Blue Oak Post-Acute

Inspectors wroteBased on interviews and record review, the facility's Social Services Department failed to ensure the discharge planning process was documented for one resident (Resident 1) of five sampled residents when the facility planned to discharge Resident 1 from the facility to a shelter without having documented: that the shelter could meet Resident 1's medical needs, Resident 1's involvement in the discharge process, and without preparing Resident 1 to transfer to the new facility. This failure decreased the facility's potential to ensure Resident 1 had a safe discharge and prevent Resident 1's readmission to the hospital. [...]

Inspectors wroteBased on interview and record review, the facility's Social Services Department failed to provide the Ombudsman (an independent official who mediates disputes between residents and the facility) and one resident (Resident 1) of five sampled residents with the required written discharge notice when the Social Services Department informed Resident 1 that he was going to be discharged with two days notice. This failure led to Resident 1 experiencing fear from not understanding the reason for his discharge, not knowing where he was being discharged to, and the prevention of the Ombudsman from performing mandated oversight of Resident 1's right to be informed of his rights regarding the discharge process. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan of one of five sampled residents (Resident 1) when the care plan for a toileting program was not carried out and Resident 1's noncompliance with the toileting program did not have a care plan. This failure had the potential to impede Resident 1's ability to regain her continence and delay her readiness for discharge home. During a phone interview on 6/8/26 at 2:54 p.m., Family Member (FM) stated she had spoken with five staff members regarding Resident 1's every-two-hour toileting program including two social services staff, the Director of Nursing, an occupational therapist, and one of Resident 1's nurses. FM stated the nurse had told FM that Resident 1 had been refusing to go to the toilet every two hours per the program. [...]

Inspectors wroteBased on interview and record review, the facility Social Services Director (SSD) failed to make a medical appointment for one of five sampled patients (Resident 1) when Resident 1 was admitted to the facility with a physician order for a neurosurgery appointment that was never carried out for eleven weeks. This failure potentially prolonged a spinal condition that caused Resident 1 to have difficulty walking, and may have been surgically corrected had Resident 1 been able to see the neurosurgeon. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident in a census of 123 (Resident 2) received quality nursing care that was resident-centered and in accordance with her goals of care, as indicated in her Nursing Care Plan (a document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) when she experienced a Change of Condition (sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains; without intervention, the deviation could lead to clinically significant complications up to and including death) at approximately 8 a.m. on [DATE], but her responsible party (RP; individual with decision-making authority regarding the patient's care) was not notified until approximately 11 a.m. [...]

Inspectors wroteF600 The facility failed to ensure residents were free from physical abuse, including resident to resident abuse, when it did not implement effective preventative resident abuse nursing care planned interventions to prevent three resident to resident altercations for three of five sampled residents (Residents 2, 3, and 5). As a result, Resident 2 sustained head trauma to the right side and back of his head, with pain, swelling and redness; Resident 3 sustained abrasion with bleeding to his right ear, and Resident 5 sustained skin injury resulting in redness on his jaw. These failures resulted in abuse, pain, physical injuries and increased risk of psychosocial harm. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to fully implement one out of four sampled residents (Resident 3) fall care plan (CP, a detailed, written document that outlines a resident's individual needs, goals, and how their care will be managed) when Resident 3's bed was not in the lowest position as indicated on his fall CP.This failure put Resident 3 at increased risk for falls and fall related injuries.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure their call light system (communication devices/system that allows residents to instantly alert nursing staff, aiding in safety, fall prevention, and resident-centered care) allowed residents to be able to directly communicate with staff when they needed assistance for two out of three sampled residents (Residents 1 and 2) when:1. Resident 1's call light volume was too low to be heard, and2. the light outside Resident 2's room, by their door, failed to illuminate upon call light use. These failures put the residents at risk for delayed provision of care and unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to provide the State Survey Agency (California Department of Public Health [CDPH]) written investigation reports (an investigation conducted by the facility following the allegations of abuse) of two facility reported abuse allegations within five calendar days, for four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4). This failure decreased the facility's potential to ensure relevant interventions were in place and implemented to prevent further abuse and psychosocial (a combined influence of psychological [the mental and emotional state of a person] factors and the surrounding social environment on physical, emotional, and/or mental wellness) harm for Resident 1, Resident 2, Resident 3, and Resident 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident care met professional standards of practice for two of six sampled residents (Resident 1 and Resident 2) when:1: A skin assessment was not completed following the report of bruising/discoloration sustained to Resident 1's right arm after an abuse allegation, and;2: The facility did not conduct 72-hour monitoring every shift (morning [AM], evening [PM] and night shift [NOC]) following Resident 2's change of condition (COC). These failures resulted in inaccurate documentation and monitoring of Resident 1's injuries and decreased the facility's potential to ensure that consistent monitoring and safety measures were provided to Resident 2.1: [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect the residents' right to be free of physical abuse by another resident for two of eight sampled residents (Resident 2 and Resident 3) when:1. Resident 2 was struck several times in the back of his head by Resident 1; and2. Resident 3 was struck in the head by Resident 4. These failures resulted in Resident 3 having mild facial pain and fear and had the potential to result in serious bodily harm to the residents.

Inspectors wroteBased on interview and record review, the facility failed to protect one of five sampled resident's ( Resident 1) right to be free from psychological abuse by a Certified Nursing Assistant ( CNA 1) and Unlicensed Staff 1, when Resident 1 was forced to unclog her room's toilet , which contained urine and feces, with her own gloved hands while the door to room was purposely left open. This failure made Resident 1 feel embarrassed, humiliated and victimized and negatively impacted her psychological well-being. A review of Resident 1's admission record indicated she was admitted in 05/25, with the diagnosis of Paranoid Schizophrenia (a serious mental health condition where a person has a hard time telling the difference between what is real and what is not). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an abuse allegation was properly investigated when the facility did not interview other residents as part of its investigation. This failure prevented the facility from identifying other residents who could have been affected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' rights to confidentiality for a census of 142 residents, when residents' meal tickets containing personal and medical information were found in a kitchen trash can. This failure decreased the facility's potential to protect the residents' personal details and health information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their medication storage policy and procedure (P&P) for a census of 142 residents, when multiple medications were not labeled and stored in a safe manner. This failure decreased the facility's potential to prevent unsafe medication administration to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the recipe for a pureed diet (consists of foods that have been blended or mashed to a smooth, pudding-like consistency) for nine residents of a census of 142, when [NAME] 1 (C 1) did not add the correct amount of bread slices and broth cups while preparing pureed lunch for residents. This failure decreased the facility's potential to serve the right food consistency to residents with specific nutritional needs and dysphagia (difficulty swallowing).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate five residents' (Resident 119, Resident 14, Resident 43, Resident 44, and Resident 129) food allergies, intolerances, and preferences for a census of 142, when:1. Resident 119 had lactose allergy and was served mashed potatoes with sour cream; and2. Resident 14, Resident 43, Resident 44, and Resident 129's food preferences were not served as indicated on their meal tray tickets. These failures increased the residents' potential to sustain an allergic reaction and unmet nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly prepare and store food for a census of 142 residents, when:1. Food items were found undated, unlabeled, unsealed and expired;2. Food bins were stored on a corroded metal shelf;3. One cutting board had brown stains, another contained a sticky substance, one frying pan had an oily substance and brown residue on the inside, a steam warmer tray had brown residue on the outside;4. Two insect control machines were placed on walls above a food preparation area and a toaster;5. The inside of a ceiling ventilation fan had a thick, black substance; and6. The second step of the cool down log for cooked food items was incomplete from June to September 2025. These failures increased the facility's potential to serve contaminated food and cause foodborne illnesses among vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented for a census of 142 residents, when:1. Two washing machines in the behavioral unit were found closed while not in use with moisture inside and the washing machine in station B had black spots around the door seal;2. Licensed Nurse 2 (LN 2) did not perform proper hand hygiene prior to medication preparation; and3. Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce the spread of multidrug-resistant organisms [MDRO]) were not followed for Resident 5, Resident 135, and Resident 4. These failures had the potential to spread infection among residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call systems (an electronic communication network that allows residents to alert staff when they need assistance) were provided for 46 residents out of a census of 142, when the residents' rooms and bathrooms in the behavioral unit (a specialized area that provides focused care for residents who have mental health disorders, substance use disorders, or complex behaviors) were found without a functioning call system. This failure decreased the facility's potential to maintain residents' safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 31 sampled residents (Resident 28 and Resident 140) were free from abuse, when both residents were subjected to offensive language and profanity during an argument as witnessed by staff. This failure decreased the facility's potential to maintain Resident 28's and Resident 140's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess the nutritional status for one of 31 sampled residents (Resident 127), when a Minimum Data Set (MDS; an assessment tool) quarterly review indicated Resident 127 had no weight loss. This failure decreased the facility's potential to identify Resident 127's severe weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of care were followed for enteral feeding and medication administration for one of 31 sampled residents (Resident 132), when:1. Resident 132's physician's order for enteral (involving or passing through the intestine, either naturally via the mouth and esophagus, or through an artificial opening) feeding was incomplete, without start and stop times, and lacked medication administration and flushing instructions; and2. Licensed Nurse 3 (LN 3) did not follow the facility's policy during medication administration through a gastrostomy tube (G-tube; a surgical opening fitted with a device to allow feedings to be administered directly into the stomach, common for people with swallowing problems). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an enteral feeding (a method of providing nutrition directly into the stomach through a surgically placed tube) was administered as per physician's order for one of 31 sampled residents (Resident 33), when Resident 33's feeding pump was observed off during scheduled feeding times. This failure increased Resident 33's potential for malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets) and dehydration (occurs when the body uses or loses more fluid than it takes in).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care services according to professional standards of quality for one of 31 sampled residents (Resident 28), when Resident 28's administered oxygen was not consistent with the physician's order. This failure decreased the facility's potential to follow the physician's order when providing respiratory services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate documentation, disposition, and storage of controlled medications for one of 31 sampled residents (Resident 135), when:1. Resident 135's controlled drug was found in a sealed plastic bag stored inside a general medication drawer in the medication cart; and 2. Resident 135's Controlled Drug Record (CDR-a paper log of controlled drug removal for administration to residents) did not match the actual medication count. These failures had the potential to contribute to unsafe controlled medication handling and/or risk of controlled drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose garbage for a census of 142 residents, when a kitchen garbage dumpster was found to have two warped lids. This failure had the potential to produce unsanitary conditions for residents due to easy access for rodents and other pests.

Inspectors wroteBased on interview and record review, the facility failed to maintain record of Coronavirus disease 2019 (COVID-19) vaccination status for one of two sampled staff (Certified Nursing Assistant 2; CNA 2), when CNA 2 was not provided an education regarding COVID-19 vaccination and the refusal of the vaccine was not documented. This failure decreased the facility's potential to assess staffs' vaccination status against infectious disease.

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for one resident (Resident 1) of two sampled residents when Resident 2 threw water at Resident 1. This failure resulted in Resident 1 having had water thrown at him.

Inspectors wroteBased on interviews and record reviews, the facility failed to honor the right to self-determination (making own decisions) nor ensured one out of three sampled residents (Resident 1) was treated with respect and dignity, when Licensed Nurse (LN) B touched Resident 1 without consent. This failure resulted in Resident 1 feeling she was not treated with respect and dignity and that her rights were violated.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an abuse allegation was reported timely, not later than two hours, for one out of three sampled residents (Resident 1), when an allegation of abuse was made on 7/7/25 but wasn't reported to the local police department until 7/8/25. This failure could result in continued harm and further abuse.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure medications were secured and inaccessible to unauthorized staff and residents when one medication cart was left unlocked and unattended. This failure had the potential to put all 95 facility residents at risk for unauthorized access to and ingestion of unsecured medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the preservation of dignity for one of two sampled residents (Resident 1), when Resident 1 was left on a soiled bedpan (a medical device used to collect urine or feces for individuals who are unable to leave their bed to use a regular toilet) for hours without any response to his multiple call light (typically a light or bell used in healthcare setting to notify staff that a resident requires assistance) activation attempts to get assistance from facility staff. These failures resulted in Resident 1 being made to endure an undignified experience being left for hours, on a soiled bedpan, feeling helpless and embarrassed with an increased potential for skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to complete and provide a timely investigation report for one of two resident abuse allegation incidents (Resident 1) to the Department. This failure subjected Resident 1 to the potential reoccurrence of abuse, and lack of information had the potential to hamper the Department's ability to intervene, should protective actions be required to ensure the safety of the 60 other vulnerable residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure supervision for one of three sampled residents (Resident 1) when Resident 1 eloped (the act of leaving a facility unsupervised and without prior authorization) fell and sustained injuries. This failure resulted in Resident 1 sustaining a fracture (broken bone) of the left distal phalanx (a small bone on the tip of the thumb located under the nail) and abrasions (a partial loss of skin, usually due to scraping) to his face and both knees.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) received proper treatment to maintain hearing abilities, when the facility did not arrange for suitable transportation to a scheduled hearing appointment. This failure resulted in a delay of treatment for a period of five months and a decreased quality of life for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect, when: 1. Unlicensed Staff D was observed assisting Resident 137 with meals, in the standing position; 2. Unlicensed Staff E and Unlicensed Staff F were observed chatting in the facility's hallway adjacent to the dining room, speaking a language other than English during lunch time, and; 3. Licensed Nurse G was observed texting in her personal cellphone during regular work hours. These findings had the potential to result in loss of dignity, and feelings of neglect and frustration for the residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure 13 of 13 sampled residents (Resident 44, Resident 61, Resident 81, Resident 63, Resident 34, Resident 93, Resident 23, Resident 112, Resident 10, Resident 85, Resident 98, Resident 80 and Resident 120), who attended the Resident Council meeting on 11/15/23 at 10 a.m., knew where to find the information to file a complaint with the State Department. This failure had the potential to result in lack of ability to advocate for their care at the facility, and poor quality of care.

Inspectors wroteBased on observation and interview, the facility failed to ensure the sliding doors and the sliding screens on five of six resident rooms (Rooms 115, 214, 218, 317, 321) were intact and in good working conditions. This failure created a safety hazard for the residents at the facility and exposed them to insects and pests.

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of 14 residents (Resident 210, Resident 140, Resident 202, Resident 92, Resident 7, Resident 203, Resident 118, Resident 442, Resident 4, Resident 60, Resident 37, Resident 301, Resident 302, Resident 303), when nine Facility-Reported Incidents of resident abuse, were not reported to authorities within two hours after the allegation was reported. This failure to report allegations of abuse within the Federally-mandated requirement of two hours, had the potential to contribute to ongoing resident abuse, physical harm and the potential for mental and emotional harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 10 sampled residents (Resident 137 and Resident 22) had resident-centered comprehensive care plans when: 1. Resident 137, who was in palliative care (A type of medical care aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses), did not have a resident-centered comprehensive care plan for pain/discomfort that was resident-specific and included nonpharmacological interventions (Interventions to help relieve pain not consisting of medications), and; 2. Resident 22, who had a left lower leg surgical wound, did not have a comprehensive care plan for care of the wound. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 7 sampled residents (Resident 137), received assistance with Activities of Daily Living (ADLs-Activities related to personal care such as dressing, bathing and toileting) such as incontinence care (Cleaning the skin and changing the soiled undergarments and clothing of people with bowel or bladder incontinence [inability to control urination and defecation])., bed repositioning and bathing, as needed. This failure had the potential to result in feelings of neglect, frustration, shame, and skin breakdown for Resident 137.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 7 sampled residents (Resident 49) was kept comfortable when she experienced pain of 10/10 (Pain scale where 10 is the worst pain experienced in a person's lifetime, and 0 is no pain) for a prolonged period of time, and the assigned nurse (Licensed Staff R) did not transfer her to the hospital despite multiple verbal requests by Resident 49, until more than two hours after the pain started. In addition, Licensed Staff R did not document administering any medications to treat Resident 49's pain. This caused Resident 49 a lot of suffering, and had the potential to result serious harm, including death to Resident 49.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was enough staff available to meet the needs of residents, when call lights were not answered promptly. During a Resident Council Meeting, three of 13 sampled residents (Resident 81, Resident 85 & Resident 93) complained the call lights were taking more than ten minutes to be answered. One resident indicated the call light took up to an hour to be answered. In addition, family members of Resident 137 also stated the call light took a long time to be answered. These findings had the potential to result in inability for residents to obtain assistance when needed, decreased resident satisfaction and safety, and poor perception of health care quality.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure food was prepared and stored in accordance with professional standards of food service safety, when the roast beef was not cooled down (a processing technique used to reduce the temperature of the food from one processing temperature to another or to a required storage temperature) properly. This failure could put residents at risk for foodborne illness due to growth of bacteria and microorganisms.

Inspectors wroteBased on interview and record review, the facility failed to have a Social Services Director with the qualifications required by the Federal regulations, since April of 2023. This finding had the potential to result in inability to provide medically-related Social Services to the residents of the facility and poor quality of care.

Inspectors wroteBased on observation and interview, the facility failed to ensure the televisions (TVs) of five of five residents (Resident 78, 81, 34, 23 & 85) worked properly. In addition, the call bells of two of two residents (Resident 33 & 78) did not work properly either. These failures prevented the residents from watching the TV channels they liked and placed other residents at risk of not being able to watch the channels of their preference. These failures also placed Resident 33 and Resident 78 at risk of not being able to get the help or assistance they needed, due to the malfunctioning call bells, which could have resulted in harm and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of six residents (Resident #7, Resident #203, Resident #202, Resident #92, Resident #201, Resident #140), when they did not have an effective abuse prevention program which provided staff with updated reporting information. This failure to have the correct information available to staff for orientation, yearly in-service and availability in the nursing stations, resulted in delayed reporting of abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the physician was notified for a significant weight loss (5% in 1 month, 10% in 3 months and 7.5 % in 6 months) for one out of two sampled residents (Resident 38). This failure had the potential to further aggravate and compromise his medical status.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident was free from abuse for one out of two sampled residents (Resident 118), when another resident (Resident 442) hit him on his face three times with open palm and one time with a closed fist. This failure led Resident 118 feeling in pain and afraid. This failure could also result in injury.

Inspectors wroteBased on interview and record review, the facility failed to timely complete a nutritional assessment by a Registered Dietician for one of three residents (Resident 131) at risk for malnutrition. Resident 131 was admitted with a Body Mass Index (BMI - a nutritional status indicator) score of 15.1 (BMI scores less than 16.5 indicate severely underweight). The Registered Dietician assessment was completed ten days after admission. This failure placed Resident 131 at risk of suffering complications from being underweight.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents who require dialysis, receive such services consistent with professional standards of practice, for one out of two sampled residents (Resident 8), when staff were not regularly assessing the hemodialysis (HD, a treatment used to filter wastes and water from your blood) access site on his left arm. This failure could result in staff not being able to detect infection, bleeding or a failed HD access site.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure: 1. the menu was followed for a pureed (a paste or thick liquid suspension usually made from cooked food ground finely) diet, when the cook did not follow the menu instruction while preparing a pureed meatball, for two out of two sampled residents (Residents 58 and 137); and, 2. the development of a plant-based menu. These failures had the potential to alter the taste of the food when not following the menu and residents not meeting the recommended daily intake (RDI, the average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all (97-98 per cent) healthy individuals in a particular life stage and gender group) for certain nutrients like protein or vitamins, which could further compromise their medical status.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure food was prepared and stored in accordance with professional standards of food service safety, when the roast beef was not cooled down (a processing technique that is used to reduce the temperature of the food from one processing temperature to another or to a required storage temperature) properly. This failure could put residents at risk for foodborne illness due to growth of bacteria and microorganisms.

Inspectors wroteBased on interview and record review, the facility failed to ensure it offered COVID-19 immunizations and education to two of five residents (Residents 11 and 61) and failed to ensure it had a COVID-19 Policy and Procedure available for consultation and reference. These failures placed facility residents at risk for COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of COVID-19 vaccination status of two of five staff members (Licensed Staff G and Unlicensed Staff Q). This failure placed residents at risk of COVID-19.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the kitchen walls were in good repair, when cracks and holes in the walls were noted during rounds. This failure could result in rodents and pests accessing the kitchen area through these cracks and holes which could put residents at risk for harmful diseases.

Inspectors wroteBased on observation and interview, the facility did not ensure eight residents (Residents, 109, 112, 113, 11, 76, 18, 59, and 128) were offered the opportunity to choose whether they wanted condiments or substitute foods during meal service. The failure to ask residents or their families about things important to their lives and how they enjoyed their food, had the potential for each resident, who did not like their food, to not eat and potentially experience weight loss, or depression.

Inspectors wroteBased on interview, observation, and record review, the facility did not ensure seven Residents' (Resident 129, Resident 112, Resident 71, Resident 3, Resident 1, Resident 1A, and Resident 1B), Minimum Data Set Documentation (The MDS is a health status screening and assessment tool used for all residents, to ensure that facilities have provided resident-specific information for payment and quality measure purposes, and to enable a facility to better monitor each resident's decline and progress over time. Computer-aided data analysis facilitates a more efficient, comprehensive and sophisticated review of health data) was completed and submitted, according to the regulations. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure resident care plans were reviewed, revised and updated, at least every three months, for 9 residents (Residents 71, 113, 128, 135, 40, 11, 9, 19, and 93). This failure to follow the Policy and Procedure (P&P) for Care Planning, had the potential for these residents to not receive the care and services necessary to meet their physical, psychosocial and functional needs.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure Certified Nursing Assistants (CNAs) were provided at least 12 hours a year of in-services annually. The failure to provide education in-service for CNAs had the potential to result in resident harm from cross-contamination and infection by staff who did not know how to properly don and doff Personal Protective Equipment (PPE) and when to engage in hand hygiene after contact with residents and their surroundings.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to: 1A. Ensure 3 of 3 refrigerated insulin injections (Basaglar, Victoza and Admelog) were stored at the temperature required to maintain their overall safety and effectiveness. This failure had the potential to reduce the efficacy of the medication, from exposure to excessively low temperatures, thereby being potentially ineffective to residents receiving insulin. 1B. Ensure 1 of 3 medication refrigerators was monitored for an acceptable temperature for refrigerated medications. This failure had the potential to reduce the efficacy of the medication, from exposure to excessively low or excessively high temperatures, thereby being potentially ineffective to residents receiving these medications. 2. [...]

Inspectors wroteBased on interview and document review, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to identify and develop a QAPI Plan (A QAPI plan is the written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved. The plan describes how the facility will conduct its required QAPI and QAA committee functions. The facility is required to develop a QAPI plan), and implement Performance Improvement Plans to address: 1. Residents' food preferences for seasonings or substitutions. (Reference F561) 2. Required resident assessment and documentation completion and submission, according to policy and procedure. (Reference F640 3. Resident Care plan reviews and updates to reflect resident needs. (Reference F657) 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an Infection Prevention Program was followed to prevent transmission of communicable diseases and did not follow its Policy and Procedure (P&P) when: 1. Screening Visitors and Staff for Covid Symptoms, before entering the facility; 2. a) Donning and doffing (putting on and taking off) Personal Protective Equipment (PPE); b) Staff did not follow its P&P for hand hygiene; and, 3. Trash cans were not placed inside resident rooms, in the Red Zone. These failures to follow Infection Prevention P&P had the potential for resident harm and possible death from cross-contamination and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 441) was free from abuse when they did not follow its Policy and Procedure (P&P) for assessment, monitoring or documenting allegations of abuse by Resident 441. This failure had the potential for harm, when Resident 441 was not assessed for physical harm or monitored for safety or signs of psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement care plan interventions to monitor a resident with a known history of elopement attempts, for one of three residents (Resident 54). This failure resulted in Resident 54 leaving the building, unsupervised, in the early hours of the morning on 8/8/21, putting Resident 54 at risk for serious injury or death.

Inspectors wroteBased on interview and record review, the facility did not provide a current Facility Assessment. The failure to conduct, assess and document the resources needed to care for facility residents, had the potential for resident harm if staffing, resident care, and equipment were not provided, as needed.