California Terrace

Inspectors wroteBased on interview and record review, the facility failed to a) provide a physician ordered non-invasive imaging test in a timely manner b.) follow treatment/dressing changes as ordered c.) implement resident directed care in accordance with professional standards, resulting in a delay in referring the resident for a vascular consultation c.) provide interdisciplinary collaboration care that ensures resident's highest practicable physical, mental, and psychosocial well-being for one (R1) resident out of three residents reviewed for quality of care. As a result of the facility's failures, R1's left foot wounds worsened, demonstrated signs of infection, and, according to documented measurements, increased in size. The facility's failure to provide timely and appropriate care ultimately contributed to the need for amputation.

Inspectors wroteBased on interview and record review, the facility failed to provide specialized rehabilitative services per resident's physician order for one (R2) resident out of three residents reviewed for quality of care. This failure has the potential to affect a resident from attaining, maintaining, or restoring their highest practicable level of physical, mental, functional and psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide documentation related to the maintenance and upkeep of the facility elevator and failed to provide interventions to ensure the elevator was kept in good working condition. This failure affects 85 wheelchair bound residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide linen inventory documentation to ensure there was enough linen for all the residents of the facility. The failure affects all 237 residents that reside in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control that eliminated roaches in the facility. This failure affected one (R1) of three residents (R1, R2, R3) reviewed for pest control and has the potential to affect all 247 residents in the facility.

Inspectors wroteBased on observations, interviews and records reviews, the facility failed to follow their policy on providing a clean home-like environment to residents. This failure affected all 244 residents residing in the facility.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow their residents' rights policy by failing to manage resident clothing in a clean manner. This failure affected one (R2) of six residents reviewed in sample of 15. R2's medical diagnosis on R2's current face sheet includes but not limited to schizoaffective disorder, bipolar type, muscle wasting and atrophy, multiple sites, rheumatoid arthritis. MDS (Minimum Data Set) section C-Cognitive Abilities dated [DATE], documents R2's Brief Interview for Mental Status (BIMS) as 9/15 indicating R2 has moderate cognitive impairment. On 03/13/2026 at 3:09PM, R2 observed lying in bed. R2 was difficult to understand and was observed to be teary eyed. On 03/13/2026 at 3:09PM, V4 (Licensed Practical Nurse-LPN/ first floor supervisor) opened R2's closet. V4 started pulling out R2's clothes from his closet. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect residents from resident-to-resident physical abuse. This failure affects one (R8) resident out of five residents reviewed for abuse in a total sample of fifteen. As a result of this failure, R9 pushed R8 on 12/15/2025.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment for two residents (R2, R10) in a sample of 10. This failure has the potential to affect 117 residents residing on the 3rd and 4th floor. Facility's (2/2726) roster documents 117 residents residing on the 3rd and 4th floor.1. R10's is a [AGE] year-old with diagnosis not limited to: hemiplegia and Hemiparesis, Cerebrovascular Disease Affecting Left Dominant Side, Aphasia, Cerebral Infarction, Type 2 Diabetes Mellitus with Moderate Non-proliferative Diabetic Retinopathy Without macular Edema, Bilateral, Constipation, Essential (Primary) Hypertension, Gastro-Esophageal Reflux Disease Without Esophagitis, Hyperlipidemia, Unspecified, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and AnxietyR10 resides on the 3rd floor. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to prevent live roaches from being in residents' rooms and crawling in bed with residents. This failure affected four residents (R2, R6, R18, and R21) in a sample of 10. This failure has the potential to affect all 250 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to answer call lights in a timely manner for four residents (R1, R2, R4, R9) and failed to accommodate timely repairs for furnishings for three residents (R1, R3, R4) out of a total sample of 14 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a clean and home-like environment for six (R2, R4-R8) out of a total sample of 14 residents with a potential to affect multiple residents on the first, second, third, and fourth floors.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow a resident's (R2) plan of care and failed to recognize potential accident/hazard in the patio. This has the potential to affect all residents who go out to the patio.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that foods were stored and/or prepared under sanitary conditions. These failures have the potential to affect all 229 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the dumpster grounds were free from food related trash and that the dumpster lid was closed. These failures have the potential to affect all 231 residents residing at the facility. Facility Ray, Carlyn (36383) - KitchenFindings include:On 8/11/2025, V1 (Administrator) stated that the resident census was 231 residents at the facility. On 8/13/2024 at 11:00 am, Surveyor and V31 (Dietary Manager) inspected the facility outside dumpster area and observed dietary trash covering the grounds and one dumpster lid open. Trash items surrounding the dumpster grounds included open individual-sized milk cartons, used paper plates, foam drinking cups, dietary napkins, and other dietary related trash. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a facility wide system to monitor the use of antibiotics. This failure has the potential to affect all 231 residents that reside in the facility.

Inspectors wroteBased upon observation, interview and record review, the facility failed to maintain an effective pest control program to ensure that the facility free of insects. This failure has the potential to affect all 231 residents at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain an order for two residents (R136 and R138) to self-administer medications. This failure affected two residents and has the potential to affect all 55 residents residing on the 3rd floor and all 56 residents residing on the 4th floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's environment was free from hazard. This failure affected 1 (R138) resident reviewed for accident hazard and has the potential to affect all the 25 residents in Unit 3A.

Inspectors wroteBased on observation, interview, and record review the facility failed to dispose of loose pills in the bottom of the medication cart (Team 2) on the 2nd floor. This failure has the potential to affect all 33 residents receiving medications from cart 2 on the 2nd floor.

Inspectors wroteBased on observations, interviews and record review, the facility failed to perform appropriate hand hygiene after contact with residents during tray pass, prior to entering and after exiting resident room on Enhanced Barrier Precautions (EBP), and between residents medication pass; failed to ensure staff does not touch a resident's oral medications; failed to ensure staff sanitize shared medical equipment between each resident's use; failed to ensure EBP sign was posted and Personal protective equipment (PPE) bin available for residents on EBP; and failed to ensure staff do not store soiled linen on clean linen cart in an effort to prevent the spread of infectious microorganism. These failures affected six (R10, R129, R141, R157, R228, and R237) residents reviewed for infection control and have the potential to affect all 180 residents on 2nd, 3rd and 4th floors.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a code status physician's order was in a resident's electronic medical record (EMR). This failure affected two residents (R5 and R114) in a sample of 54 residents reviewed for advance directives.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident with new diagnoses of schizoaffective disorder was referred to the appropriate state-designated agency for a new Preadmission Screening and Resident Review (PASRR). This failure affected 1 (R9) resident reviewed for PASRR in the total sample of 54 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who depend on staff's assistance for their ADL (Activities of Daily Living) care received grooming and shaving. This failure affected two residents (R64 and R186) out of 54 residents reviewed for ADL care.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the low air loss mattress was set on the recommended setting. This failure affected 1 (R238) resident reviewed for the prevention of pressure injury in the total sample of 54 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to contain oxygen equipment (nebulizer masks and nasal cannula tubing) per facility's policy. This failure affected three residents (R30, R165 and R205) reviewed for oxygen equipment, in a total sample size of 54 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to prepare insulin syringe dosage according to the prescribed sliding scale order. This failure affected one resident (R220) reviewed for medication administration and has the potential to affect all 10 residents receiving insulin products, that are residing on the second-floor unit of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor personal refrigerator temperature logs; and failed to ensure that a residents personal refrigerator had a thermometer. These failures affected two residents (R2 and R109), and out of 54 residents in the total sample.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident had a privacy curtain which extended around the bed. This failure affected one resident (R15), out of 54 residents in the total sample.

Inspectors wroteF600: Abuse:Based on interview and record review the facility failed to prevent resident to resident physical assault for two (R1, and R2) out of three residents reviewed for abuse. This failure resulted to R1 sustaining a head injury with staples. Findings Include:R1's Minimum Data Set (MDS) dated [DATE], Brief Interview Score/BIMS (14) indicates he is cognitively intact. R2' MDS dated [DATE], BIMs score (15) indicates he is cognitively intact. On 7/30/25 at 10:02 AM, R1 stated he has been in this facility for over a year. R1 stated, on 7/1/25 around 1pm, he was watching a program on his television (TV) and listening to his radio. R1 got up to assist R2 to pick up his lunch tray when R1 accidentally fell on R2. R2 then hit the back/side of R1's head with a dumbbell. R1 stated staff came into his room to attend to his bleeding head. [...]

Inspectors wroteBased on interview and record review the facility failed to protect one resident (R5) out a sample of 3 from verbal and emotional abuse. This failure has the potential to affect one resident (R5) out of a sample of 3.

Inspectors wroteBased on interview and record review the facility failed to supervise a confused wandering male resident from wandering in female rooms during smoke times causing resident mental abuse. This failure affected 2 (R2 and R6) residents in a sample of 57. The facility failed to prevent residents from smoking inside the facility (R7, R10) per policy.

Inspectors wroteBased on interview, observation and record review the facility failed to ensure reasonable accommodations of residents needs by failing to ensure nurse calls are assessable to the residents and answered in a timely manner in 7 (R1, R2, R3, R6, R7, R8, R9) of a sample of 20 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light system was functional and failed to monitor its call light system. These failures have the potential to affect 121 residents residing on the third and fourth floors of the the facility.

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect a resident from resident-to-resident physical abuse. This failure affects one (R1) resident out of three residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the third and fourth floor shower rooms were clean and sanitary. This has the potential to affect all 33 residents residing on the third floor and all 60 residents residing on the fourth floor.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the daily nursing staffing and failed to ensure the daily nursing staffing information was complete and accurate. These failures affected all 230 residents residing in the facility.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that the residents'common shower room was without debris and dirt on the floor. This failure has the potential to affect all 66 residents that reside on the second floor.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that residents' rooms were free of cockroaches. This failure has the potential to affect all 66 residents that reside on the 2nd floor.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one resident with documented skin issues (R2) did not develop maggots in his foot wound. This failure has affected one of three residents reviewed for wound care.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their care plan policy to develop, implement, and supervise a newly admitted resident with self- injurious and suicidal behavioral concerns. These failures resulted in a resident (R3) gaining access to a shaving blade/razor and cutting his right arm; in a separate incident R3 found a spoon in which R3 was able to break in 2 places and use the pieces to cut his arm; and another incident in which R3 punched a picture with a glass frame which resulted in R3 sustaining an injury that required R3 to be sent to the ER (Emergency Room) and receiving 7 sutures to the left hand. The facility's immediate jeopardy began on 05/31/24. On 11/12/24 at 10:17 AM, the Administrator and Director of Nursing were notified of the immediate jeopardy. The immediate jeopardy was removed on 11/13/24 at 01:19 PM. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to protect a residents' (R2, R11, and R12) right to be free from verbal and physical abuse form another resident (R1) for three out of 13 residents reviewed for abuse. This failure resulted in staff not providing needed supervision for an aggressive resident causing R1 to get into a verbal altercation with R12, R11 having to physically stop R1 from striking R11 with a cane and R1 punching R2 in the face.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy by not reporting an allegation of abuse to V1 (Administrator) and reporting it to the (State Agency) for two of R1's incidents. This affected 3 (R1, R11, R12) out of 13 residents reviewed for abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the temperature of the walk-in cooler and walk in freezer were checked daily, failed to ensure the scoop for dry food was contained, failed to ensure Dietary staff wore appropriate beard guard, and failed to ensure facility staff used unexpired test strips in checking the concentration of chemical used to sanitize kitchen utensils in an effort to prevent food borne illnesses. These failures have the potential to affect all residents at the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the dumpsters were not overflowing with trash, failed to ensure the dumpster lids were close, and failed to ensure there was no gap between the two doors which led to the loading dock of the facility in an effort to maintain an effective pest control program. These failures have the potential to affect all the residents at the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a homelike environment to 8 (R71, R73, R104, R172, R178, R179, R193, and R202) residents reviewed for home-like environment in the total sample of 67 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the environment was free from hazards for one resident (R189). This failure has the potential to affect all 64 residents on the third-floor unit.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to properly label and date oxygen equipment (humidifier bottled, and nebulizer mask) and failed to properly contain oxygen equipment (nebulizer mask) per the facility policy. These failures affected four residents (R48, R78, R135 and R205) reviewed for respiratory care in a sample of 67 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an accurate account of the controlled substance record and failed to dispose expired medication. These failures affected four residents (R165, R202, R203, and 456) reviewed for controlled substance and medication storage in a sample of 67 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that four residents (R5, R118, R174, and R556) was placed on Enhanced Barrier Precautions (EBP); failed to ensure staff appropriately [NAME] and Doff gloves and change wash clothes during ADL (Activities of Daily Living) care for one resident (R61). These failures affected one resident (R61) and has the potential to affect all 56 residents on the first floor, all 68 residents on the second floor and 64 residents on the third-floor unit.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the fourth floor resident pantry was clean and sanitary. This has the potential to affect the 65 residents residing on the fourth floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nail care is provided for one resident (R75). This failure has the potential to affect all residents in the sample size of 67.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor personal refrigerator temperature logs for two residents (R98 and R174). This failure affected two residents (R98, R174) out of 67 residents in the total sample.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that resident's call device was functioning to allow resident to call for staff assistance. This failure affected 1 resident (R250) reviewed for functioning resident call device in a total sample of 67 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was not left inside the room of a resident whose ability to safely self-administer medications was not assessed. This failure affected one (R4) resident reviewed for self-administration in the total sample of 7 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who required assistance with incontinence care received necessary services in a timely when requested for one (R6) resident out of three residents reviewed for improper nursing care in the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a functioning call light that is accessible to one resident (R7) to allow the residents to call for staff assistance and failed to provide a specialized call light for one resident (R2) who is unable to use standard call light out of three residents reviewed for call lights in the sample.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with needed supplies for Activities of Daily Living such as linen. This failure affects all 252 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure food items were covered, labeled and dated and failed to ensure staff appropriately wear beard restraints in an effort to prevent food borne illness. These failures have the potential to affect all residents receiving oral nutrition at the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the dumpsters were not overflowing with trash, failed to ensure the dumpsters were closed and failed to ensure the ground surrounding the dumpster was free of trash in an effort to prevent pest and rodents migration to the facility. These failures have the potential to affect all residents at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 4 residents (R7, R25, R175, R299) received nail care to preserve their dignity and increase self-esteem. This failure affected 4 out of 71 residents in the sample.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the safety for 4 residents (R27, R111, R163, R173) by removing disposable razors from the resident's room and failed to provide supervision for 2 residents (R27 and R131) by leaving oral medicine and eye drops at the resident's bedside. The failure has the potential to affect all 5 residents out of a sample of 71.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 3 residents on the 4th Floor Team 2 medication cart who are prescribed controlled substances and 5 residents on the 4th Floor Team 1 medication cart who are prescribed controlled substances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a bedside table was accessible when being served lunch in resident's room, which affected one resident (R449) in the sample of 71 reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide clean linen for 2 residents (R27, R175) out of a sample of 71 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure new skin alteration was reported to the nurse and failed to ensure the low air loss mattress was set appropriately. These failures affected 1 (R67) resident reviewed for prevention and treatment of pressure ulcer/injury in the total sample of 71 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the feeding tube was disconnected and flushed after the completion of feeding. This failure affected 1 (R46) resident reviewed for tube feeding in the total sample of 71 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly log refrigerator temperatures for two resident's (R98 and R180) personal refrigerators and failed to provide a thermometer in one resident's refrigerator(R180). This failure has the potential to affect all 71 residents in the sample.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow the abuse prevention policy, failed to implement interventions, failed to acknowledge (R4's) behaviors, failed to immediately remove (R4) from resident contact to ensure safety, and failed to ensure that one of four residents (R5) reviewed for abuse remained free from abuse. On (11/25/23) R5 sustained blunt head trauma during physical altercation with (R4) resulting in left frontal scalp contusion/hematoma and age indeterminate mildly displaced right nasal bone fracture. R5 also reported enduring chronic dizziness and headaches subsequent the altercation.

Inspectors wroteBased upon observation, interview and record review the facility failed to ensure that call lights were accessible for two of four residents (R1, R2) reviewed for call lights.

Inspectors wroteBased upon observation, interview and record review the facility failed to follow the abuse prevention policy, failed to report required information, and failed to report accurate information and/or injury to the State Agency for two of four residents (R4, R5) reviewed for abuse.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow the smoking safety policy and failed to provide supervision to one of five residents (R1) reviewed for hazards. These failures have the potential to affect 251 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to supervise a resident and provide individualized fall prevention interventions, for a cognitively impaired resident, who had four repeated falls. This failure affected one resident (R1) of three residents, reviewed for falls. As a result, R1 was sent to the hospital three times within seven weeks. The last fall incident of R1 resulted in an open fracture of the nasal bone.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure that resident's meals were the proper portion size. This failure has the potential to affect 245 residents that currently depend on the facility to meet their nutritional needs.

Inspectors wroteBased on observation, interviews and record review, the facility failed to: ensure that one dependent resident (R1) was clean and dry within two hours of requesting incontinent care; and the facility failed to ensure that one resident (R1) with scaly feet and overgrown toe nails received foot care. This failure affected one of three residents reviewed for Activities of Daily Living.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide adequate supervision for a dementia resident (R1) who is a fall risk. This failure resulted in R1 falling in the hallway, sustaining a laceration to his forehead, requiring emergency department evaluation and receiving eight sutures. Findings Include, R1's clinical record documents in part: R1 is a [AGE] year-old with the medical diagnosis of dementia, vascular dementia, muscle weakness, history of falling, cognitive communication deficit, unsteadiness on feet, metabolic encephalopathy, dysphagia, weakness, and reduced mobility. Minimum data set [MDS] Brief Interview Mental Status Score indicates R1 is cognitively impaired. R1's Care Plan documented in part five falls. Two falls 5/24/23 and 9/20/23 resulted in injury. -R1 is at risk for falls due to co-morbidities: Fall 10/17/23: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide reasonable accommodation of needs by not supplying enough linen for five (R7, R9, R10, R11,12) residents out of a total sample of 12 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective Pest Control Program for two resident rooms and a hallway.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to keep two residents (R6, R8) free from abuse for 2 of 12 residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to follow its policy and procedures for Fall Prevention for one (R2) of three residents reviewed for falls. This failure resulted in R2 sustaining a fall resulting in fractures to the Humerus and finger of R2's left hand.

Inspectors wroteBased on observation, interview and record review, the facility failed to (a) provide all 244 residents residing in the facility with needed supplies for Activities of Daily Living care items(bedsheets, gowns, towels, incontinence briefs) (b) failed to provide appropriate eating utensils to accommodate 241 residents that eat from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received food in the acceptable amount to maintain nutritional values. This failure has the potential to affect the 241 residents receiving food from the kitchen.

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow their call light system policy by failing to maintain a properly functioning call light system that allows residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. This deficient practice has the potential to affect all 244 residents residing in the facility.

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow their activities of daily living and dignity policy to provide one resident (R1) of 3 reviewed for activities of daily living(the necessary services to maintain, grooming, and personal hygiene of three residents reviewed).

Inspectors wroteBased on observation, interview and record review the facility failed to follow its policy and procedures for Fall Prevention & Post Fall Assessment by a.) not providing individualized preventative fall risk measures, b.) not following fall risk care plan interventions prior to fall, c.)failed to complete new or updated fall risk assessment post fall, d.) failed to update care plan with any new fall interventions after fall incident for one (R3) out of three residents reviewed for falls. This failure resulted in R3 sustaining a fall resulting in a laceration requiring five sutures with risk for falls ongoing for lack of interventions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was served at a palatable temperature. This deficient practice has the potential to affect all 240 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program to keep pests out of the facility. This deficient practice has the potential to affect all 243 residents residing at the facility.

Inspectors wroteBased on observation, interviews, and review of records the facility failed to follow pain assessment and management program by not addressing and documenting pain for 1 out of 3 residents (R1) reviewed for pain management. These failures have the potential to affect 1 resident (R1) daily pain status and comfort.