California Post Acute

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement an effective discharge planning process for one of the three sampled residents (Resident 1) who was bedridden (a person is forced to stay in bed because of severe illness, injury, weakness, or old age) and was dependent on staff for feeding via his G-Tube (Gastrostomy tube - a small, flexible medical device inserted directly through the abdomen into the stomach) by failing to:1. Developing a care plan which focuses on the Resident 1's discharge goals.2. Verify that Resident 1 had 24-hour caregiving services and providing orientation. This deficient practice resulted in Resident 1 being left alone from 4/16/2026 approximately 3 pm to 4/17/2026 at approximately 8 am. [...]

Inspectors wroteBased on interview and record review the facility failed to implement the nursing interventions according to the care plan for two of four sampled residents (Resident 1 and Resident 2). 1. For Resident 1, the facility failed to monitor and record food intake after each meal.2. For Resident 1 and Resident 2, the facility failed to specify in the care plan the frequency of obtaining their weight, what time of day the weight should be taken and specify the scale that would be used to obtain their weights. These deficient practices had the potential for the facility not meet Resident 1's and Resident 2's needs to maintain ideal body weight.1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to revise the care plan for one of four sampled residents (Resident 2). The facility failed to:1. Ensure the care plan reflected that Resident 2 was on enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs, germ that is resistant to many antibiotics) due to the presence of indwelling catheter (medical devices that remain in the bladder (body organ that stores urine) to continuously drain urine in patients who are unable to void spontaneously).2. Obtain physician order to place Resident 2 on EBP.These deficient practices had the potential to spread infection to other residents, staff and visitors. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure resident's belongings were stored safely to prevent loss for one of three sampled residents (Resident 1). For Resident 1, the facility failed to:1. Update Resident 1's Clothing and Possessions List by including Resident 1's wheelchair after the wheelchair was delivered on 12/28/21.2. Ensure Resident 1's wheelchair was stored securely to prevent loss. 3. Ensure Resident 1's wheelchair was returned to Resident 1 after Resident 1 was discharged from the facility on 3/17/25. These deficient practices resulted in Resident 1's wheelchair being lost and Resident 1 does not have a wheelchair to use for mobility. During a review of the admission Record indicated the facility admitted Resident 1 on 12/10/20 and re-admitted on [DATE] with diagnoses including morbid obesity, muscle weakness and chronic pain syndrome. [...]

Inspectors wroteBased on interview and record review the facility failed to implement its abuse policy for one of two sampled residents (Resident 1). For Resident 1, the facility failed to:1. Report to the state survey agency when Resident 1 eloped (the act of leaving a facility unsupervised and without prior authorization) on 12/13/25. The facility did not know where Resident 1 was on 12/13/25 from 6:30 a.m. to 1 p.m.2. Investigate how Resident 1 eloped from the facility on 12/13/25. These deficient practices resulted in a delay in the investigation to ensure Resident 1 was safe while out in the community. Findings; During a review of the admission Record indicated, the facility admitted Resident 1 on 5/14/25 with diagnoses including low back pain, osteomyelitis (infection in the bone) of the left shoulder and history of mental and behavioral disorders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that two of five exit doors (Door 1 and Door 2) were properly fitted with a functioning lock. The main entrance (Door 1) and the door near the kitchen (Door 2) had no functioning locks. This deficient practice had the potential to compromise the safety of residents, staff and the public. During observation and concurrent interview on 12/18/25 at 7:54 a.m., at the front entrance of the facility, licensed vocational nurse (LVN) 2 stated Door 1 does not lock even at night. During observation, LVN 2 tried to lock Door 1, but LVN 2 stated the front door does not lock. During observation and concurrent interview on 12/18/25 at 8:30 a.m., a short facility tour was conducted with the housekeeping (HKP). During observation, HKP tried to lock Door 1 and Door 2, using its keys. HKP stated .the locks do not work. [...]

Inspectors wroteBased on interview and record review the facility failed to allow the resident to return to the facility after hospitalization for one of two sampled residents (Resident 1). For Resident 1, the facility failed to re-admit Resident 1 on 10/27/25 when Resident 1 was ready to return to the facility. This deficient practice resulted in Resident 1 not given his right to return and stay at the facility. During a review of the admission Record indicated the facility admitted Resident 1 on 10/23/25 with diagnoses including schizophrenia (mental illness that is characterized by disturbances in thought), osteoarthritis (condition that causes the joints to become painful and stiff) of the knees and generalized muscle weakness. During a review of the admission summary dated [DATE] at 2:57 p.m., indicated Resident 1 was alert and oriented to person, place, date and situation. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure blood sample was collected from one of three sampled residents (Resident 1). For Resident 1, the facility failed to obtain blood sample on 11/10/25 for complete blood count (CBC, a group of blood tests that measure the number and size of the different cells in the blood), basic metabolic panel (BMP, a group of blood tests that provides information about the body's metabolism), c-reactive protein (CRP, blood test to check inflammation in the body) and erythrocyte sedimentation rate (ESR, blood test that can show inflammatory activity in the body) as ordered by the physician on 11/7/25. This deficient practice had the potential for the facility not to meet the needs of Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for one of two sampled residents (Resident 1). For Resident 1, the facility failed to notify the physician or initiate a Change of Condition (COC- communication tool used by healthcare workers when there is a change of condition among the residents) when Resident 1 experienced continuous side effects of Quetiapine (a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought]). These failures delayed treatment for Resident 1 and had the potential to cause functional decline, hospitalization, permanent injury, and death. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 61) for closed record review was immediately provided with cardiopulmonary resuscitation (CPR, a lifesaving emergency procedure for a victim who has signs of cardiac [heart] arrest [a situation when a victim becomes unresponsive, no normal breathing, and no pulse], consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe]) in accordance with the facility's policy and procedure titled, Cardiopulmonary Resuscitation (CPR) by failing to: 1. Verify Resident 1's code status (a set of instructions for medical staff about what to do or not do in a medical emergency) from the hospital record, dated 5/21/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 61) who required hemodialysis (HD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) received HD care and services in accordance with Resident 61's Medical Director 1 (MD1) orders, care plan, and the facility's policies and procedures by failing to: -Ensure the licensed nurses (in general) and the Social Services Director (SSD) had ongoing communication and collaboration with Dialysis Center 1 (DC1) to coordinate Resident 61's HD care and services when the transportation did not pick up Resident 61 as scheduled on [DATE] at 11 AM. -Ensure Licensed Vocational Nurse 5 (LVN5) and other licensed nurses (in general) assessed Resident 61 prior to Resident 61 being transported to DC1 on [DATE] at 4:45 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 6) reviewed for pressure ulcer (an injury to the skin and underlying tissue caused by continuous pressure on the skin) care area did not develop a pressure ulcer by failing to: 1. Ensure that the Certified Nurse Assistant (CNA) monitored and documented the repositioning of Resident 6, who was assessed for a high risk of developing a pressure ulcer. 2. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance committee (QAA, a group of facility staff who identifies, evaluates, and implements measures to improve the quality care and life for the residents in the facility) and Quality Assurance Performance Improvement (QAPI, a group of facility staff who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to identify concerns related to cardio-pulmonary resuscitation (CPR, an emergency procedure that combines chest compressions and rescue breathing to help someone who has stopped breathing or whose heart has stopped beating) and dialysis (a treatment to cleanse the blood of wastes and extra [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the drug regimen of two of five sampled Residents (Resident 7 and Resident 11) were free of unnecessary psychotropic medications (types of medication that affects brain activity and is used to treat mental health disorders) medication by: Failing to ensure the gradual dose reduction (GDR, a method used to slowly and carefully decrease the dosage of a medication over time) for risperidone (Risperdal, a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought]) was performed in February 2025 for Resident 7. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident's needs for three of 14 sampled residents (Resident 3, Resident 10, and Resident 11) as evidenced by: Failing to specify Resident 3's significant personal interests and activities to support coping with auditory hallucinations (when someone hears sounds or voices that are not there). Failing to reduce environmental noise while cleaning Resident 10. Failing to develop a comprehensive person-centered care plan for Resident 11's diagnosis of dementia (a progressive state of decline in mental abilities). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that three of five sampled employees' (Licensed Vocational Nurse 8 [LVN8], Treatment Nurse [TN], and for Interim Director of Nursing [IDON]) files were complete with a performance evaluation, skills competency checklist, and Basic Life Support (BLS, life saving techniques for someone experiencing breathing of heart emergencies) certification. This failure had the potential to result in the staff underperforming, which could affect the residents' care.

Inspectors wroteBased on observation, interview and record review, the facility failed to: Ensure adequate medication supply for Resident 40 when alogliptin benzoate (a medication used to treat type 2 diabetes [a condition where the body either does not produce enough insulin or does not properly use the insulin] 12.5 milligrams (mg, unit of measurement) oral tablets were not available for administration. Maintain a narcotic count (refers to the systematic process of counting and documenting the amount of controlled substances at specific times to ensure accurate inventory and prevent misuse or diversion) without discrepancy for Resident 65 when the narcotic count sheet for buprenorphine-naloxone (a medication that treats opioid use disorder) 8-2 mg sublingual (situated or applied under the tongue ) film indicated 18 films available and the medication count revealed 17. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: Administer medication according to the physician order when: Resident 4 received MiraLax (a medication used to facilitate bowel movements) oral powder 17 grams (gm, unit of measurement) per scoop in 7 ounces of water. Resident 4 received acetaminophen (a medication used to relieve pain and reduce fever [elevated body temperature above the normal range]) two 325 milligrams (mg, unit of measurement) tablets for pain. Resident 40 did not receive alogliptin benzoate (a medication used to treat type 2 diabetes (a condition where the body either does not produce enough insulin [define] or does not properly use the insulin) 12.5 mg oral tablets. Preform blood sugar level monitoring prior to insulin administration when Resident 40 received 50 units of insulin glargine subcutaneous solution. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: Maintain the temperature in the medication refrigerator between 36 degrees Fahrenheit (F, a temperature scale) to 46 degrees F when the thermometer indicated 21 degrees F. Dispose Resident 66's medication within 90 days of discharge when a lidocaine (a medication used to numb a specific area of the body) 5% patch was in the medication storage room. Discard medications inside the medication waste bin when tablets were on the bin rim and accessible. Implement accurate medication labeling when insulin lispro (a medication used to control blood sugar in people with diabetes [a condition where the body does not produce or use insulin properly]) 3 milliliter (mL, unit of measurement) injection for Resident 20 did not include a pharmacy medication label. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 7/21/2025 by failing to ensure pureed diets (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding.) were prepared in accordance with the international Dysphagia Diet Initiative (IDDSI - a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks). This failure had the potential to result in meal dissatisfaction and increased choking risk for residents on pureed diet. During an observation of the tray line (tray line-a system of food preparation, in which tray move along an assembly line) service for lunch on 7/21/2025 at 11:30AM, the pureed meat, pureed corn and potato looked thin and loose consistency. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation in the kitchen when:1. One medium size tray of previously prepared tuna salad was stored in the walk-in refrigerator over three days, exceeding storage period for prepared salad. Six bunches of bananas that were very soft, brown in color and peeled open were stored in the dry storage area with no date. A peeled banana was touching the wall, there were stains on the wall and on the floor under the shelves. One can opener blade was dirty with dried brown residue and when the blade was worn and dented with the potential to harbor harmful bacteria.2. One Dietary Aide (DA1) working in the dishwashing area did not wash hands when removing clean and sanitized dishes from the dish machine.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster areas was maintained in a sanitary manner. By failing to ensure one large trash bin was covered and two recyclable trash bins were not overfilled with boxes and left uncovered. This deficient practice had the potential for harborage and feeding of pests. During a concurrent observation of the facility's trash area and interview with the dietary supervisor (DS) on 7/21/2025 at 9:00AM, one large trash bin that was observed not covered and two recyclable trash bins were observed overfilled with boxes and uncovered. A cat was observed around the trash area in the parking lot. The DS stated trash bins had to be covered to prevent the feeding of animals and attracting flies. The DS proceeded to cover the lid of the large trash bin. [...]

Inspectors wroteBased on observation and interview, the facility did not maintain privacy for one of five sampled residents (Resident 21) due to broken window blinds that were visible from the main street in Resident 21's room. This failure had the potential to result in Resident 21 being exposed to people outside of the roomFindings: During a review of Resident 21's Face sheet (admission Record) dated 7/21/2025, the Face sheet indicated Resident 21, a [AGE] year old female, was admitted to the facility on [DATE], with diagnosis that included heart failure (a condition where the heart does not pump blood as well as it should making it hard for the body to get the oxygen and nutrients needed) and muscle weakness (a condition where the muscles do not have as much strength as before). [...]

Inspectors wroteBased on interview and record review, the facility failed to notify Resident 61's primary physician (MD 1), for one of three sampled residents (Resident 61), by failing to: 1. Ensure the licensed nurses (in general) informed MD 1 that General Acute Care Hospital 1 (GACH 1) could not accept Resident 61 on [DATE] for dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) and experiencing shortness of breath (SOB) and weakness.2. Ensure licensed nurses (in general) informed MD 1 and initiated a change of condition (COC, internal form) when Resident 61 was not transferred out to GACH 1. These failures resulted Resident 61 did not receive dialysis care and services and did not receive medical interventions for the SOB and weakness. [...]

Inspectors wroteBased on interview and record review the facility failed to provide mandatory information on Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN: a Skilled Nursing Facility [SNF] must issue this notice to a resident when it believes that Medicare may not cover their care or stay. The SNF must provide the notice to the resident before providing the non-covered care.) appeal process in a timely manner for one of three randomly selected residents (Resident 42). This deficient practice denied Resident 42 the right to accept or decline non-covered specific skilled services or file an appeal. Placing Resident 42 at risk for unexpected financial burden/crisis.

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was created and transmitted to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program, among other health-related programs like Medicaid and the Children's Health Insurance Program) for one of 10 sampled residents (Resident 24), when Resident 24 was discharged from the facility on 6/17/2025. This failure had the potential to result in delayed discharge care for Resident 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 40 maintained clean and intact skin in the perineal area (area between the anus and the external genitalia) when Resident 40 developed Moisture-Associated Skin Damage (MASD, a type of skin damage that occurs when prolonged exposure to moisture, such as urine, weakens the skin's protective barrier, leading to inflammation, breakdown, and potential infection). This failure resulted in Resident 40 developing MASD in the perineal area and experiencing discomfort and pain in the affected area due to skin breakdown and exposure to urine and feces.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply resting hand splints to both hands for one of 14 sampled residents (Resident 56). This deficient practice has the potential to led for worsening contracture (a condition where muscles, tendons, and skin tighten, leading to a reduced range of motion) and a decrease in right hand mobility for Resident 56.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the fall risk care plan for one of 14 sampled residents (Resident 5) when Resident 5 was not frequently visually monitored to prevent a fall. This failure had the potential to result in Resident 5 experiencing excessive bleeding and serious injury from a fall.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 55) received the appropriate treatment and services needed to maintain and prevent gastrostomy tube (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) complications. By failing to label the resident's tube feeding container and syringe with an open date. This failure placed Resident 55 at risk for gastrointestinal (the digestive system) complications such as infection, diarrhea (frequent loose bowel movements), nausea (sensation of feeling the urge to vomit), and vomiting (forceful expulsion of stomach contents though the mouth).

Inspectors wroteBased on observation and interview, the facility failed to ensure dietary preferences were honored for one of five sampled residents (Resident 21) when the resident received food that was listed on the meal ticket as a disliked food. This failure had the potential to result in Resident 21 experiencing a loss of autonomy in choosing meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when: Resident 5 did not have an order for enhanced barrier precautions (EBP- are an infection control strategy used in healthcare settings, particularly skilled nursing facilities, to reduce the spread of multidrug-resistant organisms (MDROs). Resident 1 did not have proper signage before entering the isolation room. These failures had the potential to result in the spread of infection and placed the residents, staff and visitor at risk to become infected and seriously ill, leading to hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 17 of 66 sampled resident rooms (Rooms 3, 5, 6, 7, 8, 9, 11, 14, 15, 16, 18, 19, 21, 22, 23, 24, and 25) met the minimum space requirements of 80 square feet for each resident in multiple resident bedrooms. This failure had the potential to result in inadequate space to provide safe nursing care and privacy for the residents in Rooms 3, 5, 6, 7, 8, 9, 11, 14, 15, 16, 18, 19, 21, 22, 23, 24, and 25).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their infection control policy for storage of clean laundry. During observation, on 7/1/25 at 10:32 a.m. and at 1:38 p.m., two laundry carts that contained the clean linen for the residents were in the facility's parking lot. This deficient practice had the potential for the clean linen to be contaminated with dust and allergens that can potentially affect the health and safety of the residents. During observation and concurrent interview on 7/1/25 at 10:32 a.m. two laundry carts with clean linen and towels were observed in the parking lot of the facility. The linen carts were observed to be covered with plastic. The Maintenance Supervisor (MS) stated the carts contain clean linen. MS stated the laundry carts were placed in the parking lot because there was no space inside the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to implement their Policy in reporting unusual occurrences for one of three sample residents (Resident 1). The facility failed to report to the state survey agency (SSA) when Resident 1 eloped (the act of leaving a facility unsupervised and without prior authorization) on 5/18/25. This deficient practice resulted in a delay in the investigation of the elopement of Resident 1 and to ensure Resident 1 was safe.

Inspectors wroteBased on interview and record review the facility failed to prevent elopement (the act of leaving a facility unsupervised and without prior authorization) for one of three sampled residents (Resident 1). Resident 1 who was identified as an elopement risk, the facility failed to provide one-to-one sitter (staff member that provide one-to-one care and observation to ensure resident ' s safety) to prevent elopement. This deficient practice resulted in Resident 1 eloping from the facility on 5/18/25 at 11 a.m., exposing Resident 1 to danger while out in the community.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a care plan for nutrition for one of five sampled residents (Resident 1). For Resident 1, the facility failed to develop and implement a care plan to address Resident 1 ' s nutritional and hydration needs. This deficient practice had the potential for the facility not to address Resident 1 ' s hydration and nutritional needs.

Inspectors wroteBased on interview and record review the facility failed to evaluate the nutritional and hydration (maintain adequate amount of fluid in the body) needs of one of five sampled residents (Resident 1). For Resident 1, the facility failed to ensure: 1. Resident 1 ' s intake (amount of fluid entering the body) and output (amount of liquid leaving the body) were monitored as ordered by the physician on 2/8/25. 2. The registered dietitian (RD) evaluates Resident 1 ' s nutritional needs regularly. 3. Resident 1 was given a fortified diet as recommended by the RD on 1/20/25. These deficient practices had the potential for the facility not to be able to meet the hydration and nutritional needs of Resident 1.

Inspectors wroteBased on interview and record review the facility failed to provide adequate staffing for one of 5 sampled residents (Resident 2). Resident 2 stated on 5/3/25 and 5/4/25 she called for assistance to have her pull ups changed during the night shift. Resident 2 stated she did not get the assistance she needed timely. This deficient practice resulted in Resident 2 not provided the necessary services timely affecting Resident 2 ' s psychosocial and physical well-being.

Inspectors wroteBased on interview and record review the facility failed to follow physician orders to evaluate resident ' s nutritional and fluid needs for one of five sampled residents (Resident 1). For Resident 1, the facility failed to: 1. Assess, monitor and evaluate Resident 1 ' s nutritional needs regularly and as needed. 2. Monitor Resident 1 ' s intake and output as ordered by the Resident 1 ' s primary physician. 3. Discuss and meet with the weight variance interdisciplinary team (IDT, professionals from different discipline, as appropriate, will work together to provide the greatest benefit for the resident) to discuss Resident 1 ' s nutritional needs. These deficient practices had the potential for the facility not to meet Resident 1 ' s nutritional needs to maintain Resident 1 ' s highest practicable well-being.

Inspectors wroteBased on interview and record review the facility failed to provide interventions to prevent complications for residents who were receiving enteral (form of nutrition that is delivered into the stomach as a liquid) through the gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for one of five sampled residents (Resident 1). For Resident 1, the facility failed to follow physician order to: 1. Always keep Resident 1 ' s head of the bed elevated at 30 degrees and higher during feeding and for one hour after feeding has stopped. 2. Check the tube placement before initiation of formula, medication administration and water flushing at least every eight hours. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the medical records were kept accurate for one of five sampled residents (Resident 1). For Resident 1, the facility failed to accurately reflect in Resident 1 ' s medical record that a care meeting was held between the facility and Resident 1 ' s responsible parties (RPs) on 2/27/25. This deficient practice resulted in inaccurate and incomplete medical record for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free form sexual abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 2), who was subjected to Resident 1's sexual aggression, who had diagnoses of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). The facility failed to: -Implement the facility's policy and procedure titled, Abuse Prevention Program-Abuse Prohibition, revised May 2024, which indicated the facility shall uphold resident's right to be free from sexual and physical abuse. [...]

Inspectors wroteBased on interview and record review the facility failed to provide treatment and care in accordance with professional standard of practice for one of three sampled residents (Resident 1). For Resident 1 who reported on 12/8/24 that he had a fall on 12/8/24 at 4 a.m., the facility failed to: 1. Assess Resident 1 immediately after he reported that he had a fall. 2. Notify Resident 1's physician immediately after Resident 1 reported he had a fall on 12/8/24. 3. Ensure the Magnetic Resonance Imaging (MRI, test that produces clear images of the organs and structures inside the body to diagnose a variety of conditions) ordered by the physician on 12/9/24 was carried out as ordered. These deficient practices had the potential for Resident 1 not to receive necessary treatment timely for possible injuries resulted from the fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and accident-free environment for one of three sampled residents (Resident 1), who had visual impairment (blindness, difficulty seeing), a left above the knee amputation (AKA - surgical removal of the portion of the leg above the knee), and had history of fall with injury, by failing to: - Follow the Physician's Order dated 4/15/2024 for Resident 1 to receive visual hourly safety checks for fall prevention. -Review and update the At Risk for Falls Care Plan after a fall and change in condition on 4/15/2024, including implementation of individualized care and maximizing the resident's safety. [...]

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 risks, benefits and alternatives offered) for one of two sampled residents (Resident 1) before starting Resident 1 on quetiapine fumarate (Seroquel: antipsychotic medication) 150 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount). This deficient practice resulted in Resident 1 being administered an antipsychotic without knowing the risks and benefits of taking the quetiapine fumarate and alternative treatment available.

Inspectors wroteBased on interview and record review the facility failed to provide indication and monitoring for adverse reaction when resident was started on psychotropic medication (any drug that affects behavior, mood, thoughts, or perception such as an antipsychotic) for one of two sampled residents (Resident 1), by failing to ensure: 1. The physician order for the Seroquel (antipsychotic medication) included the indication for the use of (reason why the medication is being ordered for the resident) and targeted behavior and manifestation. 2. Resident 1 was monitored for adverse (negative) reactions that included lethargy. These deficient practices resulted in Resident 1 receiving Seroquel unnecessarily and had the potential for Resident 1 to have adverse effects from the Seroquel.

Inspectors wroteThis is a Repeated Deficiency from 10/8/2024 and 12/3/2024. Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had a history of falls, was a high fall risk, and was dependent on staff for toilet transfer, received the care and services necessary to prevent accident and falls by failing to assist Resident 1 for transfer to the toilet every two hours, per the Bowel and Bladder Incontinence care plan. As a result, on 11/28/2024 approximately at 11:30 PM, Resident 1 tried to go to the bathroom by himself and fell. Resident 1 was transferred to the General Acute Care Hospital (GACH) for further evaluation where he was diagnosed with a displaced intertrochanteric (where hip and thigh meet) fracture (a partial or complete break in a bone) of right femur (the thigh bone).

Inspectors wroteBased on interview and record review, the facility failed to review, revise and update the care plans quarterly addressing risk for fall, incontinence, and activities of daily living (ADL) for one of four sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to have recurrent falls, urinary tract infections (UTI- an infection in parts of the urinary system kidneys, bladder and or urethra), or decline in functional ability.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who was incontinent (having no or insufficient voluntary control over urination or defecation) and dependent on staff for toilet transfer, was properly monitored with evaluation of the resident's bladder habits (volume, or quality of stream). There was no monitoring of Resident 1's continence status at regular intervals (a check and change strategy) to restore continence to the extent possible. As a result, on 11/28/2024 approximately at 11:30 PM, Resident 1 tried to go to the bathroom by himself and fell. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure one out of three sampled residents (Resident 1) were free from physical abuse (an act where one person uses their body to inflict intentional harm or injury upon another person) from staff by failing to acknowledge and investigate allegations, assess monitor, and implement allegations of Resident 1 being slapped by Certified Nursing Assistant (CNA) 1 This deficient practice had the potential to result in the continued physical abuse to Resident 1 and resident sin the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 2 did not release a hoyer lift (a medical device use to transfer patients with limited mobility from one place/surface to another) control quickly when transferring one of four sampled residents (Resident 2). 2. Inspect the hoyer lift for any malfunction or operational concerns before using it to transfer dependent residents including Resident 2. These deficient practices resulted in the hoyer lift control hitting Resident 2 in the face and the resident sustaining a bruise (an injury appearing as an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) to the right eye, and had the potential for further injuries to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure three sampled Certified Nurse Assistants (CNA 1, 2, and 3) had a completed annual performance evaluation when providing care to Resident 1. This deficient practice violated the facility's Performance Evaluations policy and had the potential for Resident 1 to not receive appropriate services.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse for one of three sampled residents (Resident 1), when Licensed Vocational Nurse (LVN) 1 told Resident 1, Don't make me get my belt. This deficient practice had the potential for Resident 1 to experience emotional distress (negative or uncomfortable feelings), loss of dignity (the quality or state of being worthy of honor or respect), and feeling unsafe in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement its Personal Property policy by failing to update the residents inventory list monthly for four of four sampled residents (Residents 1, 2, 3, and 4). This deficient practice resulted in Resident 1 having a lighter at his bedside and starting a fire on 10/2/2024 at about 2 AM, and had the potential for other residents to have prohibited items at bedside.

Inspectors wroteBased on interview and record review, the facility failed to implement its Unusual Occurrence Reporting policy by failing to report a fire that occurred on 10/2/2024 at 2AM, as required by current law and / or regulations within 24 hours of the incident for one of four sampled residents (Resident 1). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the unusual occurrence was investigated timely and could lead to a delay in prevention of further hazards for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the environment was free of accident hazards for one of four sampled residents (Resident 1), who was a smoker. On 10/2/2024 at about 2 AM, Resident 1 used a lighter to spark a fire in his room. This deficient practice caused an increased risk in resident safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment entry for special treatments, procedures, and programs in the Minimum Data Set (MDS- a federally mandated resident assessment tool) was accurately documented to reflect the resident's use of oxygen for two of three sampled residents (Resident 2 and 3). This deficient practice had the potential to negatively affect Resident 2 and 3's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of three sampled residents (Resident 1 and 2). For Resident 1 who had a diagnosis of chronic respiratory failure and for Resident 2 who had diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), the facility failed to ensure the resident received two liters of oxygen per minute as ordered by the physician. The facility also failed to change the oxygen tubing, change the oxygen humidifier bottle (a device used to make supplemental oxygen moist), and clean the external oxygen concentrator filter every Sunday as ordered by the physician for Resident 1 and 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the vital signs (measurement of the most basic functions including the heart rate, breathing rate, temperature, and blood pressure) were monitored and recorded every shift based on professional standards of practice for one of four sampled residents (Resident 1). For Resident 1 who had a temperature of 101 degrees (normal temperature is between 97 degrees Fahrenheit [F, unit of measurement] to 99 degrees F) on 8/7/24, the facility failed to ensure the complete vital signs were obtained and documented accurately every shift. This deficient practice resulted in Resident 1 ' s medical record incomplete and not accurately documented.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call lights were answered timely for two of five sampled residents (Resident 3 and Resident 4). The facility failed to answer the call lights timely and attend to the needs of Resident 2 and Resident 3 promptly when they called for assistance. These deficient practices resulted in Resident 2 and Resident 3 stating that they felt frustrated when they call for assistance and no comes to help them timely.

Inspectors wroteBased on interview and record review the facility failed to provide a copy of the medical record as a requested for one of five sampled residents (Resident 5) within 48 hours. On 8/1/24, Resident 5 ' s legal representative sent a request for copies of Resident 5 ' s medical record to the facility by electronic facsimile (eFax, process of sending and receiving faxes over the internet instead of using the fax machine and telephone connection). The facility failed to provide the records timely as requested by Resident 5 ' s legal representative. This deficient practice resulted in facility failing to give Resident 5 the right to have copies of her medical record.

Inspectors wroteBased on interview and record review the facility failed to implement its policy and procedures (P&P) on abuse for two of five sampled residents (Resident 1 and Resident 2). For Resident 1 and Resident 2, the facility failed to report within 2 hours, to the state survey agency (SSA) when on 8/5/24, Resident 1 stated Resident 2 was arguing with him and called Resident 2 a pedophile (a mental disorder in which an adult has sexual fantasies about or engages in sexual acts with a prepubescent [before puberty] child) and derogatory (disrespective/of low opinion) language. This deficient practice resulted in: 1. Resident 2 stating that Resident 1 threatened his life and felt bad, upset, angry, and scared. 2. Delayed investigation to ensure Resident 1, and Resident 2 were safe.

Inspectors wroteBased on interview and record review the facility failed to ensure there was adequate supply of medications and administer the medication timely as ordered by the physician for one of five sampled residents (Resident 1). For Resident 1, the facility failed to ensure there was adequate supply of Norco (medication given for moderate to severe pain) 10-325 milligrams (mg., unit of measurement) as needed and failed to administer the Norco 10-325 mg. as ordered by the physician. This deficient practice resulted in Resident 1 was not given the Norco on 8/9/24, 8/10/24, and 8/11/24 because the facility had run out of Norco. Resident 1 stated he continued to have pain on his right leg and right hip.

Inspectors wroteBased on observation, interview, and record review the facility failed to update and revise the Care Plan to meet the individual needs for one out of three sampled residents (Resident 1). By failing to revise Resident 1 ' s care plan after Depakote Tablet (a medication used to treat certain psychiatric disorders by restoring the balance in the brain) was increased from 375 milligram (mg-unit of measurement) to 500 mg on 07/23/2024. This deficient practice had the potential to prevent Resident 1 from receiving care to address their specific needs, which could lead to a decline in physical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sample residents (Resident 1) had the call light within reach. This failure resulted in Resident 1's inability to call staff for assistance due to inability to see. Cross referenced with F656 and F641.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) had an accurate assessment reflective of Resident 1 ' s diagnosis of glaucoma. This failure had the potential to cause Resident 1 to obtain an injury, experience weight loss due to inability to see the food and worsening vision.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan was developed for one of three sample residents (Resident 1) addressing the resident's diagnoses of glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye). This failure had the potential to cause Resident 1 to experience worsening vision.

Inspectors wroteBased on interview, and record review the facility failed to ensure arranging suitable and reliable transportation of the designated resident to and from the dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) center for one of three sampled residents (Resident 1). As a result, Resident 1 missed dialysis appointment on 6/25/24, 6/27/24,7/2/24 and family member (FM) had to call transportation to take Resident 1 back to the facility on 7/13/24. This deficient practice had the potential for Resident 1 to build up waste products inside the body, placing the resident at risk for hospital admission or even death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: -Discard expired acetaminophen (a medication used to treat mild to moderate pain) from one of two inspected medication carts (Medication Cart 2) which was going to be administered to Resident 265. -Ensure one expired insulin pen (an injection device used to deliver medication that controls blood sugar) belonging to Resident 46 was discarded from one of two inspected medication carts (Medication Cart 1). -Ensure two unopened insulin pens belonging to Residents 14 and 31 were stored in the refrigerator according to the facility's policy in one of two inspected medication carts (Medication Cart 1). These deficient practices placed Resident 265 at risk for experiencing pain, and Residents 46, 14, and 31 were at risk for developing hyperglycemia (too much sugar in your blood).

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards of practice for food service safety by not labeling: a. one peach pie with a received date. b. three boxes of blueberry muffins with a received date. c. one bag of pasta noodle with a received date d. one bag of hamburger bread with a use by date. e. one bag of tortilla with a use by date. f. one block of cheddar cheese with a use by date. g. one plastic bag of mozzarella cheese with a use by date. h. one bag of chocolate chips with a use by date. i. one bag of marshmallows with a use by date. These deficient practices had the potential for residents in the facility to be at risk for food borne illness (caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in the kitchen when the freezer temperatures were above zero degrees Fahrenheit for approximately two weeks. This deficient practice had the potential to place the facility's residents at risk for food borne illness (caused by food contaminated with bacteria, viruses, parasites, or toxins) or contamination (process of making something dirty or poisonous, or the state of containing unwanted or dangerous substances).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure space requirements of 80 square feet for each resident were met in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for 38 Residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced resident's dignity and respect for one sampled resident (Resident 44) by assigning to the resident Certified Nursing Assistant 1 (CNA 1), whom Resident 44 complained about. This deficient practice had the potential to affect Resident 44's self-esteem, self-worth, and the resident's sense of independence.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 28 and Resident 51) had an Advance Directive (AD - written statement of a person's wishes regarding medical treatment made to ensure those wishes were carried out should the person be unable to communicate them to a doctor or to facility staff) on file as part of the resident's medical record. This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment.

Inspectors wroteBased on interview and record review, the facility failed to assess insertion site and document a signature for one of two sampled residents (Resident 27) by failing to ensure Resident 27's post-dialysis assessment was completed and the post-dialysis assessment was signed by a licensed nurse. These deficient practices had the potential for the facility to miss critical changes in the resident after dialysis treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plan for two of the 16 sampled residents (Resident 34 and 55) investigated for care planning. Resident 55 's care plan for Quetiapine Fumarate (a psychotropic medication used to treat schizophrenia [a serious mental illness that affects how a person thinks, feels, and behaves]) was discontinued and Resident 34's alteration in skin integrity care plan had a change in the interventions for the management of the pressure injury. This deficient practice placed the residents at risk for inconsistent implementation of care plans which could lead to a lack of care or delay in delivery of care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 33), who had limited range of motion (ROM - the extent of movement of a joint) and/or limited mobility, received appropriate services to prevent or maintain further decline in the range of motion to all his extremities by failing to provide a handroll for his left hand. This deficient practice placed Resident 33 at risk for further decline and contracture formation.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 41) was free of unnecessary medication by failing to follow the physician's order to administer the resident's Norco (a pain medication) 5-325 milligrams (mg - unit of measurement) as needed (PRN) every six hours for severe pain. This deficient practice resulted in Resident 41 receiving Norco on 6/5/2024 for pain level rated at four and on 6/6/2024 for pain level rated at six, placing the resident at risk for receiving unnecessary medication.

Inspectors wroteBased on interview and record review, the facility failed to monitor for side effects of psychotropic medications (drugs that affect a person's mental state) for one of three sampled residents (Resident 26). This deficient practice had the potential to lead to Resident 26 to have adverse effects of medication (ie, become oversedated [excessively drowsy], have frequent falls, or experience tardive dyskinesia [a movement disorder which causes involuntary and repetitive movements, including those of the face, mouth, tongue, arms, or legs].

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. Two medication errors out of 26 total opportunities contributed to an overall medication error rate of 7.69% affecting one of four sampled residents (Resident 265) observed for medication administration performed by one of two Licensed Vocational Nurses (LVN 1). The facility failed to: -Ensure Resident 265 received polyethylene glycol powder (Miralax, a laxative medication which increased the number of bowel movements and softens the stool) per physician's orders. -Ensure Resident 265 did not receive expired acetaminophen (a medication used to treat mild to moderate pain). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to enforce its policy titled,Enhanced Barrier Precautions, by failing to: - ensure staff members wore a gown when providing direct care to one of five sampled residents (Resident 34), and - provide personal protective equipment (PPE ) immediately outside of the resident room. These deficient practices had the potential to transmit infectious microorganisms to the other residents in the facility

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy for one of two sampled residents (Resident 1). For Resident 1, the facility failed to provide privacy when Resident 1 was transferred from the bed to the wheelchair using the Hoyer lift (a device that holds a person in hammock like sling to lift completely and transfer to another surface). This deficient practice resulted in exposing Resident 1 ' s body to everyone who passed by and had the potential to affect Resident 1 ' s dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement the care plan for one of two sampled residents (Resident 1). For Resident 1 the facility failed to ensure that two persons were available when using the Hoyer lift (Device used to transfer a person) to transfer Resident 1 from the bed to the wheelchair. This deficient practice had the potential for Resident 1 to sustain injury.

Inspectors wroteBased on interview and record review the facility failed to ensure the records were accurate for two of three sampled residents (Resident 1 and Resident 2). By failing to: 1. Ensure room changes were documented in Resident 1 and Resident 2 ' s medical record as indicated in the facility Policy titled Room Change/Roommate Assignment with a reviewed date of 1/18/24. 2. Follow up with Resident 1 and Resident 2 on how they were doing in the new environment. These deficient practices accurately reflect Resident 1 and Resident 2 ' s location and had the potential to cause a delay in care and services, anxiety, and depression.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical and mental abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for two of five sampled residents (Resident 4 and Resident 2) when: On 4/5/2024, Resident 5 threw urine from his urinal on to Resident 4 (the roommate) and both residents were engaged in a verbal altercation. On 4/7/2024, after Resident 5 was moved to a different room, Resident 5 poured urine from his urinal onto the side of his bed, which splashed onto Resident 2 (the new roommate) and both residents were engaged in a verbal altercation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) for one of 5 sampled residents (Resident 4). This deficient practice violated the resident's right to make an informed decision regarding the use of psychoactive medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and appropriately address a hazardous object for one of five sampled residents (Resident 4) when on 4/5/2024 a [NAME] axe was founded under his mattress . This deficient practice had the potential to result in an injury to a residents or facility staff.

Inspectors wroteBased on interview and record review the facility failed to administer medication timely as ordered by the physician for one of two sampled residents (Resident 1). For Resident 1, the facility failed to administer the Tamiflu (medicine used to treat the influenza (flu, a contagious respiratory [nose, throat, and lungs [breathing organ] in people two weeks of age and older who had the flu symptoms for no more than two days) 75 milligrams (mg. unit of measurement) by mouth two times a day on 12/18/23 at 9 p.m. and on 12/19/23 at 9 a.m. as ordered by the physician. This deficient practice resulted in Resident 1 stated he felt he was dying and had difficulty breathing.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents environment remained free of accident hazards for one of three sampled residents (Resident 1) and by failing to: 1. Monitor and supervise Resident 1 after Resident 1 lit an incense using a lighter inside a drawer and the drawer caught fire on 11/19/2023 at 11:45 a.m. and had another two fire incidents on 11/20/23 at 12 a.m. and 12:30 a.m. The facility was aware Resident 2 (Resident 1's roommate) was on continuous oxygen therapy on 11/19/2023 and 11/20/2023. 2. Inspect and inventory Resident 1's belongings and investigate the fire incident on 11/19/2023 at 11:45 a.m by Resident 1 to prevent another resident caused fire incident in the facility. 3. [...]

Inspectors wroteBased on Observation, interview, and record review, the facility failed to maintain a full time Director of Nursing (DON- registered nurse [RN]) and that a Licensed Vocational Nurse (LVN) did not assume the role of Assistant DON (ADON) without the direct supervision of a DON for the months of 11/2023 and 12/2023 for 60 of 60 residents in the building. This deficient practice had the potential to result in the facility inability to establish nursing standard of practices, compliance with the Stated and Federal agencies, handle emergencies in the facility, complete incident reports, initiate investigations on incidents and complete necessary forms, manage the entire nursing department and assume the responsibility for resident care in the absence of a physician, and the assume the responsibility of an Administrator in the absence of an Administrator for 60 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to follow proper food handling and preparation practices to prevent foodborne illnesses by failing to: 1. Follow the therapeutic recipe (recipes designed to support the treatment of diseases and medical conditions) approved by a dieticianrequiring the broccoli stems thicker than one inch to be cut. 2. Ensure fish served to residents was maintained out of the Danger Zone (41- 135 degrees Fahrenheit [F], the temperature in which bacteria and microorganisms can row rapidly and cause food borne illnesses). On 12/6/2023 at 12:06 p.m. cooked fish was placed on a counter allowing the temperature to drop to 110 degrees F. 3. Use the recommended therapeutic diet scooper for portion sizes for two of three sampled residents (Residents 2 and 3). Residents 2 and 3 were served a double portion of risotto rice (Italian rice). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to administer Wegovy/Semaglutide (a diabetes medication used with diet and exercise to treat adults whose diabetes is not satisfactorily controlled) (0.25 or 0.5mg) subcutaneously (SC- administration of a medication beneath the skin by injection), inject 1mg(milligrams- one thousandth of a gram) /ml(one thousandth of a liter) SC one time a day every Tuesday for morbid obesity two injections of 0.5mg per manufacturer recommendation for one of three sampled residents (Resident 1). This deficient practice caused a short supply of the weekly dose leading to a late dose administration.

Inspectors wroteBased on interview and record review the facility failed to complete required annual competencies for one of two sampled cooks (Cook 2). This deficient practice may have led to [NAME] 2 not following therapeuticrecipes (recipes designed to support the treatment of diseases and medical conditions) when preparing lunch.

Inspectors wroteBased on interview and record review the facility failed to administer medication timely as ordered by the physician for one of two sampled residents (Resident 1). For Resident 1, the facility failed to administer the Spiriva (medication that makes breathing easier by relaxing the muscles in the lungs (breathing organ] and widening the bronchi [airways] inhalation 18 micrograms (mcg., unit of measurement) one time a day, at 9 a.m. as ordered by the physician. This deficient practice resulted in Resident 1 stated he had difficulty breathing, was scared, and had anxiety attack when he did not receive his Spiriva at 9 a.m. on 11/1/2023.

Inspectors wroteBased on interview and record review, for two of four sampled residents (Resident 1 and Resident 2) the facility failed to: 1. Protect Resident 1's right to be free from verbal (the act of harassing, labeling, insulting, scolding, rebuking, or excessive yelling towards an individual) abuse and mental (controlling another person by using emotions to criticize, embarrass, shame, blame, or otherwise manipulate that person) abuse on 10/17/2023 at approximately 1:20pm, Certified Nursing Assistant 1 (CNA 1) yelled at Resident 1, told Resident 1 to shut up and [Q** J** (vulgar word(s)] in CNA 1's native language. CNA 1 continued to argue with Resident 1, after Licensed Vocational Nurse 1 (LVN 1) told CNA 1 to leave Resident 1's room. [...]

Inspectors wroteCross Reference F689 Based on interviews and record review, for one of three residents (Resident 2 [Resident 1's roommates]), the facility failed to protect Resident 2's right to be free from verbal and mental abuse by Resident 1 in accordance with the facility's undated policy and procedures titled Abuse Prevention Program. On 9/3/2023 at 5:38 AM, Resident 1 became upset after Licensed Vocational Nurse 1 (LVN 1) confiscated Resident 1's lighter torch, (a portable device used to create a controlled flame) and incense (an aromatic material that releases fragrant smoke when burnt). Resident 1 walked over to Resident 2's bed and threatened to beat up Resident 2. [...]

Inspectors wroteCross Reference F600, F609, and F557 Based on interview and record review the facility failed the Director of Social Services and Certified Nurse Assistant 2 (CNA 2) checked the belongings for one of three sampled residents (Resident 1), to ensure Resident 1 did not possess on himself or his belongings a blow torch (blowlamp - a portable device torch that shoots out extremely hot gasoline flame intensified by pressurized air) and incense. Resident 2 (Resident 1 ' s roommate) was on oxygen (odorless gas that is present in the air and necessary to maintain life) therapy. The facility had 57 Resident in house on. This deficient practice had the potential to result in fire related accidents and death for Residents 1 and 2 and all residents, staff, and guests in the facility.

Inspectors wroteCross Reference F600 and F689 Based on interview and record review the facility failed to conduct an inventory for belongings of one of three sampled residents (Resident 1) in accordance with the facility ' s undated policy and procedures titled Personal Property. This deficient practice had the potential to not account for Resident 1 ' s belongings and compromise the safety of all residents in the facility related to possession of illegal contrabands (anything prohibited by law that is considered too dangerous or offensive) not limited to deadly weapon(s) and hazardous equipment(s) by Resident 1.

Inspectors wroteCross Reference F577 and F600 Based on interview and record review the facility failed to implement it abuse prevention policy and procedures by failing to report to the State Agency (SA) the unusual occurrence of a resident to resident altercation (negative and aggressive physical, sexual, or verbal interactions between long-term care residents) to two of three sampled residents (Resident 1 and 2) in accordance with the facility ' s undated policy and procedures titled Abuse Investigation and Reporting. This deficient practice resulted in Resident 2 experienced increased anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure) with a potential for further resident to resident abuse/altercation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Fourteen medication errors out of 29 total opportunities contributed to an overall medication error rate of 48.28 % affecting four of four sampled residents observed for medication administration (Residents 4, 9, 21, and 42.), by failing to: -Ensure Licensed Vocational Nurse 1 (LVN 1) did not crush and mix six medications for administration through a gastrostomy tube (g-tube - a surgically implanted tube used to deliver food or medication directly to the stomach) for Resident 4. -Ensure LVN 1 followed Resident 4's physician orders for flushing the g-tube between each medication administration with 30-50 milliliters (ml - a unit of measure for mass) of water. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4) observed for medication administration was free of significant medication errors by failing to administer Keppra (a medication used to treat or prevent seizures [a sudden uncontrolled electrical disturbance in the brain]), Eliquis (an anticoagulant medication used to prevent blood clots) and sodium chloride (medication used for low salt level) according to physician's orders and professional standards of practice. The facility failed to: -Ensure Licensed Vocational Nurse 1 (LVN 1) crushed the medications individually, including Eliquis, and administered separately through a gastrostomy tube (g-tube , a surgically implanted tube used to deliver food or medication directly to the stomach) for Resident 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations by not placing the call light within reach for Residents 4, 5 and 40, and failed to answer Resident's 400's call light requesting for assistance in a timely manner within three minutes. These deficient practices had the potential to prevent the residents from receiving necessary care and services, which could negatively affect the residents' physical comfort and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had specific choices and treatments communicated through an Advance Directives and copies of the Advance Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) maintained in the Resident's clinical record for three of 13 Residents (Resident 4 ,18 and 23). This deficient practice had the potential for Residents 4, 18 and 23 not be given the right to accept or refuse specific medical treatments and have those options honored.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide activities that reflect the choices of the resident including group activities and outdoor activities for three of 13 sampled residents (Resident 4, 5, and 18). This deficient practice had the potential for the residents to feel isolated in their rooms, to decrease physical, cognitive, sense of belonging, and emotional health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to ensure six of 13 sampled residents (Resident 4, 5, 12, 22, 36, and 48) received appropriate treatment and services to prevent further decline in mobility and range of motion (ROM, full movement potential of a joint) as evidenced by: a. The facility did not objectively assess all residents, including Resident 4, 5, 12, 22, 36, and 48, for ROM in both arms and legs on a quarterly basis. b. For Resident 4, the facility failed to provide active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but requires some help from the therapist or equipment) to both arms per physician's order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 4 and 46 who were on enteral feeding (way of delivering nutrition directly to your stomach) received appropriate treatment, care, and ensure feeding tube was labeled for two of six sampled residents by failing to ensure: a. The head of the bed was elevated per Physician's Orders while receiving feeding through a gastrostomy tube (G-tube, tube placed directly into the stomach for long-term feeding) for Resident 4. b. Gastric feeding tubing and flushing syringe was labeled with date and the time the formula was hung for (Resident 46). These deficient practices had the potential for Residents' needs not being provided and placed the Residents at risk to develop complications of enteral feeding such as aspiration (when food or liquid goes into your airway).

Inspectors wroteBased on observation, interview, and record review, the facility failed to sufficiently train one of two Licensed Vocational Nurses (LVN 1, a healthcare professional on how to provides nursing care) and two of two Restorative Nursing Assistants (RNA, nursing aide program that helps residents to maintain their function and joint mobility) on how to provide care and services as evidenced by: a. LVN 1 crushed multiple medications together to administer via gastrostomy tube (g-tube, a tube inserted through the wall of the abdomen directly into the stomach) route. b. One of two RNAs did not provide adequate active range of motion (AROM, performance of ROM of a joint without any assistance or effort of another person) exercises to one of 32 residents (Resident 48) receiving RNA services for range of motion (ROM, full potential movement of a joint). c. [...]

Inspectors wroteBased on interview and record review, the facility failed to: - Ensure one of five sampled residents (Resident 18) was free of therapeutic duplications (unintentionally using multiple medications at the same time to treat the same condition) or in excessive dose (higher than intended dose) of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) between 2/13/22 and 3/9/22. -Ensure one of five sampled residents (Resident 44) was monitored for adverse effects (unwanted dangerous side effects of medications) and effectiveness of psychotropic medication therapy between 2/9/22, and 2/28/22. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: -Ensure unopened insulin (a medication used to control high blood sugar) was stored in the refrigerator per the manufacturer's requirements or label open insulin stored at room temperature with an open date in two out of two medication carts (Medication Carts 1 and 2) affecting residents 12, 20, 34, 40, 46, and 151. -Remove expired medications from two out of two inspected medication carts (Medication Carts 1 and 2) affecting Residents 7, 34, 42, and 48. -Remove five vials of expired medications from the emergency kit (e-kit) in one of one inspected medication room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide prescribed therapeutic diet (diet that is part of the treatment for a disease or clinical condition or to provide mechanically altered food) per physician's order for two of 13 sampled residents (Residents 5 and 12) These deficient practices had the potential to cause a decline in oral motor skills (use and function of the lips, tongue, jaw, teeth, and inner mouth structures for speech production and safe swallowing) and quality of life for both Resident 5 and 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff adhered to facility`s infection control policy and procedures by failing to ensure: - Resident 44's indwelling catheter bag (inserted tube that drains urine from the bladder into a bag outside the body) was not touching the floor. -Infection Prevention Nurse conducted an infection control surveillance and antibiotic stewardship for all infections including respiratory infections. -Treatment Nurse (TN) 1 was wearing an N95 mask (a particulate-filtering face piece, respirator that meets the U.S. National Institute for occupational safety and Health [NIOSH] and filters at least 95% of airborne particles) properly to cover his nose and mouth in resident care area. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced dignity and respect by not standing over the resident while assisting him during meal for one of the 13 sampled residents (Resident 30). This deficient practice had the potential to affect resident's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (a process by which residents or their responsible parties have the choice to accept or decline certain medication therapy or treatments once they are educated about the risks and benefits) prior to prescribing psychotropic medications (medications that affect brain activities associated with mental processes and behavior) or increasing their dose for two of five sampled residents (Residents 18 and 23). This deficient practice could have denied Residents 18 and 23 the right to be informed regarding the risks and benefits of psychotropic medication therapy possibly resulting in diminished overall physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold (Holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) notification at the time of transfer to the hospital for one of three sampled residents (Resident 47). This deficient practice denied Resident 47 information of the facility's bed hold policy and opportunity to hold or reserve her bed while absent from the facility.

Inspectors wroteBased on interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASRR) recommendation to obtain a PASRR level II evaluation for one of three 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 for range of motion for Resident 5 and indwelling catheter (a tube that drains urine from the bladder into a bag) for Resident 44 for two of 13 sampled residents. These deficient practices placed Resident 5 at risk for decline in motion and development of contractures (chronic joint stiffness associated with joint deformity and pain) and had the potential for Resident 44 to not receive appropriate care and treatment for the indwelling catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and care to one of 13 sampled residents (Resident 22), who was assessed as a moderate risk for the development of pressure sores (injuries to the skin and underlying tissue caused by prolonged pressure on the skin). The facility did not adjust the low air loss mattress (LAL, special mattress used to heal pressure sores, which are injuries to the skin and underlying tissue caused by prolonged pressure on the skin) to Resident 22's appropriate weight. The facility also failed to change the bed despite Resident 22's requests. This deficient practice placed Resident 22 at risk for increased back pain and the development of pressure sores, impacting the resident's quality of life and lowering the resident's self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post an Oxygen in Use sign outside the doorway and inside resident room, for one of 13 sampled residents (Resident 5) to indicate the presence of oxygen in accordance with the facility's policy. This deficient practice had the potential to place Resident 5 at risk for oxygen deprivation (lack of oxygen) in the event of a power outage and placed the facility at risk for fire hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for the use of one dose of a controlled substance (medications with a high potential for abuse) for one resident (Residents 150) in one of two inspected medication carts (Medication Cart 2). This deficient practice increased the risk that Resident 150 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain confidential information for residents receiving rehabilitation services. This deficient practice had the potential to provide unauthorized access to residents' personal information.

Inspectors wroteBased on interview and record review, the facility failed to implement an antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics), for antibiotic use protocol (official procedure or system of rules) for two of two sampled residents (Resident 46 and 47). This deficient practice had the potential to result in inappropriately prescribed antibiotics, and placed residents at higher risk of antibiotic resistance (when bacteria/germs change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was in functioning order for one of 13 sampled residents (Resident 23). This deficient practice had the potential to prevent Resident 23 from using the call light to alert staff for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain locked doors from 9 PM., to 5:30 AM., for resident safety. This deficient practice had the potential to place residents at risk for injury and theft.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure space requirements of 80 square feet for each resident were met in multiple resident bedrooms which had the potential to result in inadequate space to provide safe nursing care and privacy for 49 Residents.