Bonita Hills Post Acute

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the discharge process was followed for one of five sampled residents (Resident 1). * The discharge section of the Resident's Clothing and Possessions form for Resident 1 was not completed. This failure had the potential to affect the ability of the resident or resident's responsible party to be informed of their belongings.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the services to attain or maintain the highest practicable well-being for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1 had a physician's order for podiatry appointment on 1/5/26. This failure had the potential for the resident to not receive the necessary care and services to maintain their highest physical well-being and potentially delay the necessary care and treatment.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained their highest practicable well-being. * The facility failed to ensure Resident 1's physician was notified when Resident 1's urine color changed from yellow to dark amber. This failure had the potential for not providing the necessary care and services when the resident had a change in condition.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for one of three sampled residents (Resident 1). * The facility failed to ensure the medications were administered as ordered by the physician for Resident 1. This failure had the potential to negatively affect the resident's health conditions and posed the risk for possible complications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed in the kitchen when: * Pasteurized eggs were not available for one resident (Resident 62) who requested fried over easy eggs daily with breakfast. * Four fry pans were not clean and had excessively worn surfaces.* Three steam table pans were stacked and stored wet.* One food prep sink did not have a backflow prevention. * Four cereal bins were outdated. These failures had the potential to cause food borne illnesses in a highly susceptible resident population who received food prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs for one of six residents (nonsampled Resident 29) reviewed for resident council. * The facility failed to ensure Residents 29's call light was functioning properly. This failure had the potential to negatively impact Resident 29's psychosocial well-being or result in a delay to provide care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to clarify and follow up regarding the residents' rights to formulate the advance healthcare directives for two of six final sampled residents (Residents 28 and 85) reviewed for advance directive. * The facility failed to ensure Resident 28 and 85's information about advance directive were accurate. In addition, the facility failed to obtain a copy of Resident 28 and 85's advance directive to be placed in the residents' medical record. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents (Residents 28, 65, and 69) reviewed for unnecessary medications were monitored for the identified manifested episode of behavior and provided with the non-pharmacological interventions for the use of psychotropic medications. * The facility failed to ensure Resident 28's target behavior for the use of the mirtazapine (antidepressant) was monitored accurately. In addition, the facility failed to ensure Resident 28's monthly behavior monitoring summary was completed for the use of the antidepressant medication. [...]

Inspectors wroteBased on observation, interview, medical record review, and the facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for four of 21 final sampled residents (Residents 3, 5, 8, and 59). * The facility failed to develop a care plan problem for Resident 3's use of the central line and IV antibiotic medication. * The facility failed to develop a care plan problem for Resident 5's use of the midline IV and maintenance care. * The facility failed to implement a care plan specific to the administration of oxygen. Resident 8 received continuous oxygen at a rate of 4 LPM, however, physician's order was for 3 LPM. * The facility failed to develop a care plan problem for the use Resident 59's right upper arm PICC line. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to to ensure feeding assistance was provided per the physician's order for one of 21 residents (Resident 5) observed during the dining observation. * During the dining observation, the facility failed to provided one to one feeding assistance for Resident 5. Resident meal card showed the resident required total assistance with feeding. This failure has the potential to negatively affect the resident's health outcomes and well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 10) reviewed for accidents remained free from accident hazards. * Resident 10 sustained three falls while the sitter (facility staff who provides direct supervision to those residents requiring close monitoring) was distracted, and/or had left the room. * Resident 10's post fall neurological assessments were incomplete for the falls sustained on 3/3 and 8/5/25. * Resident 10's post fall, fall risk assessments were inaccurate for 7/27/25 and incomplete for 8/5/25. * The facility failed to ensure Resident 10 remained within the sitter's eyesight for 11 minutes. These failures resulted in the resident sustaining subsequent falls had the potential to place the resident at risk for serious injury and negative health outcomes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for the use of the GT (gastrostomy tube- a small tube placed through the abdominal wall into the stomach, used to provide enteral feedings and/or administer medications) for one of three final sampled residents (Resident 4) reviewed for the GT feeding and one of three residents (Resident 2) observed for the medication administration. * The facility failed to ensure LVN 3 checked for the gastric residual (volume of fluid remaining in the stomach) prior to the administration of the GT medications for Resident 2 and failed to flush the GT between the administration of each medication. * LVN 6 failed to verify Resident 4's GT placement prior to administering the tube feeding. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV accesses for four of four final sampled residents (Residents 3, 5, 59, and 83) reviewed for IV care. * The facility failed to ensure there was a physician's order for the use of Resident 3's central line. * The facility failed to ensure Resident 5's midline dressing was dated and failed to ensure for complete documentation of the maintenance flushes, as per the physician's orders. * The facility failed to ensure Resident 59's right upper arm PICC line was changed as per the physician's orders and failed to ensure Resident 59's PICC line external catheter and arm circumference measurements were obtained and documented in the resident's medical record. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for one of two final sampled residents (Resident 1) reviewed for tracheostomy services, and four of five residents (Residents 8, 22, 69, and 85) reviewed for oxygen therapy. * The facility failed to ensure only qualified staff managed the resident's oxygen delivery equipment. The SSD was observed turning Resident 1's oxygen concentrator off and on, in an attempt to troubleshoot a potential malfunction. * The facility failed to follow the physician's order for the administration of continuous oxygen for Resident 8. Resident 8 had an order to receive continuous oxygen at three LPM, however, Resident 8 received continuous oxygen at a rate of four LPM. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided for three of three final sampled residents (Residents 10, 59, and 85) reviewed for pain management. * The facility failed to administer the pain medication according to the physician's order and failed to ensure the non-pharmacological pain interventions were implemented prior to the administration of the PRN pain medications for Resident 59. * The facility failed to ensure the non-pharmacological pain interventions were implemented and documented prior to the administration of the PRN pain medications to Residents 10 and 85. These failures had the potential to put Residents 10, 59, and 85 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for one of three final sampled residents (Resident 28) reviewed for dialysis. * The facility failed to ensure a physician's order for the peritoneal dialysis was obtained including the care of the dialysis access site of Resident 28. These failures had the potential for medical complications related to not obtaining the physician's order for dialysis care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure accurate controlled medication records for one nonsampled resident (Resident 87). * Resident 87's MAR for October and November 2024 failed to show the Oxycodone/APAP (a controlled pain medication) documented on the Antibiotic or Controlled Drug Record were administered to the resident when the medication was removed from the medication supply. This failure resulted in inaccurate accounting of a controlled medication and the potential for drug diversion.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the consultant pharmacist performed a monthly Medication Regimen Review to identify potential medication irregularities for two of five sampled residents (final sampled residents, Residents 28 and 65) reviewed for unnecessary medications. * The facility failed to ensure the Medication Regimen Review conducted by the consultant pharmacist in June and July 2025 for Resident 65 addressed the use of two antidepressant medications (mirtazapine and trazodone) and antipsychotic medication (Risperidone). *The facility failed to ensure the Medication Regimen Review conducted by the consultant pharmacist for July 2025 for Resident 28 addressed the irregularities and inaccurate monitoring of the poor meal intake of less than 50% of his meals, as ordered by the physician. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 21 final sampled residents (Resident 59) was free from the unnecessary medications. * The facility failed to follow the physician's order to hold the metoprolol (blood pressure medication) medication when Resident 59's SBP (Systolic Blood Pressure) was less than 120 mmHg. This failure had the potential for Resident 59 to develop significant adverse and side effects from the medication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 29.63%. Two of three licensed nurses (LVNs 3 and 5) were found to have made errors during the medication administration observations. * LVN 3 failed to administer the complete dose for six of Resident 2's medications when significant residual of the medications were observed in the medication cups and nebulizer cup. In addition, LVN 3 combined two GT medications and failed to administer the two medications as per the physician's order. * LVN 5 failed to obtain Resident 33's heart rate prior to the administration of the carvedilol (blood pressure medication). These failures had the potential to negatively affect the residents' health.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure proper labeling and storage of the drugs and biologicals in a safe manner for one of one medication room (Medication Room B), and for three of three medication carts (Medication Carts A, B, and C) inspected.* The facility failed to ensure the 0.9% sodium chloride flush (a sterile solution used to maintain the patency of intravenous catheters and prevent complications) was not kept in Resident 59's room.* A bottle of Multivite (liquid supplement) and a bottle of LiquaCel (liquid protein) were observed with a sticky brown residue in Medication Cart B.* The facility failed to dispose of the expired medical supplies in Medication Room B.* The facility failed to dispose of expired medical supplies in Medication Cart C.* The facility failed to ensure proper storage of unopened insulin (medication to [...]

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure one of five residents reviewed for dining (Resident 67) received food prepared in a form to meet the resident's individual dietary needs. * The facility failed to ensure Resident 67 was provided with a soft and bite-size texture diet. This failure had the potential to cause choking in a medically vulnerable resident.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the residents' food brought from outside sources was stored for future consumption. * The facility failed to provide refrigerated storage for the residents' food brought from outside sources. This failure had the potential to negatively impact all the residents who received an oral diet and resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure the organic trash was disposed of properly. * The facility failed to separate the organic trash from their regular trash. This failure had the potential to increase the environmental impact of the facility, thus adversely impacting all the 71 residents' health who resided in the facility.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and prevent the transmission of diseases and infections for six of 21 final sampled residents (Residents 2, 3, 4, 46, 59, and 83). * The facility failed to ensure LVN 3 donned the gown during the medication administration observation for Resident 2. Resident 2 was on EBP (Enhanced Barrier Precaution) for her GT (Gastrostomy Tube). * CNA 8 failed to follow the EBP infection control practices while providing care to Resident 3. * LVN 6 failed to follow the EBP infection control practices while administering the GT enteral feeding for Resident 4. * LVN 1 failed to follow the infection control practices while performing the wound care for Resident 46. [...]

Inspectors wroteBased on interview, medical record review, facility P&P review, and CDC Immunization Recommendations, the facility failed to offer the COVID-19 vaccinations to three of seven residents (Residents 7, 17, and 18) reviewed for immunizations. * Residents 7, 17, and 18 were eligible to receive the COVID-19 vaccine, in accordance with the facility's P&P and CDC recommendations. However, the facility failed to offer the COVID-19 vaccine to these residents. These failures increased the residents' risk for being inadequately vaccinated against COVID-19 infection and placed the residents at risk for negative health outcomes were they to develop the COVID-19 infection.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the failed to implement and maintain an effective training program for the existing facility staff. * The facility failed to ensure only qualified staff managed the resident oxygen delivery equipment. The SSD was observed turning Resident 1's oxygen concentrator off and on, in an attempt to troubleshoot a potential malfunction. * The facility failed to complete the annual skill performance for LVN 3. * The facility failed to ensure the facility staff scheduled for the 11-7 shift were provided with the in-services on 2/21 and 3/22/25. These failures posed the risk for untrained facility staff providing care to residents, which posed the risk for adverse events and negative health outcomes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the MDS assessment was coded accurately for two of 21 final sampled residents (Residents 10 and 69). * Resident 69's MDS assessment was not coded accurately to show he was administered oxygen while at the facility.* Resident 10's MDS assessment showed the resident had one fall, instead of three falls. These failures posed the risk for the residents to not have an individualized plan of care based on the residents' specific needs.

Inspectors wroteBased on interview, medical record review and facility P&P review, the facility failed to revise the care plans for two of 21 final sampled residents (Residents 10 and 69). * The facility failed to timely resolve Resident 10's care plan for the IV therapy. * The facility failed to timely resolve Resident 69's care plan for the quetiapine (antipsychotic) medication. These failures posed the risk of not providing the residents with individualized and person-centered care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents' medical records were accurate for one of three residents (Resident 79) reviewed for closed medical record, one of 21 final sampled residents (Resident 59), and one nonsampled resident (Resident 32).* The facility documented Resident 79's temperature and pain level were obtained on [DATE], however, Resident 79 expired on [DATE].* The facility failed to ensure the accurate documentation for the administration of the Norco (narcotic) pain medication for Residents 32 and 59. These failures resulted in the residents' medical records containing inaccurate information.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure 16 resident rooms measured at least a minimum of 80 square feet per resident. This failure had the potential to not be compliance with the requirement.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the comprehensive plan of care interventions were implemented for a suspected allegation of financial abuse for one of three sampled residents (Resident 1). This failure had the potential for not providing care and services to meet the residents' needs.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the Dialysis Communication Form was completed for two of four sampled residents (Residents 1 and 4). * Residents 1 and 4's pre and post-dialysis information sections on the Dialysis Communication Form were not completed by the licensed staff. Additionally, there was no documentation of the status of the dialysis access and general condition of the residents upon returning from the dialysis center. These failures had the potential to not provide the necessary care and services to these residents as their medical information was incomplete.

Inspectors wroteBased on interview, medical record review, facility document, and facility P&P review, the facility failed to ensure Resident 1 was provided a bed hold for up to seven days when Resident 1 returned to a different room and bed upon readmission to the facility on 1/2/25. In addition, the facility failed to provide Resident 1 and/or the resident's representative a written bed hold policy upon transfer to an acute care hospital. These failures had the potential for Resident 1 and/or the resident's representative to be not informed of their rights to return to the facility following hospitalization.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of disease and infections. * Resident 2 who had salmonella was cohorted with Resident 1 who did not have salmonella. * RN 1 failed to perform hand hygiene and don the gloves and gown on while providing care for Resident 2 who was on contact isolation precautions. * The facility failed to ensure a visitor donned the gloves and gown on while sitting on Resident 2's bed. * The facility failed to ensure Caregiver 1 donned a gown on while feeding Resident 1 who was inside an isolation room for a contact precaution.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of five sampled residents (Resident 3). * The facility failed to monitor Resident 3's wound separation for the forehead area and skin breakdown for the left and right arm area every shift as ordered. * The facility failed to notify the physician of the changes in Resident 3's wound separation for the forehead area and skin breakdown for the left and right arm area as documented on the TAR. These failures had the potential to negatively impact Resident 3's well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the ST had evaluated the resident with an order for thicken liquid as per the facility's P&P for one of five sampled residents (Resident 2). This failure had the potential for not providing necessary care and services to the resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure five of five sampled residents (Residents 1, 2, 3, 4, and 5) remained free from the accident hazards. * The facility failed to assess the residents' ability to handle the containers and consume the hot beverages as per the facility's P&P for Residents 1, 2, 3, 4, and 5. Resident 1 spilled a cup of hot chocolate on her chest, causing redness and blisters to Resident 1's right side of chest. Resident 2 also spilled coffee on his lap. These failures posed the risk of injury to the residents who were consuming hot liquids in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility to ensure the food was prepared in a form to meet the resident's needs for one of five sampled residents (Resident 2). * Resident 2 did not receive thickened liquids as ordered. * The facility staff who were serving the hot beverage lacked knowledge in preparing a thickened liquid. These failures placed Resident 2 at risk for aspiration (when food or liquids are breathed into the lungs).

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure an allegation of staff to resident abuse was reported to the State Agency and failed to investigate an allegation of staff to resident abuse for one of five sampled residents (Resident 1). * The facility was informed by Resident 1's family that Resident 1 allegedly felt intimidated by the care a CNA provided to Resident 1. However, the facility failed to report the allegation to the State Agency, failed to investigate the allegation, and failed to report the results of the investigation to the State Agency within 5 working days of the alleged incident, in accordance with the facility's Abuse, Neglect and Exploitation P&P. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's right to remain in the facility was permitted. The facility initiated a transfer/discharge of the resident without having first met the regulatory requirements, specific to a facility-initiated transfer/discharge for one of five sampled residents (Resident 1). * After Resident 1 exceeded her ordered out-on-pass time and missed her scheduled medications, the facility obtained a discharge against medical advice order. However, Resident 1 returned to the facility and wanted to enter the facility, at which time the facility did not allow Resident 1 to enter the facility. The facility failed to notify Resident 1's physician that Resident 1 had returned to the facility. The facility failed to conduct an assessment of Resident 1 upon her return to the facility. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide a notice of transfer/discharge to the resident and resident's representative, before the facility initiated a transfer/discharge for one of five sampled residents (Resident 1). This failure posed the risk for Resident 1 and Resident 1's representative not being aware of their appeal rights and potentially jeopardizing the appeal process in the event Resident 1 and/or Resident 1's representative felt the facility-initiated transfer or discharge from the facility was inappropriate and involuntary.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Residents 4) received care and services to address their pain and skin condition. * Resident 4 complained of pain; however, the resident's pain was not comprehensively assessed for location, timing, frequency, duration of pain, pattern, radiation of pain. There were no nonpharmacological interventions offered before the pain medication administration. Resident 4 complained of moderate pain but was given a pain medication prescribed for severe pain. In addition, the physician was not informed of the resident's moderate pain. * Resident 4 was admitted with multiple skin issues; [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 5) remained free from accident hazards. * While residing at the facility, Resident 5 sustained five falls. On 9/19/24 at 1340 hours, Resident 5 informed the CNA she needed to use the bathroom; however, the CNA failed to provide the resident with assistance; and at 1430 hours (per the medical record), Resident 5 was found lying on the floor in the bathroom and sustained a fractured right humerus after she attempted to transfer herself to the toilet. This failure resulted in the resident sustaining a fracture to the right humerus and hospitalization.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for the indwelling urinary catheter care to restore as much normal bladder function as possible for one of five sampled residents (Resident 4). * The catheter care was not provided in accordance with the facility's P&P for Resident 4. This failure posed the risk for the development of infection.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to offer a copy of the inventory of the resident's personal belonging and follow up with the resident's family regarding the personal belongings for Resident 4. This failure had the potential to affect the ability of the resident or resident's responsible party to be informed of their belonging. Findings Review of the facility's P&P titled Resident Personal Belonging dated [DATE], showed the inventories of all the items are to be reviewed and examined by social services designee and the resident's representative. Recipients of such personal items at the time of discharge or death shall sign off their legal signature acknowledging receipt of all personal belonging presented. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, safe, and homelike environment for one nonsampled residents (Resident C). This failure posed the negatively effects on Resident C's well-being.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to obtain the approval for the room sizes that were not meeting the required square footage. This failure had the potential for not compliance with the requirement.

Inspectors wroteBased on observation, interview, facility document review and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: 1. The kitchen equipment were not air dried before storage. 2. The cutting boards were not kept in sanitary condition and with cleanable surfaces. 3. A thawing process was not followed for meats. 4. The ice machine ice storage bin's splash guard and outside left area of ice machine were not clean. These failures posed the risk for food borne illnesses in highly susceptible resident population of 75 facility residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe for two of 18 final sampled residents (Residents 59 and 72) and one nonsampled resident (Resident 9) to self-administer the medications. * Resident 59 was observed with a bottle of Lung Cleansing Spray Fast Absorption Active Antibacterial Action (used to thin out mucus in the airways) at bedside. Resident 59 did not have the assessment, physician's order, and care plan addressing the resident's self administration of medications. * Resident 72 was observed with two packets of hydrocortisone acetate (used to treat skin swelling, itching and redness) 1% cream and a tube of Pain-A-[NAME] (used to treat muscle pain) pain relieving cream at bedside. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of three final sampled residents (Residents 62 and 476) reviewed for ADs were assisted in formulating the ADs. This failure had the potential for the facility to provide treatment and services against the resident's wishes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the notice of transfer/discharge information and notification of Ombudsman regarding transfer/discharge were completed for one of three closed medical records (Resident 33) reviewed. * The facility failed to document Resident 33's notice of transfer/discharge information in the medical record and provide documentation the Ombudsman was notified. This failure had the potential of miscommunication of information and not providing necessary care and services for this resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to coordinate an assessment with the PASRR program for two of 18 final sampled residents (Residents 13 and18) reviewed for PASRR as evidenced by: * The facility failed to update Resident 13's PASRR when the resident had a new diagnosis of mental disorder, for the PASRR level II review. * Resident 18's initial Level 1 PASSR screening conducted on 4/22/22, was positive for mental illness and no Level II mental health evaluation was performed. These failures posed the risk for Residents 13 and 18 not receiving the necessary specialized services specific to treat mental illness and had the potential for inappropriate placement in a skilled nursing facility.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one of 18 final sampled residents ( Resident 57) to ensure the resident maintained their highest physical well-being. * The facility failed to follow Resident 57's physician's order to provide the winged LALM (a special mattress designed to distribute the resident's body weight to prevent skin breakdown). This failure had the potential for Resident 57 to not receive the appropriate care and services needed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of five final sampled residents (Residents 57, 62, and 726) reviewed for respiratory care. * The facility failed to ensure Resident 57 was administered oxygen as ordered by the physician. * The facility failed to ensure Resident 62's continuous oxygen was administered as ordered. * The facility failed to ensure Resident 726's incentive spirometer was stored in a bag when not in use and the use of incentive spirometer addressed in the plan of care. These failures had the potential to negatively affect the respiratory health and well-being of the residents in the facility.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the ongoing assessment before, during, and after dialysis treatments for one of two final sampled residents (Resident 476) reviewed for dialysis services was accurate. This failure had the potential of not identifying negative outcomes for the dialysis resident (Resident 476).

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the proper storage, and disposal of medications. * The facility failed to dispose of the expired medications including three pieces of Bisacodyl (laxative) 10 mg suppositories which were stored together with Goodsense Clearlax Polyethylene Glycol 3350 Powder for Solution Osmotic Laxative (oral medication house supply). * The facility failed to dispose of the wasted narcotic medication stored in Medication Cart A. These failures had the potential for the medications to be accidentally administered and/or diverted.

Inspectors wroteBased on interview and facility P&P review, the facility failed to ensure the use and storage of food brought to the facility by the family members or visitors with safe food handling practices. This failure had the potential for unsafe food handling which could lead to food borne illness.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to implement their infection control program when: * CNA 2 failed to wear the proper PPE when performing the high-contact care for one nonsampled resident (Resident 579) who was on Enhanced Barrier Precautions. * A soiled cloth pad was placed on top of the toilet tank of adjoining bathroom of Rooms A and C. * CNA 4 did not sanitize her hands before and after providing care for one of 18 final sampled residents (Resident 55) and one nonsampled resident (Resident 53). These failures posed the risk for transmission of communicable diseases to other residents in the facility.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in safe operating condition when: * The ice machine was not cleaned and sanitized as per the manufacturer's instructions. This failure had the potential for the essential equipment not functioning in the way they were intended and in turn cause contamination of food, leading to illnesses for the residents.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for two of 18 final residents (Residents 17 and 62) and one nonsampled resident (Resident 726) reviewed for the side rails use. * The facility failed to ensure Residents17, 62, and 726's entrapment assessments were completed and included the assessments for Zones 6 and 7. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the comprehensive plan of care for one nonsampled resident (Resident 21) was revised to reflect the current care needs and interventions. * Resident 21's plan of care was not accurately updated to reflect the resident's DNR status. This failure had the potential for not providing care and services to meet the resident's needs.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure two of two compost bins were overflowing with lids not properly closed. This failure had the potential to attract pests/rodents that carry diseases.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for two of 18 final sampled residents ( Residents 18 and 72) were complete. * Resident 18's MAR was incomplete for monitoring signs and symptoms of bleeding and bruising related to anticoagulant therapy, monitoring for bipolar disorder manifested by angry outburst for no apparent reason, and monitoring of pain levels. * Resident 72's MAR was incomplete and accurate for the monitoring for the resident's body temperature and oxygen saturation level every shift for suspected/confirmed Covid 19 and the pain evaluation every shift. These failures had the potential for the residents' care needs not being met.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well- being for one of three sampled residents (Resident 2). * The licensed nurse did not follow the physician's order to hold the antihypertensive medication when the resident's blood pressures were below the prescribed parameter for Resident 2. This failure had the potential for Resident 2 to experience adverse effects.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to one of three sampled residents (Resident 1). * The facility failed to notify Resident 1's primary care physician regarding a missed dialysis (a process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) appointment. * The facility failed to document and notify Resident 1's primary care physician regarding significant weight changes. These failures had the potential for the primary care physician to not be aware of changes in Resident 1's care and needs.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure proper labeling and dating of food items in the kitchen, dry storage, and refrigerator. * The facility failed to ensure proper storage of the employees' food in the kitchen. * The facility failed to ensure the kitchen equipment and utensils were clean. * The facility failed to ensure the cutting boards were in sanitary condition. * The facility failed to ensure the resident dishware had a smooth cleanable surface. * The facility failed to air dry the dietary equipment. * The facility failed to ensure the employee personal items were not stored in the food preparation area. [...]

Inspectors wroteh. Medical record review for Resident 30 was initiated on 1/14/22. Resident 30 was admitted to the facility on [DATE]. Review of the Order Summary Report dated 12/1/21, showed a physician order dated 9/10/21, to have RNA perform PROM exercise to all extremities three times per week every day shift for 3 months ending on 12/10/21 Review of Resident 30's Restorative record of November, December 2021, and January 2022 showed RNA services provided on the following entries: - 11/11 and 11/25/21 - 12/15 and 12/29/21 - 1/5 and 1/7/22. There were missing RNA services documentation for the months of November, December 2021, and January 2022 for Resident 30. i. Medical record review for Resident 25 was initiated on 1/14/22. Resident 25 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * An expired bottle of lorazepam oral concentrate (medication for anxiety) was observed in Medication Cart 1. In addition, a bottle of lorazepam oral solution was stored in the medication drawer and not refrigerated as per the manufacturer's instruction. * Multiple expired, unlabeled medications with no open dates were observed in Treatment Cart 1. * Multiple expired medications were observed in Medication Cart 2. In addition, Medication Cart 2 was observed being unlocked and unattended on multiple occasions. * IV/Crash Cart 1 had an expired medication and was left unlocked. These failures had the potential to result in unsafe administration and diversion of medications.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to establish and maintain the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * There were no contact precaution signs posted outside Rooms A, B, C, D, and E in the facility's Yellow zone. * The facility failed to ensure the staff donned the necessary PPE prior to entering the contact precaution rooms. In addition, CNA 1 failed to don a gown when providing ADL care to Resident 498 who was on contact precaution. * Maintenance Supervisor 1 entered a resident's room in the Yellow zone without donning the proper PPE. Maintenance Supervisor 1 was not wearing the N95 (a particulate-filtering Facetime respirator) properly. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the call light was provided for one of twelve final sampled residents (Resident 47). * Resident 47 was not provided a call light system in order to call for assistance when needed. This has the potential for the resident's needs not being met promptly.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 47) was free from a physical restraint. * The facility placed another bed next to Resident 47's bed to prevent the resident from falling. In addition, the facility failed to ensure the least restrictive measures were attempted, the assessment was completed, and the informed consent was obtained from the resident or resident's authorized representative prior to placing an additional bed which restricted Resident 47's movement. These failures had the potential to result in injury and compromising Resident 47's psychological well-being.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the necessary treatment and services were provided to maintain, improve or prevent further decline in ROM functions for two of 12 final sampled residents (Residents 5 and 17) and one nonsampled resident (Resident 33). * The facility failed to apply a left hand resting splint (a splint to treat moderate flexion contractures of wrist/hand/thumb) seven times per week as ordered for Resident 17. * The facility failed to apply the PRAFO (Pressure Relief Ankle Foot Orthosis-a device worn on the calf and foot similar to a boot often used for patients to prevent bedsores or ulcers from developing on the back of the heel) splint on BLE (bilateral lower extremities) seven times per week as ordered for Resident 33. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 12 sampled residents (Resident 15) was provided a safe and accident free environment when Resident 15's bed was left unsupervised in a high waist-level position. This failure had the potential to result in Resident 15 experiencing an accident and injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the proper respiratory care for two of 12 final sampled residents (Residents 19 and 17). * The facility failed to ensure Resident 19 was administered oxygen as ordered by the physician. Resident 19's nasal cannula (a small, flexible tubing with two open prongs placed in the nostrils to deliver supplemental oxygen) was dated 11/29/21. * Resident 17's humidifier bottle (aids in preventing a patients airways from becoming dry while using an oxygen) and nasal cannula were not labeled to show when it was last changed. These failures had the potential for increased risk of infection.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the residents were provided the medications as ordered by the physician for two nonsampled residents (Residents 26 and 41). * The facility to ensure Resident 41's pregabalin ( pain medication ) was administered as ordered by the physician. * Resident's 26's famotidine (medication to treat indigestion) medication was not available to be administered as ordered by the physician. These failures had the potential of not meeting the residents' needs.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the pharmacy consultant's recommendations were acted upon for one nonsampled resident (Resident 33). * The pharmacy consultant recommended for Resident 33's PRN (as needed) orders for non-antipsychotic psychotropic (any drug that affects brain activity) drugs be limited to 14 days unless the prescriber documented the diagnosed specific condition being treated, rationale for the extended time period, and duration for the PRN (as necessary) order. The facility's failure to act upon the pharmacy consultant's recommendations had the potential to put Resident 33 at risk for adverse consequences related to the medication.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one nonsampled residents (Resident 33) was free from an unnecessary psychotropic drug (any drug that affects brain activity). The facility failed to ensure Resident 33's prescription for alprazolam (antianxiety medication) PRN (as needed) had a duration when the physician extended the order beyond 14 days. This had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department. * Cooks 1 and 2 were unable to properly demonstrate the process to verify the correct thermometer calibration. * Dietary Aide 1 was unable to correctly describe how to manually wash dishes in an emergency and was unable to correctly test the chemical concentration measured in parts per million of quaternary sanitizing solution used to sanitize food contact surfaces. These unsafe food practices had the potential to lead to foodborne illnesses in a highly susceptible population of residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure 12 of 44 residents received the proper amount of pureed food items when the incorrect portion size were used to served the residents who were on a pureed diet. This failure resulted in the residents on a pureed diet not receiving the nutrition as planned.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the special eating equipment and utensils were provided to one of 12 final sampled residents (Resident 5) during mealtime. * Resident 5 was provided with the regular utensils during meals when she was assessed to need the built up utensils ( a multi-purpose handle easily to create a larger gripping surface) and inner lip plate (a plate designed to assist children, the elderly, people with limited muscle control and individuals with the use of only one hand to keep food from sliding off the plate). This failure had the potential for the resident to not maintain or improve independence in self-feeding skills when consuming meals and snacks.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to implement their P&P to ensure proper storage of food in the residents' refrigerator. The facility failed to ensure proper labeling and dating of food items in the refrigerator used for the residents' food brought in by visitors. This had the potential to result in foodborne illnesses in a highly susceptible resident population.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to dispose and store trash in a sanitary manner. This failure posed a threat for pest contamination.

Inspectors wroteBased on interview and facility document review, the facility failed to establish an infection control program which included an antibiotic stewardship program designed to monitor antibiotic use. * The facility failed to ensure the assessment of the residents' signs and symptoms was reviewed and documented for appropriateness of antibiotic use in the Infection Control Surveillance log for the months of November and December 2021. This failure posed the risk of inappropriate antibiotic usage and inaccuracy of data.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the influenza and pneumococcal immunizations were provided for one of 12 final sampled residents (Residents 498). This failure had the potential for the residents acquiring, transmitting, or experiencing complications from influenza and pneumonia.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment used to prepare, serve, and store food in the facility. * The facility failed to ensure no ice buildup in the freezer of the refrigerator used to store the resident's food bought from outside sources. * The facility failed to ensure the Robot Coupe was in good condition. * The facility failed to ensure the plate dispensing Lowerator was functioning. These failures had the potential for equipment not functioning in the way they were intended and in turn cause contamination of food and medication, leading to illnesses for the residents.

Inspectors wroteBased on interview and facility document review, the facility failed to obtain the approval for the room sizes not meeting the required square footage, creating the risk for being in compliance with the requirement.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe environment for residents, staff, and visitors. * A linen was tied around the lock bar mechanism of the fire exit door located a the end of the hallway by the kitchen area, which prevented the door from locking automatically. This failure had the potential for not maintaining a safe environment for the residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the nurse staffing information was posted in a prominent place accessible to residents and visitors. This had potential of not having the staffing information be available to the residents and the public to determine if sufficient staff were available to care for residents.