inserted through the belly that brings nutrition directly to the stomach) placement before administering medications, as indicated in the policy, for one (Resident 507) out of six sampled residents observed for medication administration. This deficient practice had the potential to result in the resident not receiving his medications.

Inspectors wroteBased on observation, interview, and record review, the facility: 1. Failed to provide a resident with heel protectors (a medical device usually constructed of foam, air-cushioning, gel, or fiber-filling, and is designed to minimize or remove weight on the heel) and failed to offload (minimize or remove weight placed on the foot to help prevent and heal ulcers) the resident's heels, as ordered by the physician, for one (Resident 43) out of four sampled residents investigated for pressure ulcer/injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin). This deficient practice had the potential to increase the resident's risk of developing a pressure ulcer. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor nutritional parameters for Resident 1's insidious weight loss (gradual, unplanned progressive weight loss over time) for one of one sampled resident (Resident 1). This failure had the potential to result in continued undesirable weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility: 1. Failed to provide a resident with a sack lunch while at the dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) center for one (Resident 40) out of two sampled residents investigated for dialysis. This deficient practice had the potential to cause discomfort to the resident and increase the resident's risk of not getting enough nutrients. 2. Failed to ensure a reliable transportation to the dialysis center was available for one (Resident 252) out of two sampled residents reviewed under the care area of dialysis. This deficient practice resulted in Resident 252's missing two scheduled dialysis treatment with the dialysis center and may have contributed to resident's transfer to the general acute care hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of medication error rate of five percent (5 %) or greater, as evidenced by the identification of five medication administration errors out of 29 opportunities (observations during medication pass) for error, to yield a cumulative error rate of 17.24 % for one (Resident 507) out of six sampled residents observed during medication administration. Registered Nurse 2 (RN 2) crushed all five medications and administered them all together at once when giving medications via gastrostomy tube (g-tube -a tube inserted through the belly that brings nutrition directly to the stomach) for Resident 507. This deficient practice had the potential to result in medication interactions, rendering them less effective for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's vancomycin (antibiotic medication used to kill bacteria in the intestines) was stored inside a refrigerator, as indicated on the label, for one (Resident 507) out of ten residents on antibiotics (medicines that fight infections caused by bacteria in humans and animals by either killing the bacteria or making it difficult for the bacteria to grow and multiply). This deficient practice had the potential to render the resident's antibiotic less effective.