California Post-Acute Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician and a resident's Responsible Party (RP) after one of three sampled residents (Resident 1) sustained a skin tear (a traumatic wound) to the right lower leg. This deficient practice had the potential to delay physician evaluation and treatment, delay timely implementation of appropriate interventions, prevent the RP from participating in care decisions, and increased the risk of wound deterioration, infection, pain, and delayed healing, and other adverse clinical outcomes.

Inspectors wroteBased on interview and record review, the facility failed to submit a report of the findings of its investigation of an allegation of abuse within five (5) working days to the State Survey Agency for one of three sampled residents (Resident 1). This deficient practice had the potential to delay regulatory oversight and verification that the allegation had been thoroughly investigated, appropriate actions have been implemented, and residents were protected from further potential abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were accurate, complete, and current for one of three sampled residents (Resident 1), by failing to:1. Ensure Treatment Nurse (TXN) 1 accurately documented Resident 1's skin tears identified on 7/13/2026 in the resident's medical records. 2. Ensure TXN 1 accurately completed, signed, and dated Resident 1's situation, background, assessment, recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents) on 7/13/2026, to reflect the resident's change of condition. These deficient practices had the potential to result in inaccurate or incomplete medical records, miscommunication among healthcare staff, delayed assessment and treatment, and compromised continuity of care for Resident 1. Cross Reference to F580.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who experienced a change in condition, received timely assessment, monitoring, and emergency intervention for one out of three sampled residents (Resident 1) when the following occurred: 1. Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 failed to promptly initiate emergency services for Resident 1 after he began experiencing a change of condition, which included a decreased oxygen saturation level of 78 percent (%, the percentage of oxygen in a person's blood, normal range 93-100 %), right hand and leg swelling, cold and pale skin, difficulty breathing, and progressive lethargy (a state of severe fatigue, sluggishness, and lack of energy or motivation that affects both physical and mental functioning).2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled Trauma Informed Care, dated 1/2026, by ensuring staff received training and/or in-services to ensure they were equipped to provide all facility residents with trauma-informed care (an organizational and clinical framework requiring skilled nursing and long-term care facilities to recognize, understand, and respond to the effects of trauma). This failure placed the facility residents at risk of not receiving care to meet their behavioral health needs, including person-centered care approaches designed to meet their individual goals.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) was not held down by Certified Nursing Assistants (CNA 1 and CNA 2) during care. This failure resulted in Resident 1 experiencing psychosocial distress and physical pain after being held down despite Resident 3's refusal of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate abuse prevention for one of two sampled residents (Resident 5) by failing to provide Resident 5 with 1:1 supervision (one-to-one, a high level of patient monitoring where a single healthcare staff member is assigned exclusively to one patient to observe, protect, and assist them continuously), as ordered by the physician, following Resident 5's involvement as the aggressor in a resident-to-resident altercation on 6/16/2026. This failure resulted in Resident 5 wandering the facility unsupervised, placing her at risk of involvement in another altercation with and abuse of another facility resident.

Inspectors wroteBased on interview and record review, the facility failed to provide one of one sample resident (Resident 3) with a daily bath or shower, as indicated in her care plan. This failure did not honor Resident 3's care preferences, and placed her at risk of not having her care needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were updated for one of two sampled residents (Resident 5) to reflect the physician's orders for 1:1 supervision (one-to-one, a high level of patient monitoring where a single healthcare staff member is assigned exclusively to one patient to observe, protect, and assist them continuously), following Resident 5's involvement as the aggressor in a resident-to-resident altercation. This failure resulted in Resident 5's care plan not reflecting the interventions needed to prevent further altercations, and placed the safety of Resident 5, and other facility residents, at risk.

Inspectors wroteBased on interview and record review, the facility failed to provide one of one sample resident (Resident 3) with her required level of assistance during provision of activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). This failure placed Resident 3's safety at risk from not having the required assistance and supervision during care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the need for specialized rehabilitation services was determined for one of one sample resident (Resident 3) following a decline in Resident 3's ability to perform activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility. This failure delayed the opportunity for Resident 3's care team to determine if Resident 3 could benefit from physical and/or occupational therapy (healthcare specialties that help individuals reduce pain, restore mobility, and regain functional independence).

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician completed the Physician Discharge Summary assessment for two of two sampled residents (Resident 3 and Resident 4). This failure placed Residents 3 and 4 at risk of being discharged without a physician assessment or a physician-guided plan of care upon discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three (3) sampled residents (Resident 4), did not develop a stage 3 pressure ulcer (a severe skin injury with full-thickness skin loss where the underlying fat is exposed) at the facility. The facility failed to:1). Ensure Resident 4's pressure points (sacrum [triangular-shaped bone at the base of the spine], coccyx [tailbone], ischium [the lower and back part of the hip bone], trochanter [hip]) were inspected daily, as indicated in its policy and procedure (P&P) titled, Prevention of Pressure Injuries (injuries to the skin over bony areas), which indicated, the facility will inspect residents' pressure points daily, for the presence of erythema (redness), skin temperature and soft tissue edema (swelling), during residents care. 2). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement it's policy and procedures (P&Ps) titled Injuries of Unknown Origin - Investigation and Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one of two sampled residents (Resident 1), following the identification of swelling to Resident 1's right eye. This failure resulted in delayed notification of the State Agency (SA), and a subsequent delay in the initiation of the facility's investigation. The failure also increased the potential for additional incidents of injury of unknown origin to occur or abuse to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures, by failing to:1). Ensure the indwelling foley catheter (catheter that drains urine from bladder into a bag outside the body) and nephrostomy tube (a thin catheter inserted directly into the kidney to drain out urine) drain bags did not touch the floor, for one of three sampled residents (Resident 4).2). Ensure Resident 4's nephrostomy tube dressing was clean and not soiled. These deficient practices placed Resident 4 at risk to develop urinary tract infection (UTI) and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Director of Nursing (DON) did not wear Smart Glasses (eyeglasses with a built-in camera to record videos and take photos) while inside the facility. This deficient had the potential for a breach in the residents' personal privacy and confidentiality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the following food safety and food preparation practices was observed:1. Ensure foods were stored and/or prepared under sanitary conditions.2. Ensure proper sanitation and food handling practices were maintained to prevent outbreak or foodborne illness.3. Ensure dishes and utensils were cleaned and stored under sanitary conditions.4. Ensure snacks in the refrigerator were dated and labeled to prevent the potential for foodborne illness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe medication administration and medication adherence for four of four sampled residents (Residents 95, 101, 114, and 76) when the facility failed to: 1. Clarify an Aspirin (a medication used for cerebrovascular accident [CVA - an interruption in the flow of blood to cells in the brain, mainly caused by hypertension (high blood pressure)] prophylaxis ([PPX] - prevention) order for two (2) of four (4) observed residents during medication administration task (Resident 95 and 101). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 79) was free of unnecessary medications when an order for Divalproex Sodium Divalproex Sodium (an anticonvulsant medication, used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and other behavioral conditions) did not indicate a specific target behavior and did not indicate behavior monitoring. This deficient practice resulted in the lack of behavioral monitoring which had the potential for the inadequate treatment of Resident 79's behavioral symptoms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 27 total opportunities contributed to an overall medication error rate of 11.11% affecting one (1) of four (4) residents observed for medication administration (Resident 110). The medication errors were as follows: 1. Resident 110 did not receive famotidine (a supplement used for heartburn) at the scheduled order time. 2. Resident 110 received multivitamins with minerals (a vitamin supplement) not ordered by Resident 110's physician. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure food items were not stored in the medication refrigerator for one (1) of two (2) inspected medication rooms (Medication Room Station C).2. Label the following in accordance with facility's policy and procedures (P&P) and manufacturer's requirements in one (1) of three (3) inspected medication carts (Medication Cart C).a. one (1) open insulin (medication used to regulate blood sugar levels) Lispro (rapid-acting insulin) pen stored at room temperature for Resident 56,b. one (1) open insulin Lantus (long-acting insulin) pen stored at room temperature for Resident 71,c. one (1) open insulin Humulin N (intermediate-acting insulin) pen stored at room temperature for Resident 123,d. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify and determine the responsible party (RP- an individual appointed to make decisions for an individual without decision-making capabilities) for one of two sampled residents (Resident 63). This deficient practice resulted in Resident 63 not having a RP who could make medical decisions on his behalf. Cross Reference F552, F580, and F842.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for two of two sampled residents (Residents 63 and 79) prior to the administration of the following:1. Resident 63's influenza (viral infection that attacks the respiratory system) and Coronavirus Disease 2019 (COVID-19- a highly contagious respiratory illness) vaccinations (medications used to prevent diseases usually given by injection or by mouth).2. Resident 79's Divalproex Sodium (an anticonvulsant medication, used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and other behavioral conditions). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician and/or responsible party (RP- an individual appointed to make decisions for an individual without decision-making capabilities) for two of two sampled residents' (Residents 79 and 63), after Resident 79 sustained self-inflicted scratches to his face, and after Resident 63's change of condition on 3/4/2026 and 5/4/2026. This deficient practice had the potential to result in a delay in Resident 79's care and resulted in a lack of advocacy for Resident 79 and 63's care. Cross Reference F551 and F842.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident care equipment was stored appropriately and resident room surfaces were maintained in a clean repaired condition one of one residents (Resident 6). This deficient practice had the potential to expose Resident 6 to contamination and infection risks and failed to ensure all residents resided in a clean and homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin to the State Agency (California Department of Public Health [CDPH]), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement for one of one sampled residents (Resident 79) when Resident 79 was found to have a purple-blue discoloration under his left eye. This deficient practice resulted in a delay of an onsite investigation and had the potential to result in further injury to Resident 79.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR-a federal assessment requirement to help ensure individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care and referred to special services as needed) Level 2 evaluation was completed for one of one sampled residents (Resident 12). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan addressing behaviors of scratching and the use of supplemental oxygen (medical treatment that delivers extra oxygen to the lungs) for two of two sampled residents (Residents 79 and 29). These deficient practices had the potential to negatively affect Residents 79 and 29's physical and psychosocial well-being and had the potential to delay the delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's fingernails were maintained in a trimmed and clean manner one of one sampled residents (Resident 7), who was dependent on staff for care. This deficient practice had the potential to result in a negative impact on Resident 7's quality of life and self-esteem, and had the potential for the development of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure wound care orders were transcribed and dressing changes were performed from 5/15/2026 to 5/17/2026 for one of one sampled residents (Resident 5). This deficient practice had the potential to place Resident 5 at risk for delayed care and delayed wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents' (Resident 98) room was free of accidents and hazards when wheelchairs were observed blocking the room pathways and bathroom entrance. This deficient practice placed Resident 98 and other residents at risk for injury and an unsafe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide suprapubic urinary catheter care (a hollow tube inserted into the bladder through the lower abdomen to drain or collect urine) for one of two sampled residents (Resident 9). This deficient practice had the potential to result in Resident 9 developing a urinary tract infection (UTI- an infection in the bladder/urinary tract).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen therapy was administered continuously via the nasal cannula (a thin, flexible plastic tube that delivers supplemental oxygen directly into the nostrils), as ordered by the physician, for one of one sampled residents (Resident 83) receiving oxygen therapy. The deficient practice had the potential to place Resident 83 at risk for inadequate oxygenation, shortness of breath, respiratory distress, decreased cardiopulmonary function, altered mental status, fatigue, dizziness, and other adverse outcomes associated with interruption of prescribed oxygen therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacist's recommendation for valproic acid (an anticonvulsant medication, used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and other behavioral conditions), comprehensive metabolic panel (CMP- a routine blood test that measures 14 different substances in the blood to help determine overall health), and complete blood count (CBC- a blood test that measures the amount and types of cells in the blood) laboratory tests were ordered for one of five sampled residents (Resident 79). This deficient practice resulted in the delay in valproic acid level, CMP, and CBC being ordered which would result in a delay in identifying and treating abnormal laboratory values.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor food preferences and offer meal substitutes of the same nutritive value (food that gives the body enough nutrients to stay healthy) for one of one sampled resident (Resident 122). These deficient practices had the potential to alter Resident 122's nutritional status.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 63), who did not have decision-making capabilities, was not listed as self-responsible on their admission Record (Face Sheet). This deficient practice resulted in the facility discussing the plan of care with Resident 63 instead of with an individual who could make medical decisions on his behalf. Cross Reference F551 and F580.

Inspectors wroteBased on interview and record review, the facility failed to ensure the most recent plan of care was obtained for hospice (services that address physical, spiritual and emotional needs of terminally ill residents) services for one of one sampled residents (Resident 12) under hospice care. This deficient practice had the potential to result in a delay or lack of coordination in the delivery of hospice care and services to Resident 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control measures for two of four sampled residents (Resident 124 and Resident 5) by failing to:1. Ensure an Enhanced barrier precaution (EBP- an infection control measure to protect residents at high risk for multidrug-resistant organisms [MDRO- bacteria resistant to multiple classes of antibacterial medication]) sign was displayed in front of Resident 124's room. 2. Ensure Treatment Nurse (TN) 1 wore an isolation gown, performed hand hygiene, and applied new gloves after removing a soiled dressing and prior to cleaning a wound during a wound dressing change for Resident 5. These deficient practices had the potential to result in the avoidable spread of bacteria and disease to Residents 124 and 5, and other residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident call lights were within reach for two of two sampled residents (Resident 3 and Resident 51). This deficient practice had the potential to place Residents 3 and 51 at risk for delayed staff response, unmet needs, accidents, falls, injuries, and an inability to timely request assistance.'

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from unnecessary psychotropic medications (medications that affect the mind, emotions, and behavior) when: a. Resident 1's order for Depakote (a prescription anticonvulsant and mood-stabilizing medication), started 3/18/2026, did not indicate a documented behavior for use. b. Resident 1 was not monitored for the effectiveness of her use of Depakote. This deficient practice placed Resident 1 at risk for experiencing potential adverse effects from continued Depakote use, including liver failure and severe inflammation of the pancreas (an organ of the digestive system and endocrine system of vertebrates).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) accurately reflected the visual and clinical status for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1 not having a care plan developed to address her impaired visual status and created the potential for the severity of her visual impairment to be unidentified. This deficient practice also created the potential for Resident 1 to not receive the necessary care and interventions for the medications she was receiving.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was provided with one-to-one supervision (1:1, close supervision) per the care plan. This deficient practice resulted in Resident 1 wandering into another resident (Resident 2's) room multiple times, and Residents 1 and 2 having a witnessed resident-to-resident altercation in the hallway on 4/2/2026.

Inspectors wroteBased on interview and record review, the facility failed to ensure accident hazards and fall risks were identified and care planned for one of two sampled residents (Resident 1) when: a. Resident 1, who was at risk for falls, did not have a care plan to address her impaired vision. b. Staff failed to conduct a fall risk assessment following Resident 1's fall on 10/6/2025. c. Staff failed to document a Change of Condition (COC) assessment following Resident 1's unwitnessed fall on 3/20/2026. These deficient practices placed Resident 1 at risk for repeat falls, with subsequent injuries and complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a sanitary environment in the kitchen, by failing to: Ensure the kitchen utility room was not dirty and free from clutters and debris (litter). Ensure there was no pooling (accumulation) of dirty water and debris under the manual washing station (where kitchen staff wash the dishes using hands) and sanitizing station (a designated area or portable unit equipped with supplies to clean, disinfect, and sanitize hands or surfaces to prevent the spread of germs and diseases). These failures had the potential to result in the growth of harmful bacteria and cross contamination (transfer of harmful bacteria from one place to another), that could lead to foodborne illnesses to residents who received food from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, safe and sanitary environment, by failing to: Ensure Closets A, B, and C were kept cleaned and maintained in good working condition. Ensure 1 of 3 residents (Resident 1) room (room [ROOM NUMBER]), was free of spoiled and moldy food. Ensure rooms [ROOM NUMBERS] were clean and did not have dirty, pooled (accumulated) water in the basins. These deficient practices led to Resident 1 feeling dehumanized and caused the affected residents to live in an unsanitary environment and had the potential to cause infections, sickness and pests infestations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program. This failure had the potential for pest infestation in the building affecting 121 of 121 residents at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Rooms A, B, C, D, E, F and G were clean and sanitary. These failures resulted to an environment that was not comfortable and home-like to the affected residents.

Inspectors wroteBased on interview and record review, the facility failed to release medical records requested by one of three sampled residents (Resident 5), within 30 days, as indicated in its policy and procedure (P&P) titled Access to Personal and Medical Records. This deficient practice violated the resident/ resident representative's rights.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records, for one of three residents (Resident 1), by failing to:1). Ensure Resident 1's Transfer Sheet (documentation of resident's condition during hospital transfer, including skin condition) contained Resident 1's skin condition when transferred to a General Acute Care Hospital (GACH).2). Ensure the weekly skin assessment for Resident 1's sacral (the large, triangular bone at the base of the spine between the hip bones) skin tear identified on 12/26/2025 was completed. This deficient practice had the potential for the receiving GACH to not know and provide the resident's wound treatment causing the wound to worsen and get infected. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1), wheelchair and ice chest was returned to him in a timely manner after his room was fumigated (a method of using a lethal gas to exterminate pest within an enclosed space) on 1/15/2026. This failure resulted in Resident 1 having feelings of harassment, retaliation and had the potential in Resident 1 feeling powerless without his wheelchair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection prevention and control measures for three of four sampled residents (Residents 1, 2 and 3) by failing to:1. Ensure staff (Certified Nurse Assistants [CNA] 1, 3 and 4) 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 1, 2 and 3, who were on Enhanced Barrier precautions (EBP - an approach to the use of PPE to reduce transmission of Multidrug Resistant Organisms [MDRO- bacteria that are resistant to multiple antibiotics]). This failure had the potential to result in the transmission (spread) of disease-causing organisms leading to illness to residents.

Inspectors wroteBased on interview and record review, the facility failed to report to the California Department of Public Health (CDPH), when Certified Nurse Assistant (CNA) 1 allegedly yelled at one of four residents, Resident 1. This deficient practice resulted in a delay of investigation by the CDPH and placed Resident 1 at risk for abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being).

Inspectors wroteBased on interview and record review, the facility failed to investigate the allegation of abuse for one of three residents (Resident 1), within 24 hours, as indicated in the facility's policy and procedure (P&P) titled, Abuse and Neglect Prohibition Policy. This failure placed the Resident 1 at risk for potential verbal abuse. This failure resulted in the facility to not protect the residents from potential abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure skin assessment was performed for one of three sampled residents (Resident 1), who was readmitted back to the facility on [DATE]. This deficient practice resulted in a delay in identifying wounds and delayed in providing the care necessary to ensure good wound healing process and to prevent wound complications.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of care by not talking loud at one of three sampled residents, (Resident 1). This deficient practice had the potential to result in verbal aggression and altercation, verbal abuse and can affect the resident's quality of life. This deficient practice had the potential to violate the resident's right to be free from any forms of abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff was trained regarding reporting requirements on alleged resident abuse, as indicated in its policy and procedure (P&P) titled, Abuse and Neglect Prohibition Policy. This deficient practice resulted in the delay of the facility's investigation of the alleged abuse incident and delayed reporting to the Licensing and Certification (L&C) Program District Office.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) call light was placed within reach. This deficient practice had the potential for the resident not to be able to call when assistance is needed, or when emergency arises, resulting in the delay of care and interventions which could be life threatening.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean and home-like environment for 4 of 6 sample residents (Residents 1, 2, 5 and 6) by failing to ensure:1. The walls behind Resident 1 and 6's headboards were clean.2. The feeding pumps (device that delivers formula [liquid, nutrient-rich mixture designed to provide complete nutrition] directly into the stomach of a resident who is unable to take food or liquids by mouth) for Residents 1 and 2 were clean.3. Resident 2, 5 and 6's privacy curtains were clean. This deficient practice had the potential to violate resident's right to have a clean, home-like environment and cause residents to get ill due to unsanitary living conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary practices were followed in the kitchen when:1. The grill food waste receptacle was not emptied or kept clean.2. Empty, crushed soda cans and a cell phone were kept in the resident's food storage shelf. This deficient practice had the potential to attract pests and result in harmful bacterial growth or cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to protect resident's right to be free from verbal abuse for one of five residents (Resident 1), who was subjected to Certified Nursing Assistant (CNA) 1's yelling on 8/25/2025. The facility failed to:1. Follow its Policy and Procedure (P&P) titled Abuse and Neglect Prohibition Policy, which indicated the facility would identify, correct, and intervene in situations in which abuse was more likely to occur.2. Follow its P&P titled Quality of Life - Dignity, which indicated residents shall be treated with dignity and respect at all times. 3. Honor Resident 1's rights to choose his preferred CNA on 8/24/2025. These deficient practices resulted in Resident 1 being subjected to CNA 1's verbal abuse. It also negatively impacted Resident 1's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review the facility did not implement their care plan interventions for three out of three sampled residents (Resident 2, 4, and 5) by failing to ensure staff:1. Separated Resident 2 and Resident 4 after an alleged sexual abuse; and2. Monitored Resident 5's location. These deficient practices potentially exposed Resident 2 to further sexual abuse and allowed Resident 5 to leave the facility without notifying staff.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan for one of two sampled residents (Resident 4) after the resident was observed touching another resident. This deficient practice increased the risk of Resident 4 inappropriately touching another resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure titled Resident on Pass for one of three sampled residents (Resident 5) when the facility failed to ensure, 1. The licensed nurse completed the Out On Therapeutic Pass/Leave of Absence form when Resident 5 left and returned back to the facility from out on pass. This deficient practice did not ensure Resident 5's safe release from the facility. This deficient practice also did not provide a system to ensure Resident 5's safe return back to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address the psychosocial needs (emotional, social, and cultural factors that influence an individual's well-being and mental health) for two of two sampled residents (Resident 2 and Resident 4) after an allegation of abuse when, 1. The Social Services Director (SSD) failed to assess Resident 2 after an alleged abuse incident. 2. The SSD failed to develop a care plan to address Resident 2 and 4's psychosocial needs. These deficient practices had the potential to negatively impact Resident 2's psychosocial needs.

Inspectors wroteBased on interview and record review, the licensed vocational nurse failed to:1. Document the administration of insulin (a hormone that removed excess sugar from the blood, could be produced by the body or given artificially via medication) Aspart (a fast-acting insulin used for diabetes mellitus [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing]) 35 units (a way to measure the strength or amount of a drug), for one of five residents (Resident 1), on the Medication Administration Record (MAR) on 8/16/2025 at 6:30 a.m. 2. Document the findings related to a change of condition (COC), for one of five residents (Resident 1), on the nursing progress notes for the evening shift on 8/25/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents (Residents 1 and 2) were treated with dignity and respect when the facility:1. Did not assist Resident 1 to use the bedside commode (a portable toilet for individuals with limited mobility to use at their bedside) in a timely manner. 2. Did not ask permission prior to taking Resident 2's bag of belongings from the resident's room. This failure resulted in Resident 1 urinating on the floor and damaging Resident 2's belonging of sentimental value (an item used as a reminder of important memories, loved ones, or experiences). This failure also had the potential to negatively affect Resident 1 and Resident 2's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing staff to meet residents' needs and requests for Activities of Daily Living (ADL) assistance in a timely manner, for three of four sampled residents (Residents 1, 2 and 4). This failure resulted in Resident 1 urinating on the floor and Resident 4 feeling upset. This failure also had the potential to cause accidents with injuries from falls and could negatively affect Resident 1, 2 and 4's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the nursing records were completely and accurately documented by failing to complete the oral intake for one of four residents (Resident 1). This deficient practice had the potential to result in lack of communication between staff and delay and interrupt the provision of care needed to maintain the residents' highest practicable, physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow sanitary (clean, healthy, free from dirt, germs, or other elements that could cause disease or harm) requirements for kitchen staff by failing to ensure all kitchen staff wore hair restraints (an item used to prevent hair from the head or face from contaminating food or other products) while in the kitchen. This failure had the potential for clean surfaces, food preparation areas, and the food of 117 residents to be contaminated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was administered effectively and efficiently, as the facility Administrator was not involved with an effective pest control program of the facility. This deficient practice caused an increased risk for 117 residents to suffer complications and illness from pest infestations and the mandated kitchen closure due to cockroach infestation. Cross Reference F925Findings: During an observation and interview on 7/10/2025 at 9:15 a.m. with the Assistant Director of Nursing (ADON) and Director of Nursing (DON), the Administrator was not onsite at the facility. The ADON stated that the Administrator (Admin) was not at the facility and was currently on vacation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of cockroaches. This failure had the potential for clean surfaces, food preparation areas, and the food of 117 residents to be contaminated and suffer from complications of food contamination such as food borne illness or hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor dietary choices for one resident of four sampled residents (Resident 1) by not ensuring dietary staff honored Resident 1 food dislikes. This deficient practice placed Resident 1 needs not to be met and caused Resident 1 not to eat.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan for one of five sampled residents (Resident 1) who was diagnosed with Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and anxiety (a mental health condition where feelings of fear, worry, and unease are intense). This deficient practice had the potential to negatively affect Resident 1's physical, mental, and psychosocial well-being and had the potential to delay the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to offer one of nine sampled residents (Resident 8) showers. This deficient practice resulted in Resident 8 not receiving showers and had the potential to result in infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure feeding assistance at eye-level was provided to one of nine sampled residents (Resident 6). This deficient practice had the potential to result in affecting Resident 6's self-esteem and self-worth. Cross Reference F689.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident's privacy for one of nine sampled residents (Resident 9), when Resident 9 was undressed sitting on a shower chair in the room without the privacy curtain drawn or door closed. This deficient practice violated Resident 9's rights and dignity. This deficient practice also had the potential to negatively impact Resident 9's physical and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan (a document that outlined a resident's health needs and the care they required) for one out of nine residents (Resident 1), when the facility did not address Resident 1's preference of having a female certified nursing assistant (CNA) to provide showers. This deficient practice had the potential to delay and negatively affect the delivery of care for Resident 1's overall wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely input one of nine sampled residents' (Resident 6) diet order upon readmission to the facility. This deficient practice resulted in Resident 6 receiving his breakfast tray two hours after the scheduled breakfast time and could have resulted in Resident 6 becoming hypoglycemic (low blood sugar).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of nine sampled residents (Residents 6 and 7) were free of potential accidents and hazards by failing to: 1. Provide feeding assistance to Resident 6 at eye-level. 2. Ensure Resident 7 wore non-skid socks (socks designed with special tread or grip on the bottom of the sock to provide extra traction and stability) when ambulating (walking). These deficient practices had the potential to result in Resident 6 choking and Resident 7 sustaining an avoidable fall.

Inspectors wroteBased on, interview and records review, the facility failed to notify the Resident ' s physician when 1 of three sampled residents, Resident 1 refused to go for hemodialysis treatment (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed). This deficient practice had the potential to delay other alternative treatment and placed Resident 1 at risk for medical complications like fluid overload, leading to hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident's right to be free from sexual abuse for one of three residents (Resident 1), who was subjected to Resident 2's sexual advancements. The facility failed to: 1. Follow its policy and procedure (P&P) titled Abuse and Neglect Prohibition Policy, which indicated the facility should be identifying, correcting, and intervening in situations in which abuse was more likely to occur. 2. Follow its P&P titled Wandering Behavior Management, which indicated each resident who was a wandering risk was provided the appropriate intervention and adequate supervision. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly notify the physician of a change in condition (COC) regarding multiple medications refused for one of three sampled residents (Resident 2). This deficient practice resulted in delayed treatment and placed Resident 2 at risk of harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was accurately coded to reflect the resident ' s wandering behavior for one of three sampled residents (Resident 2). This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) and a potential to negatively affect Resident 2 ' s plan of care and delivery of necessary services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the clinical records for four of six residents (Residents 1, 3, 4, and 6) were complete and accurate. This deficient practice had the potential to result in a lack of communication between the staff involved in the residents ' care and had the potential to delay and interrupt the provision of care when needed to maintain the residents ' highest practicable, physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan (a document that outlined a resident's health needs and the care they required) for two out of six residents (Resident 1 and 6) by failing to: 1. Ensure the facility developed a resident centered care plan for Resident 1's behavior of wandering into other residents ' rooms. 2. Ensure the facility developed a resident centered care plan for Resident 6's behavior of calling 911 without notifying staff. This deficient practice had the potential to delay and negatively affect the delivery of care for Resident 1 and 6's behavioral management.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR, a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified Nursing Facility) was accurate for one of four sampled residents (Resident 3). This deficient practice placed Resident 3 at risk of not receiving the required care and services needed for his diagnosed mental illnesses, including a Level II PASRR screening (a comprehensive, person-centered evaluation to confirm the suspected Level I PASRR condition and determine the most appropriate placement and services).

Inspectors wroteBased on interview and record review, the facility failed to ensure the posted nurse staffing information: 1. Included the facility's name and actual direct hours provided. 2. Was documented on the State-specific nursing hours per patient day (NHPPD) form. This created the potential for possible inaccuracy in calculating the required number of nursing hours, and for facility residents/visitors to not receive clear information about the daily facility staffing.

Inspectors wroteBased on interview and record review, the facility failed to ensure behavioral health services were provided to one of four sampled residents (Resident 3) by failing to: Ensure Resident 3's Level I Preadmission Screening and Resident Review (PASRR, a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified Nursing Facility) accurately reflected Resident 3's multiple diagnoses of serious mental illness and prescribed psychotropic medications (any drug that affects brain activities associated with mental processes and behavior). [...]

Inspectors wroteBased on interview and record review, the facility failed to initiate one of two sampled residents ' (Resident 9) 72-Hour Neurological Check (series of tests over a 72-hour period to assess for changes in neurological function) immediately after being struck in the head by Resident 10. This deficient practice resulted in Resident 9 ' s Neurological Check delayed seven hours and had the potential for Resident 9 to suffer undetected neurological deficits.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff served omelets as indicated on the menu for 124 residents. This deficient practice resulted in the residents being served scrambled eggs instead of an omelet for breakfast on 2/27/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary food storage practice in the kitchen that affected 146 residents out of 146 sampled residents when: 1. The refrigerator contained food items with no in date (the date when the food was placed in the refrigerator) and no use by date (date the food item must be consumed by), and an unlabeled juice pitcher with no in date and use by date. 2. The freezer had food that was not labeled with an in date and a use by date. 3. The dry storage room had food items that were not labeled with a use by date, empty cans and empty cracker packages on the food rack. 4. The dietary staff did not ensure pasteurized eggs (eggs that have been heated to kill harmful bacteria without cooking them) were available for residents. 5. Dietary Aide (DA) 1 did not remove their gloves when moving to another task. 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to retain Medication Regimen Review ([MRR], thorough evaluation of the medication regimen of a resident) documentation for all the residents in the facility prior to December 2024. This deficient practice had the potential to result in the facility not carrying out the recommendations made from the consulting pharmacist and attending physicians.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Residents 110, 66, and 4) received appropriate care and services by failing to: 1. Monitor Resident 110's urinary drainage from the indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine [pee]) for presence of sediment (a buildup of particles within the catheter tubing, often caused by factors like dehydration, urinary tract infection [UTI- an infection in the bladder/urinary tract], improper catheter care, or the presence of certain bacteria that promote crystal formation), urine color, and foul odor. 2a. Ensure Resident 66's condom catheter (a medical device that fits like a condom [rubber covering worn over the penis] to collect urine) had a physician's order. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignity and respect the rights of one of 32 sampled residents (Resident 66 and Resident 99) by failing to remove Resident 99's breakfast tray from his room. These deficient practices resulted in Resident 99 feeling frustrated and unattended to.

Inspectors wroteBased on interview and record review, the failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to the administration of Trazodone (an antidepressant [a medication used to treat depression, which is a mood disorder that causes a persistent feeling of sadness and loss of interest]) on 6/19/2024 and Seroquel (antipsychotic medication [medications that affect the mind, emotions, and behavior]) on 6/20/2024 for one of five sampled residents (Resident 81). This deficient practice resulted in the removal of Resident 81's right to make decisions about his care and treatments received in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the medical record was updated to show documentation that an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) was discussed with the resident and/or responsible parties for one of eight sampled residents (Resident 109). 2. Review and complete Resident's 277's Physician Orders for Life-Sustaining Treatment ([POLST], a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life). [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician or responsible party of a change in condition for three of three sampled residents (Resident 4, 18 and 97) when: 1. Resident 4 did not receive oxybutynin chloride (used to treat symptoms of an overactive bladder, such as incontinence (loss of bladder control) or a frequent need to urinate) 5 milligrams ([mg] one thousand of a gram) on 2/21/2025 and 2/22/2025, as ordered. 2. Responsible Party (RP) 2 was not notified of Resident 18's verbal altercation with another resident. 3. RP 1 was not notified of Resident 97's elopement (the act of leaving a facility unsupervised and without prior authorization) attempt on 2/23/2025. 4. Inform the physician and RP 1 the Resident 97 had obtained possession of a used, disposable razor without facility staff supervision or knowledge on 2/24/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to report abuse allegations to the State Agency (Department of Public Health), the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and the police department for two of 32 sampled residents (Residents 18 and 103) when: 1. Resident 18 and Resident 103 had a verbal altercation, on 2/26.2025, with both residents saying hurtful things to one another. 2. Resident 103 informed the Director of Nursing (DON), on 2/26/2025, that Certified Nursing Assistant (CNA) 1, made her feel unsafe in the facility. These deficient practices resulted in the delay of notification to the State Agency, ombudsman, and police department and had the potential to result in a delay of an onsite inspection. Cross Reference F610.

Inspectors wroteBased on interview and record review, the facility failed to implement interventions to prevent further potential abuse for one of three sampled residents (Resident 103) when Resident 103 informed the Director of Nursing (DON), on 2/26/2025, that Certified Nursing Assistant (CNA) 1, made her feel unsafe in the facility. This deficient practice resulted in CNA 1 not being suspended for the rest of her shift, which put Resident 103 and the other residents in the facility at risk of further potential abuse. Cross Reference F609.

Inspectors wroteBased on interview and record review, the facility failed to ensure a smoking safety assessment was complete for one of five sampled residents (Resident 115). This deficient practice had the potential to result in injuries during smoke breaks for Resident 48.

Inspectors wroteBased upon interview and record review, the facility failed to ensure a quarterly Minimum Data Set (MDS- a mandated resident assessment tool) assessment was completed for two out of two residents (Resident 1 and Resident 51). This deficient practice had the potential to negatively affect the provision of necessary care and services.

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 Evaluations for four out of four sampled residents (Resident 5, Resident 19, Resident 97, and Resident 60) were completed. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Residents 5,19, 97, and 60.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) and/or implement interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) for of 32 sampled residents (Residents 36, 8, 115, 81, 99, and 97) by failing to: 1. Implement Resident 97's Attempted Elopement Care Plan, initiated 10/5/2024, and Resident 97's At Risk for Elopement Care Plan Intervention, dated 1/24/2025, to ensure Resident 97's location was monitored every 60 minutes, one-on-one sitter was provided and a wander guard (a device placed on the resident that triggers an alarm when a resident attempts to exit the facility) was placed on Resident 97 after he attempted to elope on 2/23/2025. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan was revised for one out of six sampled residents (Resident 97) after Resident 97's elopement (the act of leaving a facility unsupervised and without prior authorization) attempt on 2/23/2025, and after Resident 97 was observed with a disposable razor on 2/24/2025. This failure resulted in Resident 97 obtaining a used, disposable razor on 2/24/2025 and 2/25/2025, which had the potential to result in self-harm and injury. This failure also had the potential for Resident 97 to elope the facility, which could have to bodily injury or death. Cross reference F689 and F656.

Inspectors wroteBased on observation, interview and record review, the facility failed to timely document and reassess the following for one out of six sampled residents (Resident 327): 1. Resident 327's temperature after his temperature was 101.4 degrees Fahrenheit (F [measure of temperature] normal range 97 to 99 degrees Fahrenheit) on 2/24/2025. 2. Resident 327's blood sugar level (measure of glucose [sugar] in the blood [normal range 70- 100 milligrams [mg, unit of measurement] per (/) deciliter [dl, unit of measurement] mg/dl) after his blood sugar level reading was 450 mg/dL before Resident 327 left for his dialysis session and after Resident 327 returned from dialysis on 2/24/2025. [...]

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 four out of four sampled residents (Resident 4, 36, 60, and 110). This deficient practice had the potential to cause the development, worsening or reinjury of pressure ulcers (injuries to the skin and underlying tissue) to Resident 4, 36, 60, and 110.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of eight sampled residents (Resident 97, 277 and 115) were free of accidents and hazards by failing to: 1. Follow its policy and procedure (P&P) titled, Safety and Supervision of Residents, which indicated the facility would ensure resident safety and supervision and assistance to prevent accidents were facility-wide priorities by failing to ensure the following for Resident 97: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to place oxygen signage at the doorway indicating oxygen was in use for one of two sampled residents (Resident 36) receiving oxygen therapy. This deficient practice had the potential to place all residents' and staff's safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer pain medication as ordered and effectively manage severe pain for two of six sampled residents (Residents 117 and 99) by: 1. Failing to ensure Resident 117 was reassessed for inadequate pain relief. 2. Failing to administer pain medication for Resident 117's severe pain as ordered by the physician. 3. Failing to follow Resident 117's care plan goal to maintain comfort and manage resident's pain. 4. Failing to administer Norco (an opioid medication used to treat pain) to Resident 99, which was available in the emergency kit ([e-kit], small supply of medication that can be used when pharmacy services are unavailable), while waiting for the Norco to be delivered to the facility by the pharmacy. 5. Failing to effectively manage Resident 99's chronic back pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) access site ( an arteriovenous (AV) shunt - an access site formed by the joining of a vein and an artery in the arm to provide hemodialysis) was assessed upon return to facility for one of two sampled residents (Resident 36).

Inspectors wroteBased on interview and record review, the facility failed to ensure to follow up on a resident's transfer to a locked nursing facility (a nursing home that has a secure area for residents who need extra supervision or protection, commonly due to dementia [a progressive state of decline in mental abilities] or behavioral issues) after the transfer was requested by the resident's responsible party (RP) on 12/13/2024 for one out of one sampled residents (Resident 97). This failure resulted in a two-month delay in Resident 97's transfer to a locked skilled nursing facility to better manage Resident 97's behaviors and psychiatric (mental) condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Reorder Resident 62's Arginaid (a powder or liquid supplement that contains arginine and antioxidants to help with wound healing) medication timely. 2. Ensure Resident 62's ProHeal (a liquid protein supplement used to manage wounds and other conditions that require additional protein) medication dosage was clarified by Resident 62's physician. 3. Ensure Resident 4 received oxybutynin chloride (to treat symptoms of an overactive bladder, such as incontinence (loss of bladder control) or a frequent need to urinate) 5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount), on 2/21/2025 and 2/22/2025. 4. Reorder Resident 4's medication timely and caused Resident 4 to miss two days of medication. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the correct indication of use and monitoring for two of five sampled residents' (Residents 277 and 81) medication by failing to: 1. Ensure the correct indication of use for Resident 277's use of pregabalin (anticonvulsant [medication to prevent or treat seizures] and can be used to treat nerve and muscle pain). This deficient practice resulted in the licensed nurses administering pregabalin to prevent seizures instead of the treatment for diabetic neuropathy (complication when high blood sugar levels over time damage the blood vessels that nourish and protect the nerves). This deficient practice had the potential to result in the mismanagement of Resident 277's neuropathy pain. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide monitoring for two of five sampled residents (Resident 81 and 277) who received psychotropic medications (medication that affect the brain and alters mood, thoughts, emotions, and behaviors) by failing to: 1. Monitor adverse reactions and effectiveness of Resident 277's use of quetiapine (antipsychotic medication [medications that affect the mind, emotions, and behavior]). 2. Monitor adverse reactions and effectiveness of Resident 81's use of Trazodone (an antidepressant [a medication used to treat depression, which is a mood disorder that causes a persistent feeling of sadness and loss of interest]) and Seroquel (an antipsychotic medication). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a medication error rate of less than 5 percent (%) for one of three sampled residents (Resident 62). This deficient practice had the potential to result in inconsistent medication administration and further skin breakdown. Findings During a review of Resident 62's admission Record, the admission record indicated Resident 62 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included ulcer of the left lower extremity (an open sore on the leg that takes more than two weeks to heal), acute kidney failure, hypertension and benign prostatic hyperplasia. During a review of Resident 62's Minimum Data Set (MDS- a resident assessment tool), dated 12/24/2024, indicated Resident 62's cognitive skills (ability to think and reason) was intact. [...]

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure a medication bottle had a legible label in Station B's medication cart. 2. Ensure insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pens were labeled in Station A's medication storage room. This deficient practice had the potential to result in medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility to failed ensure the oxygen nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was labeled and dated for one of two sampled residents (Resident 36). This deficient practice placed Resident 36 at risk infection.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent for one of six sampled residents (Resident 1) prior to administering Quetiapine (an antipsychotic medication that treats schizophrenia [a mental illness that is characterized by disturbances in thought) and bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from lows of depression to elevated periods of emotional highs]). This failure violated the Resident's right to be fully informed and consent to receiving the medication.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure titled, Care Plan Conference, to hold a care conference to meet and discuss the goals, progress and needs for one out of six sampled residents (Resident 2) by failing to: 1. Meet every 90 days for an Interdisciplinary Team meeting ([IDT] a group of health care professionals from different disciplines to coordinate care for a patient) with Resident 2 to participate in care planning. 2. Ensure to review and revise the care plan for refusal of care for Resident 2 as needed and every 90 days. These failures had the potential to leave Resident 2 ' s needs unmet and placed Resident 2 at risk for physical decline, weakness and possible hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician, when one of six sampled residents, (Resident 2), Resident 2 refused the range of motion exercises on 1/23/2025, 1/25/2025, and 1/30/2025, as indicated in the facility ' s policy and procedure (P&P) titled, Right to Refuse or Discontinue Treatment. This failure had the potential to result in Resident 2 ' s decline in functions.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident-identifiable information for three out of six sampled residents (Residents, 4, 5, and 6) were not sent to the an unauthorized person (Resident 1's Responsible Party ([RP] someone who is available to make decisions for the resident as necessary). This failure violated Resident 4, 5, and 6's right to privacy and had the potential to result in the public obtaining access to confidential (private) information regarding the residents' medical conditions and treatments without their consents.

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party (RP) when a fall occurred for one of three sampled residents (Resident 1). This deficient practice violated the RP ' s right to be informed of Resident 1 ' s change of condition (COC).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from accidents and a fall by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 provided two-person assistance to turn and reposition Resident 1. 2. Ensure CNA 1 locked Resident 1 ' s bed wheels before repositioning in bed. 3. Ensure CNA 1 used side rails while repositioning Resident 1. These deficient practices resulted in Resident 1 falling out of bed, onto the floor with left shoulder pain and had the potential to cause a fracture (broken bone) or serious bodily injury.

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent prior to the administration of psychotropic (medications that affect the mind, emotions, and behavior) medications for one out of three sampled residents (Resident 1). This failure had the potential to place Resident 1 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to the use of a psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure Restoril (a medication used to treat insomnia [inability to sleep]) ordered PRN (as needed), was limited to 14 days per regulation for one out of three sampled residents (Resident 1). This deficiency had the potential to result in the use of unnecessary medication, or non-therapeutic use of a psychotropic medication (medications that affect the mind, emotions, and behavior).

Inspectors wroteBased on interview, and record review, the facility failed to follow its policy and procedure titled, Abuse and Neglect Prohibition Policy, when Resident 2 abused two of four sampled resident (Resident 1 and 3) by failing to prevent: 1. Resident 2 pulling on Resident 1's arms who was confused, non-ambulatory (unable to walk) and attempting to pull her out of bed. This deficient practice resulted in Resident 1 being physically abused by Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive care plan (a personalized plan detailing the steps to be taken to manage a resident's condition effectively) for wandering and aggressive behavior was revised for one of one sampled resident, (Resident 2) upon readmission to the facility. This deficient practice left Resident 2 at risk for wandering in other resident's rooms unsupervised and resulted Resident 2 becoming increasingly agitated (a feeling of irritability or severe restlessness). This deficient practice also had the potential to place other residents at risk of being physically and verbally abused by Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 2) who had behaviors of wandering, pacing hallways, and going into other residents' rooms was provided with adequate supervision. This deficient practice resulted in Resident 2 wandering in the hallways, into other residents' rooms in the facility and became increasingly confused and agitated (a feeling of irritability or severe restlessness).

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff was on duty to administer intravenous ([IV] medications administered through the vein) antibiotic medications, to two of four sampled residents, (Resident 1 and Resident 2). This failure resulted in the delayed administration of IV antibiotic medications ' or medication not administered. This failure placed the affected residents and other residents at risk for complications of untreated infections, such as sepsis (a life-threatening emergency characterized by an extreme response to infection that can result in multi-system organ failure), hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff had the appropriate competency necessary, in documenting scheduled and missed medications, to two of three sampled residents (Resident 1 and Resident 2). This failure had the potential to cause medication errors and the potential to affect the quality of care rendered the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Licensed personnel had access to the antibiotics (medications to treat infections) in the emergency medication kit ([EM-kit] a kit consisting of drugs, including controlled substances, needed to effectively manage a critical care incident or need of a resident) to administer to two of 3 sampled residents, (Residents 1 & 2). 2. Licensed personnel had a system in place for accurate tracking of medications delivered by the pharmacy. These failures resulted in delayed administration of Resident 1 and Resident 2 ' s antibiotics.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2), were free from significant medication error, by failing to ensure: 1. Resident 1 did not miss three (3) intravenous ([IV] medications administered through the vein) doses of Meropenem (an antibiotic to infections caused by bacteria) for urinary tract infection (UTI) as per physician ' s order. 2. Resident 2 did not miss a total of seven (7) doses of IV Piperacillin (an antibiotic for infection) antibiotic for UTI as per physician ' s order. These failures placed the residents at risk for complications of untreated infections, such as sepsis (a life-threatening emergency characterized by an extreme response to infection that can result in multi-system organ failure), hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Registered Nurse (RN) 1 accurately documented medication administration for one of three sampled residents (Resident 1). This failure resulted in a medication error and had the potential to result in a delay of necessary care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff assisted two of four sampled residents (Resident 3 and Resident 4) with Activities of Daily Living ([ADLs] activities related to personal care) in a timely manner. This deficient practice had the potential to result in Resident 3 and 4's needs not being met, and negatively affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to protect one of one resident (Resident 1) from abuse by failing to: 1. Ensure Resident 1 was free from verbal abuse. 2. Ensure Restorative Nursing Assistant (RNA 1) did not verbally abuse Resident 1 by using profanity towards Resident 1. This deficient practice caused a verbal altercation between Resident 1 and RNA 1and resulted in causing Resident 1 to feel attacked and experience anxiety by RNA 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to maintain range of motion ([ROM] full movement potential of a joint [where two bones meet]) for one of four sampled residents (Resident 86) with mobility (ability to move) concerns, by failing to: 1. Perform a Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs) on both of Resident 86 ' s arms and legs upon admission to the facility on [DATE] and quarterly in accordance with the facility ' s policies titled, Functional Impairment - Clinical Protocol and Resident Mobility and Range of Motion. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control measures for 117 of 117 facility residents when the following occurred: 1. Oxygen delivery equipment was not stored and/or replaced per facility protocol for Resident 108 and Resident 8. 2. Laundry staff (LS) 1 failed to perform hand hygiene in between contact with dirty and clean linens. 3. Facility staff's personal belongings and beverage containers were stored on shelving designated for clean resident clothing items. 4. Soiled linens were observed on top of a storge cart containing personal protective equipment (PPE, protective garments or equipment designed to protect the wearer's body from infection) in the laundry room. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a standardized assessment and care planning tool) assessments for three of three sampled residents (Resident 82, Resident 91, and Resident 61) were completed accurately when the following occurred: 1. Resident 82's MDS dated [DATE] did not indicate Resident 82 was on oxygen therapy. 2. Resident 91's MDS dated [DATE] did not indicate Resident 91 was on hemodialysis (procedure to filter the blood when the kidneys are not working normally). 3. Resident 61's MDS dated [DATE] indicated Resident 61 was taking psychotropic medications in error. The above failures had the potential to negatively affect the care plan development process and effectiveness of the care plans for Resident 82, Resident 91, and Resident 61.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan in accordance with the facility's Policy and Procedures (P&P) for two of four sampled residents (Resident 86 and 11) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] by failing to: 1. Develop a care plan to address Resident 86's ROM limitations in the left arm and the leg since admission on [DATE] to 2/23/2024 (16 months). This failure resulted in Resident 86 not receiving intervention, including passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to the left arm and left hand. Cross reference F688. 2. Develop specific goals and interventions to address Resident 11's difficulty with expressive communication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Resident 86 and 271) received services to improve their ability to perform activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) in accordance with the facility ' s policy. 1. For Resident 271, who was independent with walking and ADLs prior to admission to the facility on 2/8/2024, the facility did not assist Resident 271 out of the bed daily and did not provide therapy services to improve Resident 271' s ability to perform ADLs, including mobility. This failure had the potential for Resident 271 to become more dependent with ADLs. Cross reference F655. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of six smokers (Resident 37) and four residents (Resident 60) transferred out of a bedroom for an active ceiling leak had adequate supervision to prevent accidents and hazards by failing to: 1. Ensure an environment that was free from hazard for one out of six sampled residents (Resident 37). Resident 37 had a lighter in his possession after designated smoking times. 2 Ensure Resident 60 had an accurate Fall Risk Assessment (brief assessment of a person ' s risk for fall) after an actual fall on 1/21/24 and was not in the room alone and unsupervised on 2/21/24 with an active ceiling leak. These failures had the potential for the facility residents, including Resident 37 and 60, to sustain physical injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure baseline toilet habits were maintained or improved for voiding (urinating) and bowel function to prevent incontinence (the unintentional loss of urine) for one of one sampled resident (Resident 271). This deficient practice had the potential for decline in bladder and bowel function for Resident 271.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen therapy was administered according to facility policy and procedure for five of six sampled residents (Resident 82, Resident 46, Resident 3, Resident 115, and Resident 63) when the following occurred: 1. Resident 82 was observed receiving supplemental oxygen at five and a half (5.5) liters per minute (L/min, a unit for measuring the flow of oxygen delivered from an oxygen delivery device), and the physician orders indicated a maximum flow rate of four (4) L/min. 2. Resident 46 and Resident 63 had no dates or initials on their nasal cannulas, tubing, and humidifiers. 3. Resident 3 had no dates or initials on his nasal cannula, tubing, and an empty humidifier dated 1/29/2024 (3 weeks old) connected to the running oxygen he was receiving. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 2/20/24 when: 1. [NAME] used small scoop size to serve Chicken Jambalaya for 56 residents on regular diet and 36 on Mechanical soft diet (consists of foods that are moist, or easily mashed requiring little chewing.) residents on regular and mechanical soft diet received ½ cup of chicken jambalaya instead of 1 cup and 3 ounces (oz.) of zucchini instead of 4 oz. 2. The facility failed to ensure staff followed food production recipes for the puree diet (food that is blended to a pudding consistency, no chewing required) and renal diet (a diet aimed at keeping levels of fluids, electrolytes, and mineral balanced in the body in individuals with kidney disease or who are on dialysis) during lunch preparation and tray line observation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared by methods that conserved texture, appearance and served at appetizing temperatures for 113 out 117 residents who received food from the kitchen. The texture of the pureed rice was thick, sticky, and lumpy and the pureed food did not taste like the chicken jambalaya served to residents on regular diet. This deficient practice had the potential to result in meal dissatisfaction, decrease food intake and place residents at risk for unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Several food items were not dated or labeled in the Walk-in refrigerator and freezer. One bag of chicken patties and one bag of turkey patties were stored in the freezer with no open date or label. Ready to eat Deli meat sliced turkey and ham with use by date of 2/16/24 exceeding storage period for deli meat was stored in the walk-in refrigerator. 2. Personal staff lunch boxes and leftover food and soda was stored in the facility walk in refrigerator. 3. Scoops were stored inside bulk food thickener container and dried potato flakes container with the handle in contact with the food. One can opener blade was had brown color sticky residue. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner. There were 30 empty cardboard boxes stored and scattered on the floor and alongside the wall in the alley and towards the main dumpster area. This deficient practice had the potential for harborage of pests and vermin, which may be attracted into the facility.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide care in a dignified manner for two of 24 sampled residents (Resident 7 and Resident 271) when the following occurred: 1. Certified Nursing Assistant (CNA) 1 left the privacy curtain open while performing perineal care (cleaning the private areas of a patient) to Resident 7. 2. The facility failed to ensure baseline toilet habits were maintained for Resident 271 who was continent (able to control bladder and bowels) upon admission but placed in an adult diaper and not assisted with toileting. The above failures had the potential to cause avoidable psychosocial harm to Resident 7 and cause unnecessary exposure of Resident 7's outer genitalia (penis and scrotum) and perineal area (area of the body including the genitals and anus) to facility staff and residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light was placed within reach at all times for one of one sampled resident (Resident 2) with a history of falls. This deficient practice had the potential to delay care and prevent resident from summoning health care workers as needed to receive assistance that may include urgent care.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure one of six sampled residents (Resident 1) had an appropriate assessment for using less restrictive measures prior to utilizing physical restraints. This deficient practice had a potential to place the resident on unnecessary restraints.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Preadmission Screening and Resident Review ([PASRR] resident screening prior to admission, to determine if the person has, or is suspected of having, a mental illness) screening was completed accurately for Resident 42. This deficient practice had the potential for Resident 42 not receiving the necessary and appropriate behavioral treatment and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a baseline care plan for therapy services in accordance with the facility's policy for one of two sampled residents (Resident 271) for new admissions. This failure had the potential to prevent Resident 271, who was independent with mobility (ability to move) and activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) prior to admission to the facility on 2/8/2024, from receiving therapy services. Cross reference F676.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of six sampled residents (Resident 75,16, and 6) care and services was provided to maintain good grooming and personal hygiene by failing to: 1. Provide oral hygiene (cleaning the mouth and tongue) for Resident 75, who needed total physical assistance with oral hygiene. 2. Provide fingernail care for Residents 16, and 6 who unable to carry out activities of daily living to maintain good grooming. This deficient practice had the potential to place Resident 75 at risk for diseases of the mouth, gums, and teeth, and negative impact on Resident 16's, and 6's quality of life and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer enteral nutrition ([tube feeding], the delivery of nutrients through feeding tubes [a flexible plastic tube placed into the stomach wall]) as ordered by the physician for two of two sampled residents (Resident 7 and Resident 11). This deficient practice had the potential to cause complications, such as malnutrition (lack of proper nutrition) and development of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for Resident 7 and Resident 11.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse (LVN) 2 failed to demonstrate competence in operating the enteral nutrition (sometimes called tube feeding, the delivery of nutrients via feeding tubes) delivery pump for two of two sampled residents (Resident 7 and Resident 11). This deficient practice had the potential for Resident 7 and Resident 11 to suffer from undetected malnutrition with possible complications such as weight loss or impaired health promotion and maintenance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of three Residents were free from medication errors (Resident 67 and Resident 34) when: 1. Licensed Vocational Nurse (LVN 4) failed to check for the expiration date of Norvasc (a medication for high blood pressure)10 milligram ([mg] a unit of weight measurement) tablet prior to medication administration to Resident 67. 2. Licensed vocational Nurse (LVN) 6 Failed to identify Resident 34 prior to administering medications. As a result, Resident 67 and Resident 34 had the potential to endure harm from incorrect medication administration. 1. During a review of Resident 67's admission Record, the record indicated the facility admitted Resident 67 on 10/02/2020. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store and/or dispose of medications for six of 117 facility residents (Resident 105, Resident 76, Resident 57, Resident 103, Resident 12, and Resident 104) when the following occurred: 1. Sixty (60) tablets of one (1) milligram (mg, unit for measuring medication dose) Risperidone (medication used to treat certain mental/mood disorders), for Resident 105 was found in an unmarked paper bag, in an unmarked cabinet, in the Station C medication storage room. 2. Five (5) opened bottles of eye drops, in Medication Cart C, were labelled with room numbers and did not have any resident identifiers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and document the condition of one out of three residents (Resident 2) prior to being sent to another facility for dialysis treatment (treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) when: 1. Licensed Vocational Nurse (LVN) 1 sent Resident 2 to dialysis treatment without clothes or a gown. 2. LVN 1 failed to document Resident 2's condition in the resident's medical record. As a result of these deficient practices, Resident 2 had the potential to be psychosocially harmed as evidenced by the resident's statement, I felt uncomfortable being sent to dialysis without a clothes or gown.