Bixby Towers Post-Acute Rehab

Inspectors wroteBased on interview, and record review, the facility's staff failed to immediately initiate Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to one of five sampled residents (Resident 1), when Certified Nurse Assistant (CNA) 1 and CNA 2, who were CPR certified (successfully completed a training course and received a credential that qualifies a person to perform CPR), failed to check Residents 1's pulse, breathing and obtain immediate assistance to initiate CPR, activate a code blue (a specific code used to signal a patient who is having a life threatening medical emergency, typically a patient experiencing sudden cardiac arrest [when the heart stops] and/or respiratory arrest [when a person stops breathing), and call 911 on [DATE] at approximately 7:30 a.m., when Resident 1 was found unresponsive (a [...]

Inspectors wroteBased on interview, and record review, the facility's QA/QAPI ([Quality Assurance/Quality Assurance Performance Improvement] data driven proactive approach to improvement used to ensure services are meeting quality standards) committee failed to ensure continued oversight of the facility's IJ Removal Plan ([IJRP] a plan to immediately correct the deficient practices) of a deficient practice identified during a previous abbreviated survey ([DATE]) that resulted in an Immediate Jeopardy ([IJ] a situation in which a facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) being called. [...]

Inspectors wroteThe facility failed to ensure the bed for one of three sampled residents (Resident 2) was locked at all times. This deficient practice resulted in Resident 2 feeling unsafe when his bed moved on several occasions when he attempted to get in it. This deficient practice had the potential for Resident 2 to be subjected to falls and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records for one of three sampled residents (Resident 1) was accurately documented to reflect activity visits by the facility's activity staff, the activity provided, and Resident 1's participation level and response to the activities. This deficient practice resulted in the inability to track activity provided to Resident 1 and had the potential for Resident 1 be socially isolated and suffer from depression and loneliness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide consistent monthly billing statements, maintain appropriate billing record practices, and ensure financial privacy for two of three sampled residents (Resident 2 and Resident 3). These deficient practices resulted in Resident 2 and Resident 3 being unable to receive clear, accurate, and confidential billing information regarding charges and account balances while in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to implement its policy and procedure (P&P) titled Cardiopulmonary Resuscitation (CPR an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) which required staff to immediately activate a Code Blue (announcement used in facilities when a resident is experiencing medical emergency), call 911(phone number used to contact the emergency services), and provide basic life support (BLS, a set of emergency medical procedures designed to sustain life by maintaining breathing and circulation), including CPR for one of three residents (Resident 1) who was a full code (a medical term indicating a patient's consent to receive all possible life-saving measures in the event of a cardiac arrest [when the heart stops breathing] or respiratory arrest [when a person stops breathing]). [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure staff were competent in basic life support (BLS, a set of emergency medical procedures designed to sustain life by maintain breathing and circulation) when Resident 1 was found pulseless by Certified Nursing Assistant (CNA) 1 on [DATE]. This failure resulted in delay in initiating Cardiopulmonary Resuscitation (CPR an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to Resident 1 when Resident 1 was found unresponsive and no pulse on [DATE] at 10:30 p.m. Resident 1 was pronounced dead at 11:12 p.m.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident, who had developed behavioral symptoms manifested by increased confusion, cursing staff, yelling at staff, and refusing personal care and treatment, had a medical doctor's (MD) order for urinalysis with cultures and sensitivity (a urine diagnostic test used to detect presence of bacteria) carried out to determine the presence of urinary tract infection (UTI- an infection in the bladder/urinary tract) and to prevent a delay in treatment for one of one sampled resident (Resident 100). The facility failed to:1. Ensure Resident 100's urine was collected for urinalysis with cultures and sensitivity as ordered by the resident's MD on 7/4/2025 due to Resident 100's onset of behavioral symptoms (cursing staff, yelling at staff, refused care and refusal of breathing treatment) to rule out (exclude) UTI.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse/neglect policy and procedures for two of three sampled residents (Resident 15 and Resident 74). Facility failed to:1. Report Resident 74's allegation of Certified Nursing Assistant (CNA 1) physical abuse. 2. Report Resident 15's fracture (broken bone) of unknown origin to California Department of Public Health ( CDPH), law enforcement, or the Ombudsman. These deficient practices resulted in a delay of an investigation and potentially increased the risk of abuse, neglect, and mistreatment of other residents. Findings1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of nine sampled residents (Residents 21 and 36) received appropriate services to prevent a decline in the range of motion (ROM, full movement potential of a joint) and mobility by failing to:1. Initiate a Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) program timely for Resident 21's lower extremities (hip, knee, ankle, feet) for passive range of motion (PROM, movement at a given joint with full assistance from another person) upon completion of Rehab Joint Mobility Assessment ([JMA] evaluates the range of motion, flexibility, and overall health of a joint) on 7/17/2025. 2. Complete a quarterly Rehab JMA for Resident 36's upper extremities (BUE, shoulder, elbow, wrist/hand) on 9/20/2024.

Inspectors wroteBased on interview and record review, the facility failed to ensure their staff had:1. Competence on reporting alleged allegations of abuse and injury of unknow origin by failing to: 1a. Ensure an injury of unknown origin was reported to the California Department of Health (CDPH), the Ombudsman, and law enforcement and investigated for Resident 15.1b. Ensure an abuse allegation was reported to CDPH, the Ombudsman, and law enforcement and investigated for Resident 74. These deficient practices potentially increased the risk of abuse, neglect, and mistreatment of other residents. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure:1. Uncovered bowl of dry cereal dated 7/21/2025 to 7/25/2025 was not stored in the dry storage room uncovered passed the use by date.2. Emergency food supply of six cans of corned beef hash with an expiration date of 12/2023 and a box of canned pulled chicken with an expiration date of 6/1/2025 were thrown away. These failures had the potential to result in the residents developing food borne illnesses ( illnesses caused by consuming contaminated foods or beverages) that could lead to other serious medical complications and hospitalizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate records for two out of 10 sampled residents (Resident 21 and Resident 52) by failing to:1. Indicate how long Resident 21 could wear a left elbow extension (straightening the elbow) splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and left resting hand splint during Restorative Nursing Aide program (RNA, nursing aide program that helps residents to maintain their function and joint mobility) treatment. 2. Accurately indicate how long Resident 52 could wear a left knee splint during RNA treatment. These deficient practices had the potential to cause injury to Residents 21 and 52 due to wearing splints for too long (skin integrity and pain) or for too little time (decline in ROM).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain three of three electrical rehabilitation therapy (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) equipment for resident use. This deficient practice had the potential for injury to any resident using the therapy equipment.

Inspectors wroteThe facility failed to ensure one of two residents (Resident 99) foley catheter ( a medical device that helps drain urine from your bladder [drainage bag]- the bag attached to the end of the catheter that collects the urine) was covered with a dignity bag ( a cover or pouch designed to hide the urine collection bag) in accordance with professional standards and the residents' right to dignity. This failure resulted in potential embarrassment, compromised privacy, and a lack of respect for Resident 99's dignity.

Inspectors wroteBased on interview and record review, the facility failed to report an abuse allegation to the California Department of Health, the Ombudsman, and the law enforcement agency for one of three sampled residents (Resident 74), when Resident 74 reported to the Assistant Director of Nursing (ADON) that Certified Nurse Assistant (CNA) 1 physically abused her while providing her with personal care. This deficient practice had the potential to place other residents at risk for physical abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure (P&P) titled Abuse Prevention Program, dated 12/1/2022 by failing to investigate an abuse allegation for one of three sampled Residents (Resident 74). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) was resubmitted and documented correctly for two of two sampled residents (Resident 9 and Resident 52). This failure had the potential to result in Resident 9 and Resident 52 not receiving the necessary care and services they need.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan for one of three sampled residents (Resident 74) when Resident 74 reported to the Assistant Director of Nursing (ADON) that Certified Nurse Assistant (CNA) 1 physically abused her while providing her with personal care. This deficient practice resulted in failure in the delivery of necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure one of the sampled residents (Resident 36) was provided with incontinence care in a timely manner. This failure resulted in Resident 36 crying and left wet in urine for an hour.

Inspectors wroteBased on observation, interviews, record review, the facility failed to ensure the water pitcher was within reach for one of seven sampled residents (Resident 11). This failure had the potential to increase Resident 11's risk of dehydration (a condition that occurs when the body loses more fluids than it takes in, resulting in a depletion of water and electrolytes) and resulted in Resident 11 complaining of feeling thirsty.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a Physical Therapy ([PT] a rehabilitation profession that restores, maintains, and promotes optimal physical function) evaluation and treatment in accordance with a physician's order dated 7/17/2025 for Physical Therapy Evaluation and treatment for one of 10 sampled residents (Resident 21). This deficient practice had the potential to cause a decline in mobility and range of motion ([ROM] full movement potential of a joint) due to a delay in provision of PT services for Resident 21.

Inspectors wroteBased on interview and record review the facility failed to correct deficiencies during the prior recertification survey (inspections conducted by the California Department of Public Health (CDPH), Licensing and Certification Division, or its authorized entities, to ensure that healthcare facilities and providers maintain compliance with state and federal regulations and continue to meet the standards for their license or certification) dated 7/12/2024, for Resident Rights, Quality of Care, Food Safety and Infection Control. These failures had the potential to result in a loss of dignity, lack of quality of care, infection and food borne illness (a disease or infection that is transmitted through the consumption of contaminated food or beverages) for all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control precautions for two of three sampled residents (Resident 86 and. Resident 64.). Facility failed to:a. Ensure family members wore appropriate Personal Protective Equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environment) while visiting and assisting Resident 86.b. Implement enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms) for Resident 64. These deficient practiced had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for the spread of infection.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two resident ' s (Resident 1) cell phone was accounted for and kept safe in the facilty. This deficient practice resulted in Resident's1 cell phone missing. Findings During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of bilateral (both) knees, muscle weakness, dysphagia (difficulty swallowing), metabolic encephalopathy (problem in the brain), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS), (a resident assessment tool), dated 5/26/2025, the MDS indicated Resident 1 ' s cognition was severely impaired. [...]

Inspectors wroteBased on interview and record review the facility did not accommodate one of one resident 's (Resident 1) family member (FM 1) request by failing to ensure Resident 1 was fed and adult disposable diaper were checked prior to the administration of Ativan (medication to treat anxiety- feeling of fear, dread, and uneasiness) dose. These deficient practices had the potential to result in Resident 1's missed feedings and Resident 1 to sit in a soiled adult disposable diaper with urine or feces for extended periods.

Inspectors wroteBased on interview and record review the facility failed to provide toileting hygiene at least every 2 hours and as needed for one of three residents (Resident 1). The deficient practice resulted in Resident 1 to be left in a soiled adult disposable diaper for extended periods and had the potential to cause skin breakdown.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one residents (Resident 1) received an oral gratification diet (therapeutic feeding allows resident to experience limited oral intake while exercising the muscles for swallowing) three times a day as ordered by the physician from 6/1/2025 to 6/4/2025. This deficient practice had the potential to result in poor health outcomes and weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three of the five sampled staff (Receptionist 1, Certified Nurse Assistant 1, and Maintenance 1) wore an identification badge as indicated in the facility ' s policy. This deficient practice did not promote a culture of safety and transparency and violated residents ' right to know who was providing care and to be treated with respect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of four sampled resident ' s (Residents 3) call light (device that allows residents to request assistance from nursing staff) was within reach. This deficient practice resulted in a delay of care and services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an extended floor mattress (a thicker safety mat [a floor pad designed to help prevent injury should a person fall] designed to provide cushion and protection in the event of a fall) was placed on the floor next to the bed for one of three sampled residents (Resident 1) who was assessed at high risk for falls and who had a history of falling, per Resident 1 ' s Care Plan dated 3/5/2025 This deficient practice resulted in Resident 1 experiencing an unwitnessed fall (4/25/2025) and being found on the floor without an extended floor mattress in place as care planned (3/5/2025). This deficient practice had the potential to result in Resident 1 sustaining aninjury. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all nursing staff were trained on the proper use of the Tilt-in-space wheelchair (a type of wheelchair where the entire seat and backrest tilt backward as a single unit) prior to its use for one out of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for falls and/or injuries due to the nursing staff ' s lack of training.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1 ' s), Family Member (FM) 1 who was also the appointed Durable Power of Attorney (DPOA - a legal document where an agent is appointed to make financial, medical, and/or legal decisions on behalf of the appointor if they become unable to make rational decisions due to a mental or physical condition) was notified prior to Resident 1 ' s ophthalmology (a medical specialty focused on the medical and surgical care of the eyes and vision) and ear, nose and throat (ENT) appointment. These failures resulted in Resident 1 being seen by the ophthalmologist on 6/10/2024 and by the ENT on 11/14/2024, without the DPOAs knowledge. These failures also resulted in a violation of Resident 1 ' s rights.

Inspectors wroteBased on interview and record review, the facility failed to obtain the manufacturer ' s guidelines and maintain a Tilt-in-space wheelchair (a type of wheelchair where the entire seat and backrest tilt backward as a single unit) per the manufacturer ' s guidelines for one out of three sampled residents (Resident 1). This deficient practice had the potential place Resident 1 at risk for injury from improperly maintained equipment.

Inspectors wroteBased on interview, and record review, the facility failed to report an Influenza A (a contagious respiratory illness caused by the influenza virus, commonly known as the flu, that infects the nose, throat and lungs) outbreak (the occurrence of cases of disease in excess of what would normally be expected) to the California Department of Public Health (CDPH) immediately for two of 10 sampled residents (Resident ' s 9 and 10). This deficient practice resulted in CDPH not being aware of the Influenza A outbreak until 2/24/2025 (three days after Resident 10 tested positive for Influenza A) and the inability to investigate the outbreak. These deficient practices had the potential for pertinent information to be lost and/or forgotten, and more resident ' s who tested positive to go unreported.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident ' s rights were upheld for one of three residents (Resident 1) when Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation of inappropriate sexual behaviors and cleared to return to the facility on [DATE]. This deficient practice resulted in Resident 1 being denied readmittance to a facility where he had resided for approximately 38 days.

Inspectors wroteBased on interview, and record review, the facility (SNF B) failed to ensure residents were free from sexual abuse (non-consensual sexual contact of any type) for one of three sampled residents (Resident 2). The facility (SNF B) failed to: 1. Ensure Resident 1 did not sexually assault Resident 2. 2. Ensure Certified Nursing Assistant (CNA) 1 and CNA 2 did not leave Resident 1 and Resident 2 alone in the room after Resident 1 sexually assaulted Resident 2 once, thus allowing Resident 1 to sexually assault Resident 2 second time. 3. Ensure CNA 1 and CNA 2 followed the facility (SNF B)'s policy and procedure (P/P) titled, Abuse Reporting and investigation, dated 1/10/2024, which indicated if the suspected perpetrator is the resident, the residents will be separated so they do not interact with each other or with another resident. [...]

Inspectors wroteBased on interview and record review, the facility (SNF B) failed to ensure a resident, who had a history of schizophrenia (chronic mental illness that affects how a person thinks, feels, and behaves) with disorganized (jumbled, or do not make sense can cause problems with communication) thoughts, aggressive and inappropriate sexual behaviors, had behaviors under control for one of three sampled residents (Resident 1) to prevent Resident 1 from sexually assaulting Resident 2 two times on 10/8/2024. The facility failed to: 1. Ensure Resident 1was evaluated by a psychiatrist (a health practitioner that specializes in the diagnosis and treatment of mental illness) upon admission and as needed during the time he was a resident in the current Skilled Nursing Facility (SNF B). 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure 2 out of 2 staff members Licensed vocational nurse (LVN ) LVN 1 and LVN 2 were provided with abuse training prior to providing direct patient care. This failure had the potential to put the residents of the facility at risk for abuse.

Inspectors wroteBased on interview and record review, the facility ' s Quality Assessment and Assurance ([QAA] to develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) committee failed to ensure the facility ' s Medical Director attended the monthly meetings. This deficient practice has a potential for the QAA committee not to identify and to respond on the QAPI program that identifies systemic problems to improve services for the residents.

Inspectors wroteBased on interview and record review the facility failed to ensure 2 out of 2 staff members Licensed vocational nurse (LVN ) LVN 1 and LVN 2 were provided with abuse training prior to providing direct patient care. This failure had the potential to put the residents of the facility at risk for abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure a tracking system was maintained for staff participation and competency in the facilitiy's on- line learning program. This failure had the potential to put the resident ' s safety at risk when not maintaining a tracking system to ensure staff are completing and competent in the assigned on-line learning.

Inspectors wroteBased on interview and record review the facility failed to ensure: 1. The primary care physician (PCP) signed Resident 37's admission orders from the hospital to continue to make sure the facility provided the care needed during the stay in the facility for one of one sampled resident (Resident 37). This deficient practice has the potential to not provide Resident ' s 37 appropriate medical intervention during facility stay.

Inspectors wroteBased on interview and record review, the facility failed to make a follow up appointment for left leg surgery, with the Orthopedic surgeon (treats injuries and diseases involving muscles, bones, joints, ligaments, and tendons) in a timely manner ensure for one of five sampled residents (Resident 1) so Resident 1 could be cleared to continue receiving Physical Therapy (PT: help strengthen weakened muscle) services under skilled nursing services (medically necessary services such as PT and occupational therapy (OT: improving residents ability to perform activities of daily living). This deficient practice resulted in delayed treatment and services for Resident 1, placing the resident at a higher risk for further decline. [...]

Inspectors wroteBased on interview, and record review, the facility's nursing staff failed to monitor and assess urine output and urinary retention for a resident, who was at risk for urinary retention (difficulty completely emptying the bladder) due to a diagnosis of benign prostatic hypertrophy ([BPH] a condition that causes the prostate gland to enlarge making it harder for the bladder to push out urine and can lead to urinary retention and a urinary tract infection ([UTI] an infection in any part of the urinary system such as kidneys, bladder, ureters, and urethra) for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA 2) and CNA 3 reported to licensed nursing staff when Resident 1 had a dry diaper (no urine output) during their eight hour shift. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of three sampled residents (Resident 1), who was prescribed and administered an anti-psychotic medication (a class of medication primarily used to manage psychosis [a condition of the mind that results in difficulties determining what is real and what is not real) (Seroquel), that the medication was prescribed and administered for appropriate indications, detailed evidence of Resident 1's behavior(s) were documented, non-pharmacologic interventions were attempted and evaluated prior to the administration/continuance of the medication, physician, psychiatric and/or psychological and nursing evaluations were conducted and evaluated to determine if continued use of Seroquel was warranted. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two of 18 sampled residents (Resident 80 and 30), was treated with respect and dignity when: 1. Resident 80's bedside commode (a piece of furniture that looks like a chair but has a container in the seat) was left with stool (feces). 2. Certified Nursing Assistant (CNA 2) was standing while feeding Resident 30. These failures resulted in Resident 80 feeling sad and had the potential to affect Resident 80 and 20's self-worth.

Inspectors wroteBased on interview and record review the facility failed to ensure four of eleven sampled residents' (Resident 77,85,82,and 45) paper and electronic medical records (eHR) reflected documentation of advance directives (legal documents that allow you to spell out your decisions about end-of-life care ahead of time) and physician orders for life sustaining treatment (POLST, a legal form that records patients' treatment wishes in the event of a medical emergency) were discussed and written information were provided to Resident 77, 85, 82,and 45, and/or responsible parties. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), form CMS-10055 for two of three sampled residents (Residents 2 and 27) when residents continued to stay at the facility after the Medicare Part A coverage ended. This failure had the potential to result in responsible parties not being able to exercise their right to receive timely and specific notification.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to 1. Ensure an accurate count of a controlled medication (a drug or chemical whose manufacture, possession, or use is regulated by a government,) lorazepam (a medication used to treat mood disorder) for Resident 32 in the medication storage refrigerator on the third floor. 2. Ensure one open foil pack of arformoterol tartrate inhalation solution (a medication used to treat breathing problems) for Resident 447 was stored in accordance with manufacturer's requirements and labeled with an open date in the medication storage refrigerator on the second floor. 3. Ensure the storage of semaglutide (a medication used to treat high blood sugar) for Resident 53 was in accordance with manufacturer's requirements on the second floor. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe and sanitary food storage practices in the kitchen when: 1. Food items in the walk-in refrigerator had no open date label. 2. Ensure facility staff personal items were not placed near the food in the dry storage room. These failures 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 foodborne illness (illness caused by food contaminated with bacteria, viruses, and parasites).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 52) was provided a touch pad call light (enables residents with limited movement to call for help). This failure had Resident 52 to feel frustrated and had the potential for his needs not met which could result to delay of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to assess and monitor multiple skin discolorations for one of two sampled resident's (Resident 23), who was identified to be at high risk for bleeding. This failure had the potential for Resident 23 to have unassessed internal bleeding.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 18 sampled residents (Resident 71) received services and treatment to address hearing loss. This failure had the potential to result in Resident 71 not being able to effectively communicate with staff and understand care and services being given.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 18 sampled residents (Resident 92) who was assessed as high risk for fall was on the Falling Star Program per facility's Fall Prevention policy and procedure. This failure had the potential to result in Resident 92, sustaining another fall with injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of 18 sampled residents (Resident 87) was provided with dental services to ensure Resident 87 could eat adequately. This failure had the potential to result in Resident 87 losing weight.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 70) had their food preferences taken into consideration. This failure had the potential to result in Resident 70 having an undesirable weight loss when nutritional preferences were not being considered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not closing dumpster (a large trash container designed to be emptied into a truck) completely This failure had a potential to attract flies, insects, cats, and other animals to the dumpster area.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 28) was free from contracting an infection when the nebulizer (a respiratory [breathing] device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or mask) tubing was not stored securely in a bag (bag open) and was not on the floor. This failure had the potential to spread germs and bacteria from the floor to Resident 28.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for one of 18 sampled residents (Resident 58). This failure had the potential for Resident 58 to develop antibiotic resistance (not effective to treat infection) from prolonged or inappropriate antibiotic use.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Responsible Party (RP 2) for one of three sampled residents (Resident 2) was notified that Pro-Stat (a protein drink to promote wound healing) was prescribed to Resident 2 and administered to him from 1/1/2024 through 1/11/2024 and when a Change of Condition (COC) in Resident 2 's mental status occurred. These deficient practices resulted in RP 2 being unaware of Resident 2's change in status and the inability for RP 2 to be a full participant in Resident 2's health care decisions, RP 2's distrust, and frustration with the facility staff. This deficient practice had the potential for unwanted changes in Resident 2's health care to be made by the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to address the concerns of the resident council during the resident council meeting on 3/27/2024 regarding food being served cold and hard. This deficient practice resulted in food being served to residents with unacceptable temperatures, was distasteful and/or not eaten. This deficient practice had the potential for food borne illness to occur and unplanned weight loss.

Inspectors wroteBased on interview, and record review, the facility failed to ensure grievances filed by the Resident 2's Responsible Party (RP 2) for one of three sampled residents (Resident 2) were investigated and the findings made available to RP 2. This deficient practice resulted in RP 2 becoming frustrated and distrustful towards the facility's administrative staff and had the potential for Resident 2's care needs to go unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plan interventions for one of three sampled residents (Resident 2) were implemented when the nursing staff did not use two people when turning and repositioning Resident 2 during care. These deficient practices resulted in one staff turning and repositing Resident 2 and had the potential to result in injury while providing care.

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident rights were maintained for one of three sampled residents (Resident 2) when the facility failed to ensure Resident 2 received a shower or bed bath on days a shower was not provided. These deficient practices caused Resident 2 to feel unclean and had the potential to cause a decline in Resident 2's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a podiatry (foot doctor) consult after one of three sampled resident (Resident 1) was noted with bleeding under the nail bed of the left great toenail on 2/12/2024. As of 3/1/2024, eighteen (18) days after it was first identified, all of Resident 1's toenails were long, and podiatry has not assessed Resident 1's toenails. This deficient practice resulted in a delay of needed foot care services and had the potential to contribute to a negative physical and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received respiratory care of Continuous Positive Airway Pressure ([CPAP] a machine that uses mild air pressure to keep breathing airways open while you sleep) device mode every night shift as ordered by Resident 1's physician and: 1. Follow Resident 1's Physician's order dated 11/15/2023 which indicated oxygen (O2) at five (5) liters(l) per minute ([min] unit of measurement) via nasal cannula ([NC]a device that delivers oxygen through two thin plastic tubes inserted into the nose) continuously every shift for Chronic Obstructive Pulmonary Disease ([COPD] a group of lung diseases that block airflow and make it difficult to breathe) exacerbation. [...]

Inspectors wroteBased on interview, and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of seven sampled residents (Resident 6) by failing to consistently document Resident 6's bowel elimination. There were ten missed opportunities where Resident's 6's bowel movements was not documented, and the entry was left blank. This deficient practice had the potential to negatively impact the delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to schedule an interdisciplinary care conference, as requested by the responsible party of one of seven sampled residents (Resident 6). The deficient practice made Resident 6 and his responsible party to feel disregarded and disallowed to participate in the plan of care of Resident 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 6) was assisted by the Restorative Nursing Assistant (RNA) to perform range of motion exercises (activity aimed at improving movement of a specific joints) to his left and right upper extremities three times a week. This deficient practice has the potential for Resident 6 to negatively affect his joint function and integrity.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who resided at the facility for approximately six years, and was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment for confusion, disorientation (state of being confused or having lost your bearings), and an elevated heart rate, was readmitted to the facility after the resident was stabilized and cleared at the GACH to return to the facility for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1 remaining at the GACH for 7 days after Resident 1 was deemed appropriate for discharge back to the facility by the GACH but was denied readmission by the facility. [...]

Inspectors wroteFacility failed to provide information on advance directives (7, 27, 41)and did not obtain the advance directives from family when it was indicated the resident had one (Residents 6 & 19) C- Blessing Resident #7

Inspectors wroteBased on interview and record review, facility failed to provide at least twelve (12) hours of annual in-services for two of 5 nurse aides. This deficient practice had the potential for a knowledge, training, and certification deficit among the Certified Nursing Assistant (CNA) leading to inadequate resident care.

Inspectors wroteFacility failed to contact the physician following the pharmacist's recommendation for Residents 7 & 26.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1. Ensure that eleven (11) external medications had the opened date written on the container. This deficient practice had the potential for harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. 2. Ensure that one (1) Thera moisturizing body shield for a resident was not expired and one (1) Aspirin adult low dose enteric coated was not expired This deficient practice had the potential for harm to residents due to the potential loss of strength of the medication, and the potential for the residents to receive ineffective medication dosages. 3. Ensure that one (1) Phytoplex moisturizer nourishing cream had the Resident 19 name identified on the container. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Dishwasher staff has the competency to check the quaternary sanitizing solution (ammonium solution used for sanitizing surfaces) with the correct quaternary test strip according to manufacturer's instructions for one of three Dishwasher staff observed. This deficient practice had the potential for inaccurate interpretation of the effectiveness of the quaternary solution, which can lead to a potential for not adequately sanitizing pots and pans, and kitchen surfaces to prevent the outbreak of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute and serve food in accordance with professional standards for food service safety when: 1. Sweet potato fries, frozen apples, frozen French fries was stored inside the walk-in freezer and milk was stored inside the reach in refrigerator that was not labeled on date opened. 2. Ensure stuffed bell peppers were discarded on the date indicated on the label. These failures placed residents at risk for foodborne illnesses (illnesses caused by consuming contaminated food or drink) from consuming potentially contaminated food (unclean) and exposure to harmful pathogens (bacteria or viruses that can cause illness).

Inspectors wroteBased on interview, and record review the facility failed to offer the pneumonia (PNA) (an infection of the lungs) vaccinations (medication to prevent a particular disease) for 5 of 12 sampled residents (Resident 3, 19, 41 and 93) and revaccination for Resident 26. This deficient practice placed Resident 3, 19, 26, 41 and 93 at a higher risk of acquiring and transmitting the pneumonia to other residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a patient-centered care plan for the use of oxygen (a colorless, odorless and tasteless gas) developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for one out 1 resident (Resident 93). This deficient practice placed Resident 93 at risk for not having interventions for the use of Oxygen and interventions for shortness of breath (SOB).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow Resident 26 diet order and ensure a correct diet was served to Resident 26. These failures have the potential to place residents at risk for Resident 26 not getting the correct nutritive value, micronutrients, and further weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement professional standards of practice by not: 1. Obtaining a physician's order for monitoring pulse oximetry (a noninvasive method for monitoring a person's oxygen saturation). 2. Assessing and monitoring oxygen saturation (blood oxygen levels) and documenting in the resident's chart. These deficient practices had the potential of resident 93 been infected with infected tubing, confusion and irritability due to continuing use of oxygen (oxygen toxicity).

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure the physician assessed Resident 192 after admission to the facility. This deficient practice had the potential of resident's treatment orders and medical services not delivered in an appropriate order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a correct diet was served and with no deviations from menu of one of two resident (Resident 26). This failure had the potential to result in resident not receiving the correct nutritive value and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility's staff failed to develop and present Quality Assurance and Performance Improvement (QAPI) plan that describes the process for conducting QAPI per Quality of Assurance Agency (QAA) activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. This deficient practice had the potential risk for residents not receiving care and services at acceptable levels of performance for quality of care, quality of life and resident safety.