Briarcrest Nursing Center

Inspectors wroteBased on interview and record review, the facility did not meet professional standards, by failing to provide a hand-off report (a vital communication tool used to pass patient care responsibility, critical status updates, from one healthcare worker or team to the receiving healthcare facility) for one of 4 residents (Resident 1), who was transferred to a General Acute Care Hospital (GACH) due to a change in medical condition. This failure had the potential for miscommunication and delay in providing care and services necessary to treat the resident's health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 4 residents (Resident 2), was provided with assistance with eating. This failure had the potential to result in Resident 2's poor food intake, dehydration and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident-centered care plan with interventions were developed to address food and medication allergies for one of 3 residents (Resident 1). These failures had the potential for the staff to serve resident allergic food and administer any of the allergic medications, placing the resident at risk for allergic reactions and potential health complications, including hospitalization. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Resident 2), who was receiving a continuous gastrostomy tube (GT, a surgical insertion of a tube into the stomach for nutrition and medication administration) feeding, had the head of the bed (HOB) elevated to 30 to 45 degrees. This failure had the potential to result in aspiration of feeding formula (when feeding formula enter into the airway), causing difficulty breathing, lung infections including hospitalization and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy and procedure (P/P) titled Handwashing/Hand Hygiene to adhere to infection control practices of removing gloves and handwashing before entering another resident's room for 1 of 7 sampled residents, Resident 4. This failure had the potential to increase the risk of spreading infection and bacteria and impeding the health and wellness of residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened and refrigerated soup was disposed of within three days, and frozen hashbrowns were covered and sealed for 104 medically compromised and vulnerable residents who received food from the kitchen. These deficient practices had the potential to place residents at risk for foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate respiratory monitoring, documentation, and assessments were completed, and oxygen signage was posted for one of three sampled residents (Resident 11) when the facility failed to ensure:a. Resident 11's oxygen administration was documented.b. Resident 11's Oxygen saturation (O2 sat- measurement of percentage of oxygen in your blood) was monitored every shift.c. Resident 11's oxygen care plan was developed to address Resident 11's continuous oxygen use.d. Display a No Smoking/Oxygen in Use sign at a resident room entrance where an oxygen concentrator (a medical device that provides oxygen-enriched air to help people breathe) was in use. These deficient practices had the potential to place Resident 11 at risk of delayed assessment, identification of respiratory complications, and delayed care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the medication refrigerator within the required temperature range for the storage of medications intended for resident use in one of one medication refrigerators reviewed. This deficient practice had the potential to compromise the stability, potency, and effectiveness of stored medications, placing residents at risk of receiving medications that may not provide the intended therapeutic effect and potentially adversely affecting their health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 73) was informed of the reason for being restricted from the nursing station. This deficient practice had the potential to violate Residents 73's rights, and potentially cause emotional distress and feelings of disrespect, resulting in a loss of dignity and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled Psychotropic Medication Use/Informed Consent dated 3/2024, for two of seven sampled residents (Resident 14 and Resident 56) when the facility failed to ensure:1. Resident 14's informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained for Depakote (a psychotropic medication that affect the mind, emotions, and behavior) prior to initiation.2. Resident 56's informed consent for Duloxetine (used to treat depression, generalized anxiety disorder, and various forms of chronic pain) was updated with the correct indication. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified in a timely manner of a resident's repeated refusal of a prescribed medication and an ordered ammonia (a blood test used to measure the amount of ammonia [a waste product] in the blood) level laboratory test for one of two sampled residents (Resident 40). This deficient practice resulted in Resident 40's physician not being informed of Resident 40's repeated refusals, and placed Resident 40 at risk for delayed assessment, delayed intervention, treatment, unmanaged change of condition, and potential adverse outcomes related to lack of physician oversight of the laboratory monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive care plans were developed for three of three sample residents (Resident 84, Resident 53, and Resident 40) addressing the following:1. Resident 84's use of oxygen therapy.2. Resident 53's use of pioglitazone (medication used to help lower blood sugar), metformin (medication used to help lower blood sugar), and glargine (medication given by injection that helps lower blood sugar).3. Resident 40's use of midodrine (medication used to raise blood pressure). These deficient practices had the potential to place Residents 84, 53, and 40 at risk for complications related to breathing, blood sugar control, and blood pressure management due to unmet care needs, inadequate monitoring of treatment, and lack of established therapeutic goals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a physician order for oxygen use for one of one sampled resident (Resident 84) who was receiving oxygen. This failure had the potential to result in Resident 84 experiencing respiratory complications, including excessive oxygenation and carbon dioxide retention (build up the body's natural waste gas in the bloodstream. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two staff-dependent sampled residents' (Resident 46 and Resident 12) fingernails were trimmed and maintained in a clean manner. This deficient practice had the potential to result in a negative impact on Resident 46 and Resident 12's quality of life and self-esteem, and had the potential to result in sustaining skin injury from scratching and developing an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents' (Resident 18 and Resident 21) room was free of accidents and hazards when Resident 18's headboard was observed broken and hanging away from the bed frame, and Resident 21's smoking assessment was not updated and smoking paraphernalia was not appropriately stored. These deficient practices placed Resident 18 and Resident 21 at risk for injury and an unsafe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the urine characteristics and document urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) care for one of one sampled residents (Resident 127), with an indwelling urinary catheter. These deficient practices had the potential to lead to delayed treatment and identification of urinary tract infections (UTI- an infection in the bladder/urinary tract) and improper urinary catheter management for Residents 127.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that feeding assistance was provided to one of four sample residents (Resident 2) who required feeding assistance with meals. This deficit practice placed Resident 2 at risk for choking, aspiration (accidental inhalation of food, liquid, or stomach contents into the airway), inadequate nutritional and fluid intake, weight loss, dehydration, and a decline in overall health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's consultant pharmacist's Medication Regime Review (MRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication, to the physician) recommendations for ammonia level (a blood test used to measure the amount of ammonia [a waste product] in the blood) laboratory test were completed for two of two sampled residents (Residents 14 and 40). This deficient practice resulted in Residents 14 and 40's recommended blood laboratory tests not being performed and had the potential to place the residents at risk for delayed identification and treatment of elevated ammonia levels and adverse drug reaction. Cross reference F580Findings: a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) and Midodrine (medication used to treat hypotension [low blood pressure]) were administered within the ordered parameters (specific, measurable, and objective clinical criteria set by a healthcare provider that dictate when a medication should be given, withheld, or adjusted) for two of three sampled residents (Residents 8 and 40). This deficient practice placed Resident 8 at risk for hypoglycemia (low blood sugar) and related complications, and placed Resident 40 at risk for an unsafe increase in blood pressure, headache, dizziness, slow heart rate, and other adverse effects related to medication administration outside of ordered parameters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 101) who was prescribed a fortified diet (diet enhanced to increase caloric content) was served a fortified lunch. This deficient practice had the potential to place Resident 101 at risk of decreased caloric intake and unmet nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) protocol for one of four residents (Residents 107) by not wearing the required personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when providing care to Resident 107. This deficient practice placed Resident 107 and other residents at increased risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the resident with an appropriate call light system that accommodated the resident's physical limitations for one of six sampled residents (Resident 95). This deficient practice resulted in Resident 95 being unable to independently summon staff assistance and placed the resident at risk for delayed response to care needs, delayed assistance, unmet needs, and potential injury due to inability to effectively communicate the need for assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan interventions were documented every shift for one out of three sampled residents (Resident 1) who was identified as a fall risk. This deficient practice resulted in Resident 1 suffering a fall on 5/5/2026 and sustaining a fracture (broken bone) to the right medial orbital wall (thin bone separating the eye socket from the sinuses).

Inspectors wroteBased on interview and record review, the facility failed to ensure the protection of residents' privacy and confidentiality when Certified Nursing Assistant (CNA) 2 recorded and photographed two of two sampled residents (Resident 1 and Resident 2) without Residents 1 and 2's knowledge or consent on her cell phone. CNA 2 shared the recordings and photographs with CNA 1. This deficient practice resulted in a violation of Resident 1 and Resident 2's rights to privacy and confidentiality, and placed Resident 1 and Resident 2 at risk for unauthorized disclosure of protected health information, loss of dignity, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Change in a Resident's Condition or Status, which indicated the nurse would notify the resident's attending physician (PCP) for changes in condition for one of three sampled residents (Resident 2) when:Registered Nurse (RN) 1 identified a discoloration/bruise to Resident 2's left hip area on 3/14/2026. Resident 2 alleged that on 3/14/2026, she was hit by a Certified Nurse Assistant (CNA). This failure had the potential to result in delayed medical care for Resident 2 and had the potential to negatively affect the resident's psychological and physical well-being. Cross Reference F842Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Bed-Hold (a resident's right to keep a bed vacant and available for seven days after their transfer to the hospital [GACH] in anticipation of their return to the facility) written notification as indicated in its policy and procedure (P&P) titled, Bed-Holds and Returns to one of three residents (Resident 3), who was transferred to the GACH on 3/10/2026. This failure had the potential to violate Resident 3's right to a bed-hold and result in the resident's inability to return to his home at the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate clinical medical records, for one of three sampled residents (Resident 2) by failing to:Ensure Registered Nurse (RN) 1 documented Resident 2's full body (head-to-toe) assessment and skin discoloration/bruise identified on 3/14/2026 in the resident's medical records. Ensure RN 1 did not document a recommendation of PCP (Primary Care Physician) in Resident 2's Change in Condition (COC) form without speaking with the PCP. This deficient practice had the potential to result in miscommunication between staff and a delay in the provision of care or interventions for Resident 2. Cross Reference F580Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct monitoring for one of two sampled residents' (Resident 4) who had behavior of aggressive angry outbursts. This deficient practice had the potential to result in the inaccurate assessment of the effectiveness of Resident 4's medication regimen.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Resident-to-Resident Altercations which indicated to separate residents after an altercation for two of two sampled residents (Residents 4 and 5). This deficient practice resulted in Resident 4 and 5 being involved in a verbal altercation which escalated to Resident 5 pushing Resident 4 into the nightstand and sustaining an abrasion (scratch) above his right eyebrow.

Inspectors wroteBased on interview and record review, the facility failed to submit a Preadmission Screening and Resident Review (PASRR- a federally mandated screening process designed to ensure individuals with serious mental illnesses or intellectual/development disabilities receive the necessary support) Level 1 Screening for one of five sampled residents (Resident 4). This deficient practice had the potential to result in Resident 4 not receiving the necessary and appropriate psychiatric level treatment and evaluation in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan with interventions for one of three sampled residents' (Resident 1) use of side rails (short rails on one or both sides of the bed that can be used to assist in bed mobility). This deficient practice had the potential to result in Resident 1 not receiving the necessary care to safely utilize the side rails. Cross Reference F700.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a side rail utilization assessment prior to installing side rails, obtain an order for the use of side rails, and ensure informed consent was obtained prior to the use of side rails for two of three sampled residents (Residents 1 and 2). These deficient practices had the potential for the unsafe use of Resident 1 and 2's side rails which could lead to entrapment (becoming caught, trapped, or tangled in between a small space) and injury.

Inspectors wroteBased on interview and record review, the facility failed to honor one of three sampled residents' (Resident 6) privacy. This deficient practice resulted in Resident 6 feeling frustrated and distrust in the facility to honor his privacy request.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the low air loss mattress (LALM- a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) guideline for the use of linens for one of three sampled residents (Resident 2). This deficient practice had the potential to result in worsening of Resident 2's pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) and the development of new skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to install bilateral (both sides) half side rails (short rails on both sides of the bed that can be used to assist in bed mobility) as ordered and provide two-person assistance prior to providing care to one of four sampled residents (Resident 5). These deficient practices resulted in Resident 5 falling off her bed on 12/26/2025.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of staff-to-resident abuse to the California Department of Public Health (CDPH) timely for one of two sampled residents (Resident 1). This deficient practice placed Resident 1, and other facility residents, at risk of sustaining abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of staff-to-resident abuse was investigated for one of two sampled residents (Resident 1). This deficient practice placed Resident 1, and other facility residents, at risk of potential abuse.

Inspectors wroteBased on interview and record review, Registered Nurse (RN) 1 failed to conduct neurological assessments ( neuro-checks, assessments that evaluate brain and nervous system functioning) at the required frequency/interval for one of two sampled residents (Resident 1) after Resident 1 was allegedly hit on the head by a male Certified Nursing Assistant (CNA). This deficient practice placed Resident 1 at risk of staff not identifying, or being delayed in identifying, potential neurological complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's medical records were complete and accurately documented for one of two sampled residents (Resident 2) by not ensuring licensed nurses1. Documented the number of behavioral episodes on the Medication Administration record (MAR);2. Monitored Resident 2 for behavioral episodes (period or event marked by unusual, disruptive, or problematic behavior);3. Had the knowledge to complete monitoring section in the MAR; and4. Licensed nurses documented Resident 2' s return to the facility. These deficient findings could potentially place other residents in the facility at risk to Resident 2's behavioral episodes. These deficient findings created miscommunication on when and at what time Resident 2 returned to the facility.

Inspectors wroteBased on interview, and record review, the facility failed to develop an individualized resident care plan for one of six sampled residents (Resident 1), who had a diagnosis of dementia (a progressive state of decline in mental abilities). This deficient practice had potential to result in the nurses not being able to provide quality care and could affect in maintaining the highest practicable physical, mental and psychosocial well-being of the resident.

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive, resident-centered care plan for one of three residents (Resident 1), who had a physician's order for fluid restriction (the amount of water the resident can drink in a day). This failure had the potential to result in Resident 1 not receiving the care and services the physician had ordered and placed the resident at risk to worsening clinical condition.

Inspectors wroteBased on interview and record review, the facility failed to follow the food allergies (abnormal response after a certain food is eaten) for one of four sampled residents (Resident 1) by serving Resident 1 fish, who was allergic to seafood. This deficient practice resulted in Resident 1 having an allergic reaction and had the potential to cause Resident 1 to have an anaphylactic shock (severe, potentially life-threatening allergic reaction) the reaction may include itchy skin, edema, collapsed blood vessels, fainting, difficulty in breathing, and death).

Inspectors wroteBased on observation, record review and interview, the facility failed to implement its infection prevention and control measures for two of four sampled residents (Residents 2 and 4) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 and Restorative Nursing Assistance (RNA) 1 wore personal protective equipment (PPE-specialized clothing or equipment such as gloves and gown worn to minimize exposure to serious illness) while providing care to Residents 2 and 4, who was on Enhanced Barrier Precautions (EBP-an approach to the use of to reduce transmission of Multidrug-Resistant Organisms [MDRO- bacteria that are resistant to multiple antibiotics].) 2. Ensure clear signage was posted to inform staff of the EBP to be followed when providing care to Resident 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN 1) supervised the medication administration for one of three sampled residents (Resident 2), who had not been assessed by the Interdisciplinary Care Team (IDT- a group of healthcare professionals who work together to manage the resident ' s care) for medication self-administration. This failure placed Resident 2 at risk for medication errors including delayed doses or missed doses and could lead to adverse drug events for the resident.

Inspectors wroteBased on interview and record review, the facility failed to assess and notify Resident 1 ' s Medical Doctor (MD) when one of three residents (Resident 1), had tachycardia (heart rate faster than normal) and tachypnea (rapid breathing) on 2/17/2025. This failure resulted in delayed treatment and the resident's transfer to a general acute care hospital (GACH) for evaluation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the following for two of four sampled residents (Resident 23 and Resident 66). 1. Certified Nursing Assistant (CNA) 4 used a two person assist when performing perineal care ([peri care] the washing of the genitals and anal area) and repositioning for Resident 23. 2. The call light was within reach and fall mats were provided for Resident 66. This failure resulted in Resident 23 falling from the bed, sustaining a bilateral (pertaining to both sides) femur fractures (broken thighbone, a serious injury, often requiring surgery and extensive rehabilitation, and is typically caused by high-impact trauma like car accidents or falls) which required surgical intervention at a general acute care hospital (GACH). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set Nurse (MDSN) 1 demonstrated the competencies required of her job position and failed to evaluate MDSN 1's ability to accurately perform MDS assessments on an annual basis. This failure placed all facility residents at risk of receiving inaccurate Minimum Data Set (MDS, a resident assessment tool) assessments, which could negatively impact the care the residents received because their care plans were based on data contained in the MDS. Cross-reference F-tag F641.

Inspectors wroteBased on observation, interview, and record review, the facility to failed ensure infection control measures were implemented for five of 26 sampled residents (Residents 84, 6, 40, 101, and 104) when: 1. Signage for enhanced barrier precautions (EBP, precautions utilized to prevent the spread of multi-drug-resistant organisms [MDROs, microorganisms, primarily bacteria, that have developed resistance to multiple classes of antibiotics] to residents) was not posted outside of Resident 84's room or Resident 6's room. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label the personal belongings of one of one sampled resident (Resident 120). This failure placed Resident 120 at risk of not maintaining possession of her belongings due to staff being unaware of who the item belonged to.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure needs and preferences were accommodated for two of 26 sampled residents (Resident 65 and Resident 40) when: 1. Staff failed to ensure the call light was within reach for Resident 40. 2. Staff failed to ensure the call light was within functional reach of Resident 65, and ensure staff assisted Resident 65 to put on her bifocal glasses. These deficient practices created the potential for a delay or an inability for Resident 40 and Resident 65 to obtain necessary care and services as needed. These deficient practices also created the potential to negatively impact Resident 65's quality of life due to her inability to see clearly without her glasses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) assessments for four of 26 sampled residents (Residents 65, 84, 23, and 109) were completed and documented accurately. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Residents 65, 84, 23, and 109's health status. This deficient practice also created the potential for Residents 65, 84, 23, and 109 to not receive the care and interventions needed to reach their highest practicable physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR- 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) Level II Evaluation was completed for one of six sampled resident (Resident 86). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Residents 86.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were developed and/or implemented for 7 of 26 sampled residents (Residents 66, 21, 65, 62, 72, 109, and 12) when: 1. Resident 66's call light was not within reach on 3/11/2025 and fall mats (cushioned floor pads designed to help prevent injury should a person fall) were not placed at the bedside on 3/11/2025, 3/12/2025, and 3/13/2025. 2. Resident 21 and Resident 66 did not have care plans for their use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). 3. Resident 65 did not have a care plan developed for her use of corrective lenses (glasses). 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain good grooming and personal hygiene for two of six sampled residents (Residents 49 and 62) by failing to keep Resident 49's fingernails, and Resident 62's toenails clean and neat. This failure had the potential to result in a negative impact on Residents 49 and 62's quality of life and self-esteem and had the potential for the development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM - a mattress designed to distribute the individual's body weight over a broad surface area and help prevent skin breakdown) was set according to the resident's weight for one of six sampled residents (Resident 282). This deficient practice had the potential to cause the development, worsening or reinjury of pressure sores (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) to Resident 282.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Director of Rehabilitation (DOR), or the assigned Licensed Vocational Nurse (LVN) were made aware of the development of a resident's right-hand contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) for one out of two sampled residents (Resident 95). This failure had the potential to result in the worsening of Resident 95's right hand contracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the midline (a long thin, flexible tube inserted into a large vein used to administer medication) insertion site at least every shift and change the dressing every seven (7) days for two of six sampled residents (Residents 330 and 72). This deficient practice had the potential for Residents 330 and 72's Midline insertion site to develop an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were provided for one of three sampled residents (Resident 65) when: 1. Resident 65's call light was not placed within reach to allow Resident 65 to call for assistance. 2. Staff failed to reposition Resident 65 at least every two hours. These failures placed Resident 65 at risk for avoidable undue pain due to staying in the same position for a prolonged period. These failures also created the potential for a delay or an inability for Resident 65 to request help from staff for repositioning, also interfering with Resident 65's ability to report her pain to staff, and request interventions to address the cause of her pain and treat it.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the following for one of one sampled residents (Resident 15): 1. Adequate documentation indicating Resident 15's physician (MD) 1 was made aware of Resident 15's newly prescribed antipsychotic (a class of medications used to treat mental health conditions medication) after being readmitted from the general acute care hospital (GACH). 2. Carry out MD 1's order for a psychiatrist consult (focusing on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders, including substance use disorders) when Resident 15 displayed physically aggressive behaviors on 3/8/2025. These failures had the potential to result in a delay of necessary behavioral health treatment and services to maintain the highest practicable physical, mental and psychosocial well-being for Resident 15.

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident window screen was the correct size and without gaping, and the toilet seat was not broken for one of six sampled residents (Resident 133). These deficient practices had the potential to place Resident 133 at risk for injury, entry of insects into the room, and negatively impact Resident 133's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of one of eight sampled residents (Resident 1) at risk for wandering by failing to: 1. Ensure the front and back exit doors were monitored, after the front lobby exit door alarm was activated by Resident 1 on 2/24/2025 at 7:43 p.m. 2. Closely monitor Resident 1's whereabouts in the facility after he attempted to leave from the front exit door on 2/24/2025 at 7:43 p.m. 3. Educate Resident 1 on the risk of leaving the facility after his first elopement (the act of leaving a facility unsupervised and without prior authorization) attempt on 2/24/2025 at 7:43 p.m. 4. Ensure the facility's back exit door alarm was activated on 2/24/2025. As a result, Resident 1 eloped from the facility's back exit door on 2/24/2025 at 7:47 p.m., four minutes after activating the front exit door alarm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices designed to provide residents a safe, sanitary, and comfortable environment, by failing to follow the posted Novel (a newly identified respiratory pathogen that cause respiratory infections) Respiratory Precautions (NRP, a precaution to minimize spread of respiratory infection in caring for infected resident in a health care settings), indicating to wear a gown (a piece of protective clothing worn to prevent the spread of disease and contamination) on room entry, wear N-95 (a respiratory protective device designed to achieve a very close facial fit to form a seal around the nose and mouth to efficiently filter airborne particles)and face shield or goggles (protective covering for the eyes to reduce the spread of a transmissible disease) prior to entry of three COVID-19 [a [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation- Reporting and Investigating which indicated injuries of unknown source would be reported to the State Licensing/Certification Agency within two hours for one of four sampled residents (Resident 1) when Resident 1 developed new, multiple skin discolorations and bruising (collection of blood underneath the skin that is caused by an injury)to the left cheek and chin. This failure delayed the investigation by the State Agency and placed Resident 1 at risk for continuous abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate injuries of unknown source for one of four residents (Resident 1) when Resident 1 developed new, multiple skin discolorations and bruising (collection of blood underneath the skin that is caused by an injury) to the left cheek and chin. This failure had the potential to result in unidentified abuse and placed Resident 1 at risk for continuous abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received treatment and care in accordance with the comprehensive person-centered care plan. This failure resulted in Resident 1 sustaining Moisture-Associated Skin Damage ([MASD] damage in the skin in response to prolonged skin exposure to moisture) to the sacrococcyx area and bilateral groin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe administration of gastric tube feeding (the administration of milk/nutrition via gastric tube [a surgical opening in the abdomen into the stomach] to one of three residents (Resident 1), by failing to ensure: 1. The gastric tube feeding was paused (on hold), while the staff was lowering the head of bed (HOB) prior to performing nursing care. 2. Licensed personnel paused Resident 1's tube feeding pump. These failures had the potential to cause Resident 1 to aspirate (inhale a substance into the lungs) and placed Resident 1 at risk for complications such as pneumonia (lung infection) and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to prevent a fall for one of four sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA 1) provided a two-person physical assist (help from two persons) when using a Hoyer Lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from the bed to a Geri-chair (padded chair to provide comfort and support for people with limited mobility). This deficient practice caused Resident 1 to fall and sustain an acute (immediate) fracture (broken bone) of the fifth cervical (relating to the neck) (C5) vertebra (bone in the spine). Resident 1 was transferred to a general acute care hospital (GACH) for evaluation and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had the right to be free from neglect for one of four sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA 1) provided a two-person physical assist (help from two persons) when using a Hoyer Lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from the bed to a Geri-chair (padded chair to provide comfort and support for people with limited mobility). This deficient practice caused Resident 1 to fall, sustain an acute (immediate) fracture (broken bone) through the fifth (C5) vertebral (neck bone), was admitted to a general acute care hospital (GACH), and had the potential to place other residents at risk for neglect.

Inspectors wroteBased on observation, interview, and record review that facility staff failed to ensure one resident out of 3 sampled residents (Resident 1) was served the correct therapeutic diet, per doctors ' order. 1. The facility did not ensure Resident 1 received food that was prepared for a minced/moist diet (MM5, food that requires minimal chewing and food that is equal or less than 4 millimeters (mm) width and no longer than 15 mm in length). Resident 1 ' s food was not finely minced and a regular bread roll was served to resident. This deficient practice had the potential for Resident 1 to have problems chewing and swallowing. This deficient practice increased the risk for Resident 1 to choke while eating.

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent (process of communication between resident/responsible party and health care provider that often leads to agreement or permission for care, treatment, or services) prior to the administration of psychotropic medication (medications that affect the mind, emotions, and behavior) for one out of one sampled resident (Residents 1). 1. The facility did not ensure an informed consent was obtained when lorazepam (medication that relieves symptoms of anxiety, causes paranoid or suicidal ideation and impairs memory, judgment, and coordination) medication dosage was increased from 0.5 milligrams (mg, unit of measurement) to 1 mg for Resident 1. This deficient practice violated Resident 1 ' s right to make an informed decision prior to the administration of lorazepam medication.

Inspectors wroteDuring an interview and record review, the license nurses failed to review, update, and/or revise a care plan (written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual) to reflect the physician current order for lorazepam (medication that relieves symptoms of anxiety [feeling of unease, excessive worry]) for one out of one sampled resident (Resident 1). This deficient practice had the potential to result in Resident 1 not receiving an accurate dose of lorazepam and had the potential to negatively affect Resident 1 ' s physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to answer call lights in a timely manner for three out of three sampled residents (Resident 1, 2, and 3). This deficient practice had the potential to cause a negative impact on Resident 1, 2, and 3's health and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide safe oxygen administration practices for one of three sampled residents (Resident 2) when the facility failed to: 1. Ensure Resident 2 received oxygen at 2 liters per minute (LMP) per the physician's order. 2. Label Resident 2's nasal cannula (a plastic medical device to provide supplemental oxygen therapy to people who have lower oxygen levels, device goes directly into the nostrils). 3. Replace Resident 2's nasal cannula tubing after the nasal tubing prongs (portion of nasal tubing that goes into nostrils) touched the floor. These deficient practices had the potential to cause a negative respiratory outcome and increased the risk for Resident 2 to acquire a respiratory infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 5) received food according to his preference. This deficient practice had the potential to result in decreased meal intake, weight loss and malnutrition (when the body does not get enough nutrients).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Maintain residents' room temperatures in a range of 71 to 81 degrees (unit of measurement) Fahrenheit (F, a scale of temperature) for 9 out of 9 resident rooms (Rooms 106, 128, 129, 130, 132, 133, 134, 135, and 136). 2. Implement the facility's contingency plan (involves making various decisions as an organization before an emergency happens) when the air conditioning (A/C) unit became inoperable on 6/22/2024 affecting 9 out of 9 resident rooms (Rooms 106, 128, 129, 130, 132, 133, 134, 135, and 136). 3. Implement cooling measures to keep residents comfortable for 10 out of 10 residents (Resident 1, 2, 12, 13, 25, 26, 27, 28, 29, and 30) when the A/C unit became inoperable on 6/22/2024, a total of 3 days. [...]

Inspectors wroteThe facility failed to support four out of five residents (Resident 1, 3, 25, and 28) in their choice of activities for by failing to ensure: 1. Resident 1 was assisted out of bed every day. 2. Resident 3 was assisted to group activities and special events. 3. Resident 25 participated in activities in a group setting and was allowed to go outside to get fresh air when the weather was good. 4. Resident 28 participated in activities in a group setting. These deficient practices had the potential to cause depression, anxiety, and other psychosocial harm to Resident 1, 3, 25, and 28 due to a lack of socialization, stimulation, and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Serving Drinking Water, for six out of 14 sampled residents (Resident 1, 2, 3, 20, 25, 27), after the air conditioner stopped working by not: 1. Offering water and providing adequate fluids to Resident 1 and Resident 3, who were completely dependent on staff for activities for daily living. 2. Ensuring fresh water was available at the bedside for Residents 2, 3, 20, 25, and 27. These deficient practices had the potential for Resident 1, 2, 3, 20, 25, 27 to become dehydrated and/or suffer from heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document the activity attendance records for one out of three residents (Resident 1). This deficient practice had the potential to result in Resident 1 not receiving services needed such as getting out of bed to prevent a lack of mobility related injuries such as skin break down, and psychosocial injuries such as anxiety (excessive worry) and depression (lowering of a person ' s mood) related to isolation and a lack of stimulation.

Inspectors wroteBased on observation and interview, the facility failed to remove medication labels that contain resident medical information from medication containers prior to disposing in the pharmaceutical (relating to medications, drugs) waste containers, in one of one inspected medication room. This deficient practice resulted in the privacy and confidentially of residents' medical records being jeopardized and not securely maintained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services were provided to prevent pressure ulcer (injury to the skin and/or underlying tissue) and/or pressure injury development for five of five sampled residents (Resident 106, Resident 96, Resident 15, Resident 17, and Resident 50). The facility failed to: 1. Ensure nursing staff turned and repositioned, and monitored Resident 106's skin integrity for skin breakdown to prevent a sacral (sacrum, tail bone) Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer from reopening. 2. Ensure the nursing staff monitored the settings of Resident 96's low air loss mattress (mattress designed to prevent and treat pressure wounds by redistributing airflow and positioning) for functionality. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for the 56 residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services. This deficient practice had the potential for 56 residents with physician's orders for RNA to experience a decline in range of motion (ROM, full movement potential of a joint) and mobility (ability to move). Cross Referenece to F-tag F688.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Account for one dose of controlled substance (CS) for Resident 420 in one of three inspected medication carts (Medication Cart 3). 2. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Antibiotic or Controlled Drug (also known as Controlled Medication or Controlled Substance [CM, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) accountability logs for 29 of 29 sampled records. As a result, the control and accountability of CS awaiting final disposition (process of returning and/or destroying unused medications) were not followed as indicated in the facility policy and procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 25 total opportunities contributed to an overall medication error rate of 8% affecting one of four residents observed for medication administration (Resident 63). The medication errors were as follows: Resident 63 did not receive a form of aspirin (a medication used to prevent stroke [condition where there is blockage of blood supply to the brain]) and was not instructed to rinse mouth after the administration of mometasone (a corticosteroid [an anti-inflammatory medication also known as steroid] medication used for wheezing [difficulty in breathing]) as ordered by Resident 63's physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Store one insulin (medication used to regulate blood sugar levels) Humulin N (intermediate acting insulin) kwikpen (type of insulin injection device) for Resident 4, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart 3.) 2. Store one insulin Humulin R (short-acting insulin) vial for Resident 116 at room temperature, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart 3.) 3. Provide a safe storage and label of medication for one of one sampled resident (Resident 51). [...]

Inspectors wroteBased on observation, interview, and record review, the facility's dietary staff failed to ensure sanitary food preparation, food storage and food distribution practices, were followed by: 1. Failing to ensure the trash can lid opened correctly at the handwashing station. 2. The Dietary Supervisor (DS) touching the lid of the trash bin after performing hand hygiene. 3. Failing to properly package and label open food items in the dry storage area. 4. Failing to ensure poured milk and poured juices were labeled with the correct date in the refrigerator. 5. Failing to discard outdated poured milk and poured juices in the refrigerator. 6. Failing to ensure gloves were changed and hands were washed after touching face and mask during meal preparation. 7. Failing to ensure kitchen staff did not come in contact with the food and plates and cause food contamination during food preparation. 8. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control program, were maintained by failing to ensure: 1. Facility staff's personal and opened beverage containers were not stored on areas designated for clean resident clothing items; soiled linens and supplies were not stored in a handwashing sink in the laundry room and not placed on top of a storage cart containing personal protective equipment ([PPE] protective garments or equipment designed to protect the wearer's body from infection) in the laundry room. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the walk-in freezer was maintained in good working condition. This deficient practice had the potential to cause foodborne illnesses and affect the quality of food for all 124 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that call lights were within reach for two of 25 sampled residents (Resident 28 and Resident 14). These deficient practices had the potential to cause avoidable harm to Resident 28 and Resident 14 from an inability to call staff for assistance and the potential for falls and associated injuries. Cross Reference See F-tag F656 and F-tag F689.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations for resident needs for one of six residents (Resident 29) by failing to: 1. Ensure Resident 29's call light was within reach at the bedside. 2. Ensure Resident 29's call for assistance was answered timely. These deficient practices had the potential to cause avoidable harm to Resident 29 from an inability to call staff for assistance and the potential for falls and associated injuries and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the certified nursing assistants (CNA)failed to notify the licensed nurse, and the licensed nurse failed to notify the physician of loose bowel movements for one of one sampled resident (Resident 50). This deficient practice had the potential for Resident 50 to exhibit dehydration, the continued unnecessary use of a laxative medication, electrolyte imbalances (important minerals in the blood), and an undetected infection of Clostridium Difficile ([C. Diff]- a bacteria that causes life-threatening diarrhea).

Inspectors wroteBased on interview and record review, the facility failed to implement interventions for six of 25 sampled residents (Residents 14, 28, 81, 15, 17, and 96) as indicated in the care plan when the following occurred: 1. Resident 28 and Resident 14 did not have theirs call lights in reach, as indicated in their fall risk care plans. 2. Resident 81 did not have a care plan in place for his tendency to wander into other facility residents' rooms. 3. Resident 15, Resident 17, and Resident 96 were not repositioned every two hours and/or provided with pressure relieving devices as indicated in their pressure ulcer (PU, injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) prevention care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 35), who had difficulty with speech and spoke a language other than English, was provided a communication device in the language that the resident was able to understand. This deficient practice prevented Resident 35 from communicating with staff and had the potential to negatively affect Resident 35's physical, mental, and psychosocial needs and potentially causing missed or delayed care and/or treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide (RNA) therapy orders were performed as ordered by the physician for four out of 10 sampled residents (Residents 83, 45, 82, and 79). This deficient practice had the potential to cause a decline in the mobility and range of motion for Residents 83, 45, 79, and 82. Cross reference to F-tag F725.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a safe and hazard free environment was maintained for four of four sampled residents (Resident 28, Resident 14, Resident 81, and Resident 43) when the following occurred: 1. Resident 28 did not have his call light in reach. 2. Resident 14 did not have his call light in reach. 3. Resident 81 entered Resident 43's room unsupervised and without permission and Resident 81 did not have a care plan in place for his tendency to wander into other facility residents' rooms. This deficient practice had the potential to cause avoidable harm to Resident 28 and Resident 14 from an inability to call staff for assistance and the potential for falls and associated injuries. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen as ordered by the physician and ensure the resident's nasal cannula (small, flexible tube that contains two open prongs intended to sit inside the nostrils for oxygen administration) was not on the floor for two of six sampled residents (Resident 274 and 60). These deficient practices had the potential to cause Resident 274 and 60 avoidable harm and respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure the policy and procedure titled, Certified Nurse Assistant (CNA) that indicated CNA will relay all pertinent information concerning a resident ' s condition to a charge nurse when required, was followed, when 1 of 3 sampled residents (Resident 1), had a fall. This failure resulted in a delayed body assessment to Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to elevate head of bed at 30 to 45 degrees during tube feeding (nutrition administered via tube surgically inserted into the stomach) as indicated in the physician ' s order and care plan interventions for 1 of 3 sampled residents, Resident 2. This failure had the potential to result in aspiration (when food or liquid is breathed into the airways or lungs, instead of being swallowed), difficulty breathing and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its infection control policy and procedures (P&P) by failing to: a. Ensure staff properly wore Personal Protective Equipment ([PPE] specialized clothing or equipment such as a gown, respirator, surgical mask and faceshield worn to minimize exposure to serious illness) while in the facility. b. Ensure staff performed hand hygiene after exiting one of one resident ' s room (Resident 4) who was on Enhanced Standard Precautions ([ESP] an infection control measure designed to reduce the spread of multidrug resistant organisms ([MDRO] bacteria that are resistant to certain antibiotics). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 2 and Resident 4) who had long rough edges toenails received foot care and treatment according to the facility's policy and procedure (P&P). This deficient practice placed Residents 2 and 4 at risk for infection of the toenails, pain and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 4 sampled residents (Resident 2 and Resident 3) gastrostomy tube ([GT] tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) feeding formula was labeled with the date and time according to the facility ' s policy and procedure (P&P). This deficient practice had the potential to result in Residents 2 and 3 receiving enteral tube feeding formula over the expiration or maximum formula hang time (how long a tube feeding formula should hang safely prior to discarding or changing) and could adversely affect the resident ' s health and wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired gastrostomy tube ([GT] tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) feeding formula was discarded according to the facility policy and procedure (P&P) and not kept in the facility storage room. This deficient practice had the potential to result in the residents ingesting expired feeding formula which could lead to symptoms such as nausea, vomiting, stomach cramps, diarrhea, and hospitalization.