Beverly Hills Rehabilitation Centre

Inspectors wroteBased on interview and record review the facility failed to ensure the facility's policy and procedures (P&P) for indwelling urinary catheter (foley catheter, is a flexible tube inserted into the bladder to drain urine, held in place by a small, water-filled balloon) were followed for two of four sampled residents (Resident 1 and 4) by failing to ensure:1. Urine characteristics were documented on the Weekly Summary Note for Resident 1 and 4, and2. A foley catheter change procedure was documented in the medical record for Resident 1. These failures resulted in incomplete and inaccurate documentation in the medical record and had the potential to affect the residents' foley care and monitoring for signs and symptoms of infection.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed transmission-based precautions (rules to prevent spreading infections) in accordance with facility policy and infection prevention standards to prevent the spread of infection, by failing to: 1. Staff properly donning (wearing) the required personal protective equipment ([PPE] - gloves, gowns, goggles, face masks) before entering the room of Resident 3 who was on contact isolation (infection control measures, requiring staff and visitors to wear gowns and gloves prior to entry),2. Develop and implement a care plan addressing contact isolation precautions for Resident 3. These deficient practices placed residents, staff, and visitors at risk for exposure to and transmission of infectious organisms.

Inspectors wroteBased on interview and record review the facility failed to ensure blood glucose (sugar) monitoring (process of measuring your blood sugar levels) three times a day and Levemir insulin (medication to use to manage high blood sugar in people diabetes) was transcribed accurately upon admission for one of nine sampled residents (Resident 1). These deficient practices had the potential to delay knowledge of or lead to hypoglycemic (low blood sugar level) or hyperglycemic (elevated blood sugar level) episodes and resulted in Resident 1 not having her blood sugar checked throughout the day as indicated in the interfacility transfer form from the General Acute Care Hospital (GACH), as well as, not receiving long-acting insulin for five (5) days at the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate and sufficient nursing staff to meet the needs of three of 28 sampled residents (Resident 61, Resident 76, and Resident 171). These failures had the potential to result in the inadequate availability of nursing services to assure resident safety and attainment of the highest practicable, physical, mental, and psychosocial well-being of each resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to follow infection control practices by failing to:1. Ensure Resident 186's sitter (refers to a caregiver who provides supervision and companionship to patients in healthcare settings) had proper personal protective equipment (PPE - garments designed to protect the wearer from injury or infection) [DATE] at 9:53 AM for Resident 186 who was on enhanced barrier precautions (EBP - infection control measures used in healthcare settings to reduce the spread of multidrug-resistant organisms [MDROs, bacteria that are resistant to one or more classes of antimicrobial agents]). 2. Ensure not to have expired hand sanitizer, disposal COVID-19 (a respiratory illness that can spread from person to person) testing kits, and disposable hand gloves in the facility's hallways, storage room, and medication carts. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care in a manner that maintained or enhanced the dignity and respect for one of two sampled residents (Resident 168) as evidenced by failing to ensure Resident 168's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag (a bag designed to collect urine drained from the bladder via a catheter) was covered with a privacy bag (a cover that discreetly conceals a urine drainage bag from public view). This failure had the potential for Resident 168 to experience psychosocial distress (a state of emotional suffering characterized by feelings of sadness, anxiety (nervousness), and other negative emotions) and violated Resident 168's right to be treated with dignity (the state of being worthy, honored, or respected).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to provide a Physician Orders for Life-Sustaining Treatment (POLST - a document that outlines a seriously ill patient's preferences for medical treatment, particularly at the end of life) to one of one sampled resident (Resident 186). This failure had the potential not to follow Resident 186's wishes for end-of-life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to develop a care plan for one of one sampled resident (Resident 175) who had a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). This failure had the potential for Resident 175 not to receive the necessary care and services for the diagnosis of depression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the appropriate Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) settings for two of five sampled residents (Resident 146 and Resident 205). These failures had the potential to cause harm to Resident 146 and Resident 205 by increasing the residents' risk of skin breakdown and development of pressure ulcers/injuries (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services to provide respiratory care for four of four sampled residents (Resident 14, Resident 28, Resident 170, and Resident 175) by failing to ensure: 1. To label and date the oxygen (a chemical element, a gas that is colorless, odorless, and tasteless and a key component of the air we breathe) tubing according to physician's order for Resident 14. 2. To display a precaution sign on the door for Resident 170 who received continuous oxygen. 3. To provide a date for the humidifier (a medical device that adds moisture to oxygen delivered during oxygen therapy) for Resident 28 and Resident 175. These failures placed Resident 14, Resident 28, Resident 170, and Resident 175 at risk for respiratory infection and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of ten sampled residents (Resident 37) received Balsalazide Disodium (medication used to treat ulcerative colitis [a condition which causes swelling and sores in the lining of the colon [large intestine] and rectum]) 750 milligrams (mg, a unit of measurement) with meals as ordered. This failure had the potential for Resident 37 to experience an upset stomach and pain.

Inspectors wroteBased on interview and record review the facility failed to ensure one of five sampled facility staff Certified Nursing Assistant 1 (CNA 1) maintained the necessary qualifications for employment at the facility. This failure had the potential to result for CNA 1 not to have the knowledge and qualifications necessary to care for the facility's residents and placed the residents at risk for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device that alerts healthcare providers that the patient needs assistance) was within reach for two of 28 sampled residents (Resident 25 and Resident 164)This deficient practice had the potential to result in delay in meeting Resident 25's and Resident 164's needs for assistance.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure one of four sampled residents (Resident 1)'s medications were not left at bedside after administering and documented according to facility's policy and procedures (P&P) titled, Administering Medications. This deficient practice increased the risk for accidents, unintended complications from receiving more or less than the required medications dose and jeopardized resident's health and safety by failing to administer necessary medications in accordance with the physician order.

Inspectors wroteBased on observation, interview and record review the facility failed to have one of four exit doors on the resident floors armed with an alarm that would sound when it was being opened. The failure had the potential to lead to a resident elopement (the act of leaving a facility unsupervised and without prior authorization) or accident.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infection (UTI- an infection in the bladder/urinary tract) for two of two sampled residents (Resident 2 and Resident 3) by failing to ensure resident's indwelling urinary (foley) catheters (a hollow tube inserted into the bladder to drain or collect urine) were placed below the level of the bladder at all times. This deficient practice had the potential to result or resulted in urinary tract infections for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident assessment and documentation were complete concerning resident's death for one of three sampled residents (Resident 1) by failing to implement facility's policy and procedure (P&P) titled, Death of a Resident when Resident 1 expired on [DATE]. This deficient practice resulted in incomplete assessment and documentation for Resident 1 required per facility's policy and procedure upon death.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control measure and prevention by failing to 1. Ensure the staff wear a gown to have a complete personal protective equipment (PPE-mask, gown, eye protection, gloves) before providing close-contact care for resident on Enhanced barrier precautions during high contact resident care activities. 2. Perform proper hand hygiene including changing gloves in between procedure while doing treatment care for three of three sampled residents (Resident 1, 2, and 3) per facility policy. These deficient practices have the potential to result in the spread of disease and infection to other residents, visitors, and staff.

Inspectors wroteBased on interview, and record review, the nursing staff failed to revise a care plan for at risk of bleeding and hospitalizations for one of four sampled residents (Resident 1), who had bleeding and emesis (the action or process of vomiting) on several occasions. This deficient practice had the potential to place Resident 1 at risk for recurrent bleeding and hospitalizations.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper care for one of one sampled resident (Resident 1)'s peripheral intravenous (PIV-a small, flexible tube placed into a small vein for intravenous therapy such as medication fluids) line and site by failing to ensure labeling with date on the PIV site; assessing/ monitoring PIV site with proper documentation and timely removal of PIV when IV therapy has been discontinued for Resident 1. These deficient practices had the potential to place residents at risk for developing infections at the IV site which could also lead to sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had history of falls and a diagnosis of dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning that interferes with doing everyday activities) received the necessary care needs and services by failing to: -Identify and develop an appropriate care plan for Resident 1's dementia through an Interdisciplinary Team (IDT) approach, with appropriate interventions including implementation of individualized care and maximizing the resident's safety. -Implement a bed alarm or provide supervision for Resident 1. As a result, on 10/20/2024, Resident 1 was found on the floor of her room and there was no proper staff assessment hours after the fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive assessment was completed after one sampled resident (Resident 1) had a fall on 10/20/2024. Resident 1 had a bruise and a cut on the right eye, but there was no documentation from the staff regarding the injury. This deficient practice placed Resident 1 at an increased risk for a delay in treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection prevention and control practices and implement interventions to prevent and control the spread of infections in the facility by failing to: a. Fit test (a test protocol conducted to verify that a respirator is both comfortable and provides the wearer with the expected protection) one of three Licensed Vocational Nurses (LVN 1) for the correct N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles). b. Ensure eight of eight staff members (Director of Nursing [DON], Infection Prevention Nurse [IPN], Registered Nurse Supervisor [RNS] 1, LVN 1, LVN 3, Certified Nursing Assistant [CNA] 1, CNA 2, and the Desk Nurse [DN]) wore the correct designated N95. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan timely for three of 29 sampled residents (Residents 117, Resident 51, and Resident 136). Resident 117, who was receiving occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) services, did not have a care plan for OT treatment. Resident 51 did not have a care plan for the Hoyer Lift during transfer and Resident 136 did not have an Out On Pass care plan. These deficient practices caused an increased risk in accidents leading to harm and there was a lack of individualized care effecting the services provided to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of three sampled residents (Resident 144, Resident 39 and Resident 294), who received dialysis (process of removing waste products and excess fluid from the body) treatment received care and services in accordance with the professional standards of practice, by failing to: -Document Resident 294's assessment in the dialysis communication record. -Communicate with the resident's dialysis center about Epogen (a medication to treat anemia caused by chronic kidney disease) being administered during dialysis treatment for Resident 39 and Resident 294.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an effective pest control program when a fly was observed in the kitchen area. This deficient practice had the potential for residents at the facility to be at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on interview and record review, the facility failed to ensure an advance directive acknowledgement form (a 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) was complete and in the resident's medical chart for one of seven sampled resident (Resident 133). This deficient practice had the potential to result in the facility not honoring the resident's medical decisions regarding end-of-life treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold notification (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) in writing, at the time of transfer to the hospital for one of three sampled residents (Resident 61). This deficient practice denied Resident 61 or the Responsible Party (RP) of being informed of the resident's right to have the facility hold and reserve his bed while absent from the facility.

Inspectors wroteBased on interview and record review, the facility failed to update one of 29 sampled residents (Resident 56) physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) and occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person ' s capability to participate in everyday life activities) care plans to reflect changes in the PT and OT services. This deficient practice had the potential for Resident 56 to receive incorrect services and minimize the facility's ability to review the effectiveness of PT and OT services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were provided a communication device or board with the language that the resident was able to understand for one of one sampled resident (Resident 133). This deficient practice prevented the resident from communicating with the staff and had the potential to delay receiving the care/treatment the resident needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain a physician's order for a low air loss mattress (LALM) and to maintain the correct setting of a LALM for one of three sampled residents (Resident 128). This deficient practice had the potential to result in the failure of delivery of necessary care to maintain the skin integrity (the health of skin) of Resident 128.

Inspectors wroteb. A review of Resident 19's admission Record indicated the facility admitted the resident on 6/5/24 with diagnoses including muscle weakness (decrease in muscle strength), difficulty in walking, and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Resident 19's Physical Therapy Care Plan dated 6/6/2024, indicated a goal for the resident for wheelchair mobility to be improved. The Care Plan indicated interventions for wheelchair mobility training but did not include ensuring foot rests must be applied during wheelchair use. A review of Resident 19's Decreased Functional Mobility Care Plan dated 6/6/2024, indicated a goal for the resident to improve activities of daily living (ADL) skills. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was an emergency drug supply (E-Kit) usage or administration log. The facility also failed to ensure there was wastage documentation of a controlled drug removed from the E-Kit. These deficient practices had the potential of drug diversion and / or medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper storage of medications for one of 10 sampled residents (Resident 76), when a bottle of Vitamin C (a nutrient that is vital to the body's healing process) was at the bedside. This deficient practice had the potential for Resident 76 to take medications without the supervision of staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards of practice by not labeling several food items with received date or use by date and failed to ensure safe and clean sanitary coffee cups were served to residents in accordance with professional standards for food service safety. These deficient practices had the potential for residents in the facility to be at risk for food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster areas were maintained in a sanitary manner. a. Two of four garbage dumpsters were overfilled with plastic bags and a cardboard box. b. One of four garbage dumpsters had the lid open. c. One of four garbage dumpsters lid was broken and cut in half. These deficient practices had the potential for harborage and feeding of pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide rehabilitative therapy services for two of seven sampled residents (Residents 136 and 117). Resident 136 did not receive a speech therapy (ST, profession that identifies, assesses, and treats speech, language, cognitive communication, and swallowing disorders) evaluation timely and the Occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) services were provided to Resident 117 without renewing an active physician's order for continuation of OT services. These deficient practices had the potential for a delay of therapy services and provision of therapy services without physician's approval.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the hospice residents binder had a copy of the Certification of Terminal Illness (CTI) for one sampled resident (Resident 8). This deficient practice resulted in failure to comply and coordinate with Hospice services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by not providing supplies for hand hygiene in the occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) gym for staff to perform hand hygiene before and after donning (putting on) and doffing (taking off) protective personal equipment (PPE, protective gloves, gowns, facemasks, and other equipment designed to protect the wearer from the spread of infection or illness) under enhanced barrier precautions (EBP, (intervention designed to reduce transmission of infectious organisms). The facility also failed to label oxygen tubing with date when it was changed for Resident 12. [...]

Inspectors wroteBased on interview and record review, the licensed nursing staff failed to offer the influenza as required or appropriate to one of five sampled residents (Resident 12). This deficient practice placed Resident 12 at increased risk of acquiring and/or transmitting the flu and pneumonia to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to offer the Coronavirus Disease (COVID-19) vaccination to two of five sampled residents (Resident 12 and 132). This deficient practice placed Resident 12 and Resident 132 at a higher risk of acquiring and transmitting the COVID-19 to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sample residents (Resident 1) was free from medication errors. This failure resulted in Resident 1 receiving a discontinued medication gabapentin (medication used for seizures or nerve pain) 100 mg (milligrams) that was not removed from the medication cart.

Inspectors wroteBased on interview and record review, the facility failed to provide protection from abuse by a family member for one of three sampled residents (Resident 1). Resident 1 reported to the facility staff and police that her Family Member slapped her in the face on 2/26/2024 and the next day the Family Member returned to the facility and was found in Resident 1's room. This deficient practice placed the resident at increased risk for further abuse from the Family Member.

Inspectors wroteBased on interview and record review, the facility failed ensure transportation to hemodialysis (is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) treatments for one of three sampled residents (Resident 3). This deficient practice resulted in Resident 3 missing six of the ten ordered Saturday dialysis treatments ordered starting 1/6/24.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from a psychotropic medication (drug that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). This failure resulted in Resident 1 receiving ordered medication Divalproex Sodium (medication used to treat seizures and also the manic [an abnormally elevated, extreme changes in mood, behaviors, activity and energy levels] phase of bipolar disorder [mental illness that causes extreme mood swings with emotional highs and lows]) Oral Tablet Delayed Release 125 milligrams (mg, unit of measurement).

Inspectors wroteBased on observation, interview and record review, the facility failed to answer the nursing station telephone on second floor in a timely manner. This failure resulted in the caller hanging in up before the call was answered and potentially delaying care.

Inspectors wroteBased on interview and record review, the facility failed ensure pressure injury (pressure ulcer/ injury or bed sore, an injury to the skin that develops over bony areas of the body from prolonged pressure to the area) precautions were followed for one of three sampled residents (Resident 1). By failing to: 1. Failing to accurately assess the resident ' s risk for pressure sore ' s upon admission on [DATE]. 2. Failing to develop a care plan for pressure sore on admission to the facility on [DATE]. 3. Follow care plan intervention for pressure reducing mattress started on 10/29/24 for decline in pressure sore. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call lights were functioning properly for three of five sampled residents (Residents 3, 4 & 5). This failure resulted in Residents 3, 4 and 5 not having a properly functioning call light to use in case they needed to call staff for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the plan of care for peripherally inserted central catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart ) was followed for one of five sampled residents (Resident 2) by failing to ensure the PICC line dressing remained intact. This failure had the potential to result in Resident 2 being exposed to PICC line infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) was given a physician ordered Zolpidem Tartrate (medication used for insomnia [sleep disorder]) timely. This failure resulted in Resident 2 having to wait until the early morning hours (3:25 am) to receive the medication she had requested at her bedtime (11:00 pm).

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive and resident-centered care plan regarding a resident ' s actual fall for one of five sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for subsequent falls and possible injury.

Inspectors wroteBased on interview, and record review, the facility failed to implement the facility's policy and procedure during a change in a resident's condition or status to inform resident's responsible party for one of six sampled residents, Resident 1. This deficient practice violated the resident and responsible party the right to be notified and participate in the changes to the plan of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality by failing to implement the facility's policy and procedure titled, Assessing Falls and Their Causes, to complete an incident report for resident falls . the incident report form should be completed by the nursing supervisor on duty at the time for one of six sampled residents, Resident 1. This deficient practice resulted in Resident 1's not receiving proper assessment and monitoring after he had an unwitnessed fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 2), was transferred from the bed to a wheelchair using a two-person assist by using a Mechanical lift (sling lift, an assistive device that allows residents to be transferred between a bed and a chair, by the use of electrical or hydraulic power). This failure had the potential to place Resident 4 at risk for falls or injury possible fracture while being transferred from the bed to a wheelchair solely by Certified Nursing Assistant (CNA 1).

Inspectors wroteBased on interview and record review the facility failed to offer and/or provide the pneumococcal (bacteria that can cause infections including pneumonia [PNA, inflammation of the lungs] and Coronavirus disease (COVID-19, a disease that is very contagious and spreads quickly) immunizations (protection against a disease through vaccination) for three of five sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for the residents to infected with pneumonia and COVID-19.

Inspectors wroteBased on interview and record review the facility failed to ensure the infection preventionist (IP, professionals responsible for the infection prevention and control program) complete 10 hours of continuing education (CE) on an annual basis. This failure had the potential for the IP to not be up to date with the latest infection control thus affecting the residents and staff in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to supervise and ensure activities of daily living (ADL- mobility, positioning, nutrition, personal hygiene, grooming, toileting, bathing and bowel and bladder) was provided for three of three sampled residents, (Residents 1, 2 , and 3). The facility determined Residents 1, 2, and 3 were dependent on staff for ADL. These deficient practice resulted in: 1. Residents 1, 2 and 3 remaining in wet or soiled incontinent briefs on 9/5/2023 during the 7 a.m. to 3 p.m. shift. 2. Residents 1 and 2 had an odor that smelled like urine on 9/5/2023 3. Resident 3 had brownish gray crust like substance was stuck all on the lips, mouth, and tongue on 9/5/2023.

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 when: 1) Sanitizer concentration level in a sanitizer bucket in the kitchen was measured below 150 ppm (parts per million - usually describes the concentration of something in water or soil). 2) [NAME] 1 failed to wash hands prior to handling cleaned kitchen equipment after touching soiled kitchen equipment. These deficient practices had the potential to result in food-borne illness (any illness resulting from the spoilage of contaminated food, bacteria-germs, viruses, or parasites that contaminate food, as well as toxins [poisons]) in 100 of 104 residents who consumed the food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interviews and record review, the facility failed to employ sufficient staff with the needed competencies and skills sets to carry out the functions of the food and nutrition services when Dietary Aide 1 (DA 1) did not know how to manually wash dishes properly. This failure had the potential to result in unsafe and unsanitary food preparation and production, and a potential for food-borne illness in 100 of 104 residents who consumed the food prepared by the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the facility's answering the Call light policy and procedures and ensure residents' call light device was within reach for three of 43 sampled residents (Residents 30, 64 and 66). This deficient practice had the potential to negatively impact the psychosocial (Social factors and individual thought and behavior) well-being of the residents or result in delayed provision of services for Residents 30, 64, and 66.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement activities of daily living (ADLs) policy and procedures and ensure one of 21 sampled residents (Resident 57) was showered, groomed, and provided personal hygiene for 11 days from 3/4/2022 to 3/15/2022. This deficient practice resulted in Resident 57 not feeling uncomfortable and untidy.

Inspectors wroteBased on observation, interview, and record review, for six of six sampled residents (Residents 2, 5, 20, 52, 58 and 64), the facility failed to ensure staff: 1. Implemented specialty mattress-pressure relieving devices policy and procedures 2. Understood how to operate and the significance for correct low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) settings consistent with manufacturer's guide. Residents 2, 5, 20, 58 and 64) had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. These deficient practices increased the risk to develop pressure injury (bed sore-localized damage to the skin and or underlying soft tissue over bony prominence) and poor wound healing of the existing pressure ulcer for Residents 2, 5, 20, 52, 58 and 64 at.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient staffing to accommodate residents' needs by not answering the call light timely for six (6) of 43 sampled residents (Resident 29, 45, 56, 57, 83 and 240). This deficient practice resulted in residents not receiving needed services timely and efficiently, which could potentially lead to falls and/or injuries negatively affecting the health and the quality of life of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1) follow portion size as written on the menu for residents on mechanical soft and pureed diet. 30 of 104 residents on mechanical soft and pureed diet received inaccurate portion. 2) follow menu as written for the secondary soup of the meal. Residents who preferred secondary soup of the meal received an unapproved substituted menu. This deficient practice had the potential for residents to receive wrong protein and caloric intake when not following the menu, which could result in undernutrition or overnutrition and further compromise their health and well-being

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 when: 1) Multiple food items in the designated refrigerators for resident food in all dining rooms were not labeled/dated per policy; 2) A cup of juice was stored in the refrigerator in a vacant resident room; 3) Resident food refrigerator in the dining room on the second floor was measured at 50°F. These deficient practices had the potential to result in food-borne illness (any illness resulting from the spoilage of contaminated food, bacteria-germs, viruses, or parasites that contaminate food, as well as toxins [poisons]) for the medically vulnerable residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infections in the facility when: 1. Three (3) sampled staff members (Certified Nursing Assistant [CNA 2], Registered Nurse [RN 2], and CNA 4) did not use proper personal protective equipment (PPE-such as gloves, gown, mask, face shield) for rooms on contact isolation precautions (as everyone coming into a resident's room is asked to wear a gown and gloves). 2. A visitor did not take off PPE before exiting Resident 140's room in yellow zone (area designated for residents who are awaiting COVID-19 test results and may have symptoms of the infection) 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the facility's assistance with meals, urinary catheter care, and quality of life-dignity policies and procedures to ensure residents were provided with care that promoted and or enhanced dignity and respect by failing to ensure: 1. Urinary catheters (a flexible tubes used to empty the bladder and collect urine) bags remained covered for four of five sampled residents (Residents 58, 59, 77, and 83) 2. Staff did not stand over residents while eating for two of five sampled residents (Residents 53 and 77). These deficient practices resulted in Resident 58 feeling embarrassed, and had the potential for psychosocial harm, lowered self-esteem, rushed feeling, and violated the right to be treated with dignity for Residents 53, 58, 59, 77, and 83.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were updated to indicate that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for three of 43 sampled residents (Residents 52, 64 and 66). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Residents 52, 64, and 66.

Inspectors wroteBased on observation, interview and record review, the facility failed to repair a broken window screen and, provide a safe and homelike environment for two of 21 sampled residents (Residents 59 and 75) by failing to ensure the window screen is not broken and in functional (working) condition. This deficient practice had the potential to negatively impact the quality of life and increased risk for physical discomfort for Residents 59 and 75.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the licensed nursing staff met professional standards of quality during medication pass for one of four sampled residents (Resident 47) when: 1. Potassium Chloride (KCL - a medicine used to prevent or treat low potassium levels in the body) 10 milliequivalents (mEq) extended release (ER) medication was crushed, not following the manufacturer's guidelines. 2. Resident 47's identification was not checked prior to medication administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that nasal cannula (NC-a device used to deliver supplemental oxygen placed directly on a resident's nostrils) was dated and replaced every seven days and that Licensed Vocational Nurse 8 (LVN 8) was knowledge when to exchange/replace NC for two of two sampled residents (Residents 2 and 68). This deficient practice placed Residents 2 and 68 at risk to develop respiratory infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication error rates are not 5 percent or greater. During medication pass observation for Resident 47, a total of two medication errors were observed out of 29 opportunities, which resulted to a medication error rate of 6.9%. These deficient practices had the potentials to administrate the medications to wrong residents, to cause medications to loss their potency and to increase risks for harmful drug interaction, resulting negative impact on residents' health and well-being. Cross Reference:

Inspectors wroteBased on observation, interview and record review, facility failed to ensure: 1. medications requiring refrigeration were not stored in one of two inspected medication cart. 2. medications were stored and locked in the medication cart. These deficient practices of failing to store medications in a locked medication cart and per the manufacturer's requirement increased the risk for the residents receiving medications that had become ineffective or toxic due to improper storage, possible medication theft, and unapproved medication use, which could lead to health complications resulting in hospitalization or death.