Camellia Gardens Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattresses (LALMs, designed to distribute a resident's body weight over a broad surface area and help prevent skin breakdown) for two (2) of 2 sampled residents (Residents 13 and 81) reviewed for pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure) were set at the correct settings in accordance with the facility's policy and procedure (P&P) and the physician's orders:Resident 13, who weighed 90 pounds (lbs.), had a LALM setting of 50 lbs. Resident 81, who weighed 103 lbs., had a LALM setting of 120 lbs. This deficient practice had the potential for Resident 13 to develop a pressure ulcer and placed Resident 81 at risk for deterioration of the resident's current pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the kitchen staff (Cook 3) failed to follow the facility's food preparation policy by not using serving utensils and not changing gloves during the lunch tray line assembly (organized process in a healthcare or food service setting where staff assemble meal trays for residents) on 4/22/2026. This deficient practice had the potential to expose residents to pathogens (germs), placing them at risk for developing foodborne illness, which may cause symptoms such as upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, and could lead to serious medical complications or hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of five (5) sampled residents (Resident 12 and 57) reviewed for unnecessary (any drug when used without adequate monitoring, and without adequate indication for use) medications were free from unnecessary psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) as indicated in the facility's policy and procedure by failing to ensure: 1.a. Resident 12's behavior of being easily irritable for the use of Depakote (also used to treat acute manic or mixed episodes associated with bipolar disorder with or without psychotic features) was monitored.b. Resident 12 was monitored for a specific manifestation of restlessness for the use of Clonazepam (Klonopin, is a prescription medicine used to calm the nervous system. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff did not develop a care plan (a dynamic, written document outlining a patient's health needs, goals, and customized interventions, formulated through assessment) to address the use of indwelling catheter (a flexible, sterile tube inserted into the bladder to continuously drain urine into a collection bag) for one (1) of 18 sampled residents (Resident 8) as indicated on the facility policy. This deficient practice had the potential for Resident 8 to have catheter-associated urinary tract infections (infection in the urinary tract due to the medical device such as indwelling catheter).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 72) reviewed for indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) were accurately monitored on 4/20/2026 and 4/22/2026, in accordance with the physician's (MD, medical doctor) order and facility's policy and procedure (P&P) by failing to ensure:Resident 72's indwelling catheter was monitored and documented for sedimentation (particles in liquid) in the urine (common causes include dehydration, kidney stone or urinary tract infection [UTI; an infection in the urinary system, which includes the kidneys, ureters, bladder, and urethra]) on 4/20/2026 and 4/22/2026. MD was notified of Resident 72's sedimentation in urine noted on 4/20/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) for one (1) of five (5) sampled residents (Resident 57) reviewed for unnecessary medications, in accordance with the facility's policy. This deficient practice had the potential for Resident 57 to receive unnecessary medications and experience adverse drug reactions.

Inspectors wroteBased on interview and record review, the facility failed to monitor the use of antiseizure medications (ASM, used to treat and prevent seizures [brief episodes of abnormal electrical activity in the brain that can cause a variety of symptoms, including involuntary movements, loss of consciousness, and changes in behavior) for one (1) of five (5) sampled residents (Resident 57) reviewed for unnecessary medications by failing to monitor for side effects and seizure episodes in accordance with the care plan and facility policy. This deficient practice had the potential for Resident 57 to experience episodes of seizures without proper monitoring and to develop adverse drug reactions (any unwanted or harmful effect that happens when a person takes a medication at the normal dose) which may result in harm, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for four (4) of 18 sampled residents (Resident 3, 8, 10 and 44 ) in accordance with the facility's policy and procedure when: 1. Licensed Vocational Nurse 4 (LVN 4) failed to put on a gown while providing care for Resident 3, who was on contact precautions (an infection control measure used in healthcare settings to prevent the spread of infections transmitted through direct or indirect contact with a resident or their environment). 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light was within reach of Resident 1 to accommodate resident when resident needed to call for help and ask for her pain medication on 3/4/2026. This deficient practice has the potential to delay in pain relief, the necessary care, services and needs not being met for Resident 1, affect the quality of life and lead to other medical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) for one (1) of two (2) sampled residents (Resident 1) when Resident 1 needed a brief change. This deficient practice had the potential for Resident 1 to develop skin issues and develop complications of MASD (moisture associated skin damage caused from prolonged exposure to moisture).

Inspectors wroteBased on interview and record review, Certified Nursing Assistants (CNAs) failed to fill out the stop and watch form on 2/10/2026 and 2/11/2026 for one (1) of two (2) sampled residents (Resident 1), when Resident 1 was coughing, congested and having difficulty swallowing. This deficient practice had the potential for Resident 1 experiencing respiratory distress which can result in hospitalization and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an injury of unknown origin (the source of the injury was not witnessed by any person and the source of the injury could not be explained by the resident and the injury is suspicious because of its extent, location, the number of injuries at a time, or the number of injuries over time) to California Department of Public Health (CDPH), local law enforcement, and Ombudsman (an official appointed to investigate individuals' complaints against the facility) within two (2) hours from when the resident was noted to have dark purple discoloration on the right eye for one (1) of 2 sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting. [...]

Inspectors wroteBased on interviews and record review, the facility failed to admit one of one sample resident (Resident 1) to the facility's first available bed from 12/18/2025 to 12/24/2025. This deficient practice has the potential to result in increased Resident 1 and his family for physical and emotional distress (an unpleasant emotional, psychological, or physical reaction to a difficult experience or ongoing stress that interferes with one's ability to cope with daily life) due to unnecessary stay in the hospital.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide a safe environment in accordance with the facility's policy and procedures when: 1. One (1) out of two (2) sample residents (Resident 2) remained in the room with water leaking from the ceiling during the heavy rain. 2. The Hoyer Lift (a mechanical device used to lift and/or transfer a person) was left outside Room A for 6 hours and left a shower chair on the opposite side of the hallway parallel to the Hoyer lift. These deficient practices could potentially result in accidents, injuries and hazard from wet slippery floors, and obstructed hallways compromising the wellbeing of the residents, staff and the visitors.

Inspectors wroteThe facility failed to provide care consistent with the professional standards of practice (the set of guidelines, principles, and expectations that govern the conduct and performance of nursing professionals) to prevent worsening of the pressure ulcer (PU, a localized area of skin damage caused by prolonged pressure on the skin) for one of two sampled residents (Resident 1) by failing to: 1. Assess and document detailed observations in SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) of Resident 1's change with skin condition and/ or wound condition on the resident's left trochanter area (a small, conical projection located on the medial side of the upper femur, specifically at the junction of the femoral neck and shaft) on 4/10/2025, 4/17/2025 and 4/24/2025. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor the intravenous (IV, a small flexible tube placed into a small vein for intravenous therapy such as medication fluids) site and change the heplock (a type of IV device for the administration of solution or medication) dressing for two (2) of 3 sampled residents (Resident 1 and Resident 2) in accordance with the facility policy. This deficient practice had the potential to result in Resident 1 and Resident 2 to develop IV complications which can lead to infection and possible hospitalization.

Inspectors wroteBased on interview and record review the facility failed to activities of daily living care assistance were provided for one of two sampled residents (Resident 1) by failing to ensure: a. Resident 1 was assessed for incontinence (involuntary loss of urine or stool) care in accordance with the plan of care. b. Resident 1 received tongue scraping (the practice of using a tool such as metal tongue scraper to gently remove bacteria, food particles, and other debris from the surface of the tongue, promoting better oral hygiene and potentially reducing bad breath) in accordance with the physician order. These deficient practices had the potential to lead to skin breakdown, poor hygiene, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, and homelike environment for two (2) of 17 sampled residents (Resident 36 and 37) when facility failed to: 1. Ensure Resident 36 and Resident 37's room did not have used gloves left on the floor. 2. Ensure Resident 36 and Resident 37's trashcan in the room was not overflowing with used disposable gowns. These deficient practices resulted in unsanitary conditions placing Resident 36 and 37 at risk for infection and uncomfortable living. Findings 1. [...]

Inspectors wrote2. During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included chronic respiratory failure, anemia (a condition where the body does not have enough health red blood cells), and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49 was assessed having severely impaired (never/rarely made decisions) cognitive skills for daily decision making. Resident 49 was dependent with oral hygiene, shoer/bathe self, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. Resident 49 was dependent with sit to lying, chair/bed-to-chair transfer, and tub/shower transfer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessment entry on the Minimum Data Set (MDS- a resident assessment tool) was accurately documented to reflect the restraint (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to his body) that was used one of four sampled residents (Resident 49) assessed for restraints. This deficient practice had the potential to negatively affect Resident 49's plan of care and deliver of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three (3) out of 3 residents (Resident 27, 36 and 37) reviewed for Activities of Daily Living (ADLs, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) were provided care and services to maintain good grooming and personal hygiene. 1. Resident 27's fingernails on both contracted hands (a condition where the fingers or palm of the hand become permanently bent or curled) were long and untrimmed. 2. Resident 36's nails on both hands were long and had brownish discolorations. 3. Resident 37's nails on both contracted hands were long and untrimmed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for four (5) of 8 sampled resident (Resident 57, 122, 9, 11 and 120 ) for the infection control care areas in accordance with the facility's policy and procedure when: 1. Resident 57's foley catheter drainage bag (a urine collection bag) was observed touching the floor on 3/6/2025. 2. Licensed Vocational Nurse 3 (LVN 3) failed to change gloves and perform hand hygiene in between task during medication administration to Resident 122. 3. LVN 4 failed to change gloves and perform hand hygiene in between task during medication administration to Resident 9. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat the resident with respect and dignity and maintain privacy for one (1) of 17 sampled residents (Resident 37) in accordance with the facility policy. This deficient practice had the potential to negatively affect Resident 37's self-worth, self-esteem and psychosocial (pertaining to the influence of social factors on an individual's mind or behavior) well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 17 sampled residents (Residents 12) were given sufficient notice prior to the last coverage day for Medicare Part A (hospital insurance) services. This deficient practice had the potential to cause stress to the residents and not be able to make adequate arrangements for charges that may incur.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide privacy and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the individual's surrogate or representative) for one of 17 sampled residents (Resident 219) when Resident 219's medical records were left exposed by leaving the computer unattended and not turning off the computer screen on 3/5/2025. This deficient practice violated Resident 219's right to privacy and confidentiality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) with individualized approaches for communicating for one of 17 sampled residents (Resident 52). This deficient practice had the potential to result in a delay or lack of delivery of care and services for Resident 52.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for one (1) of two sampled residents (Residents 37), reviewed for pressure ulcer in accordance with the facility's policy and procedure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services to one of four sampled residents (Resident 218) with limited range of motion (ROM- the extent of movement of a joint) and limited mobility to prevent further decrease in ROM and maintain or improve mobility as indicated in the facility's policy and procedure (P&P). This deficient practice had the potential to place Resident 218 at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity or rigidity of joints).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled Residents (Resident 46) was informed and understood the concept of the proposed binding arbitration (Arbitration is a procedure in which a dispute is submitted, by agreement of the parties) and the right to rescind (take back or cancel) the agreement within 30 calendar days of signing the agreement, before having Resident 46 enter into a binding arbitration agreement. The deficient practice had the potential resulted in Resident 46 unknowingly giving up their right to resolve any disputes with the facility through a court of law before a jury.

Inspectors wroteBased on interview and record review, the facility failed to ensure the antibiotic stewardship program protocols for prescribing the appropriate antibiotics (medication used to treat or prevent some types of bacterial infection) was completed in its entirety for two (2) of three (3) sampled residents (Resident 6 and Resident 218) prior to the administration of their antibiotic therapy. This deficient practice had the potential to result in the development of antibiotic-resistant organisms (not effective to treat infection), from unnecessary or inappropriate use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 2), were kept clean and provided appropriate care for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) per facility protocol and policy. These failures resulted in delayed services to maintain good grooming and personal hygiene for Residents 1 and 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain appropriate respiratory care for one of three sampled residents (Resident 1), by failing to: 1. Administer 2 liters of continuous (without interruption) oxygen therapy (a treatment that provides extra oxygen to people who have breathing problems or low oxygen levels in their blood) as ordered. 2. Maintain infection control when oxygen tubing (a flexible, clear hose that carries oxygen from a source to a delivery device), became contaminated (the presence of an infectious agents- bacteria, viruses, microbes) and was not discarded per facility protocol. These failures resulted in Resident 1 not receiving the accurately prescribed amount of oxygen and had the potential to result in respiratory complication and/or infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow up and ensure dental services were provided for one of three residents (Resident 1), as indicated in the physician ' s order and facility policy. This failure resulted in Resident 1 receiving delayed dental services with the potential risk for a decline in his oral health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there would not be a delay in physical therapy (PT- treatment that helps improve how the body performs physical movements) and occupational therapy (OT- treatment that helps improve a person ' s ability to perform daily tasks) services provided for one of three sampled residents (Resident 1), after ordered by the physician. This failure resulted in delayed PT and OT therapy treatment and services for Resident 1, and placed Resident 1 at higher risk for further range of motion (ROM-the full movement potential of a joint, usually its range of flexion and extension) decline.

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety by: 1. Failing to ensure three (3) opened/used packages of eight (8) ounces (oz - unit of measurement of volume) ground coffee was labeled with open date. 2. Failing to discard expired 3 food items found in the facility's walk- in refrigerator. The deficient practice had the potential to result in growth of bacteria and transmission of foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, and diarrhea and could lead to other serious medical complications and hospitalization of the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe proper infection control practices per the facility ' s policy and procedure for 2 of 2 sampled residents (Residents 1 and 2) when Certified Nursing Assistant 1 (CNA 1) entered a contact isolation precautions (isolation precautions taken by staff for residents with diseases caused by microorganisms [bacteria, viruses and parasites] that are spread through direct and indirect contact) room without putting on personal protective equipment (PPE; equipment such as gowns, gloves, face mask and/or face shield worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). This failure had the potential to result in the spread of infection by bacteria, viruses and/or parasites to other residents at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), had a safe and homelike environment by inserting two pillows and a wedge (triangular piece of foam cushion used to add elevation [to a portion of the body part]) between Resident 1's mattress and bedframe. These failures had the potential to result in an unsafe, and uncomfortable environment for Resident 1's and violation of right to a dignified existence. Cross reference with F689.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free of accident hazards for one of three sampled residents (Resident 1), when facility: 1. Failed to provide padded bilateral (left and right side) siderails (a barrier attached to side of the bed [ can be head of bed, or food of the bed or full length of the bed) while Resident 1 was in bed on as indicated in Resident 1's care plan and doctor's order. 2. Failed to follow the correct use of mattress for Resident 1's as indicated in manufacturer's manual. Resident 1 lying in bed with two pillows and a wedge (triangular piece of foam cushion used to add elevation [to a portion of the body part]) in between the mattress and bed frame. These failures placed Resident 1 at risk for physical harm and injury due to safety hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures as indicated on the facility policy when facility failed to: 1. Establish and maintain an effective water management program to prevent the development and transmission of Legionnaire's disease (LD, a serious and often deadly form of lung infection [pneumonia], acquired by breathing in water droplets caused by the bacteria, legionella [the bacteria that causes LD]). This deficient practice placed 70 of 70 residents in the facility at risk for developing severe respiratory infection (pneumonia). 2. Place an isolation signage for contact precautions (special precautionary measures, practices, and procedures used in the care of residents with contagious or communicable diseases) for Room A, which was occupied by Residents 6, 33, 120, and 121. 3. [...]

Inspectors wrote3. During a review of Resident 21's admission Record, admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord) and type two (2) diabetes mellitus (a disease that occurs when your blood sugar is too high). During a review of Resident 21's H&P, dated 10/6/2023, H&P indicated the resident has fluctuating capacity to understand and make decisions. During a review of Resident 21's MDS, dated [DATE], MDS indicated the resident was moderately impaired with cognitive skills for daily decision making. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Advance Health Care Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them) Acknowledgement Form was either fully filled out and witnessed or readily available in the residents' medical chart for 10 of 21 sampled residents (Residents 43, 37, 21, 24, 53, 52, 54, 55, 38, and 35) for advance directive care area, in accordance with the facility's Advance Directives policy and procedure. This failure had the potential to result in nursing staff not knowing if Residents 43, 37, 21, 24, 53, 52, 54, 55, 38 and 35 had specific resident wishes to follow in case of an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the low air loss mattress (operates using a blower based pump that is designed to circulate a constant flow of air through the mattress, commonly used to heal pressure ulcers [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) was correctly set up for two (2) of three (3) sampled residents (Resident 35 and Resident 55) for pressure ulcer care area. This deficient practice had the potential for Resident 35 to develop a pressure ulcer and delayed healing for Resident 55's sacrococcyx (tail bone) pressure ulcer, which could affect the resident's over all wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services and treatment to prevent urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, bladder [organ that stores urine] or urethra [the tube through which urine leave the body]) for two of four sampled residents (Resident 16 and 21) for catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) UTI care area by failing to: 1. Monitor and document signs and symptoms of UTI for Resident 16 who had an indwelling catheter (foley catheter, tube that drains urine from the bladder into a drainage bag). 2. Address excessive sediment (matter that settles to the bottom of a liquid) in Resident 21's indwelling catheter by changing the catheter per physician's order. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to stop the gastronomy tube feeding (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach) in accordance with the physician's ordered dose for two of three sampled residents (Residents 21 and 37) for tube feeding care area. This failure had the potential to result in Residents 21 and 37 experiencing fluid overload (when your body has too much water which can raise your blood pressure, force your heart to work harder and make it hard to breathe) which could then also lead to aspiration (when food, liquid or other material enters a person's airway and eventually the lungs by accident which can happen as a person swallows or when food comes back up from the stomach).

Inspectors wroteBased on observation, interview, and record review, the facility failed to label food in the kitchen with item names, open date, and used by date and failed to discard expired food as indicated in the facility's policy and procedure. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage were properly disposed and trash bins were not overflowing and were properly covered. This deficient practice had the potential to attract pests (a destructive insect or other animal that attacks crops, food, livestock, etc.) and rodents.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy on influenza vaccination (flu shots, vaccine that protect against infection by the flu virus) and pneumococcal vaccination (vaccine that protect against bacteria that cause illnesses such as pneumonia [infection of the lungs], ear infections, sinus infections, meningitis [infection of the tissue covering the brain and spinal cord], and bacteremia [infection of the blood]) for three of five residents (Residents 13, 40 and 53) by failing to: 1. and 2. Provide education, offer, and document influenza vaccination to Residents 13 and 40. 3. Provide education, offer, and document pneumococcal vaccination to Resident 53. This deficient practice placed the residents at higher risk of acquiring and transmitting complications from the influenza and pneumococcal disease.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy on Covid-19 (Coronavirus Disease 19, a respiratory viral infection that affects primarily the lungs and result in cough and difficulty breathing) for five of five sampled residents (Residents 13, 33, 40, 42, and 53) and 86 of 98 facility staff by failing to: 1. Provide education, offer, and document Covid-19 vaccinations for (Residents 13, 33, 40, 42, and 53). 2. Provide education, offer, and/or document Covid-19 vaccinations for 86 of 98 staff. This deficient practice place residents and staff at risk for possible Covid-19 infection due to missed vaccination dosage.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home like environment for four of 27 rooms (Room E, F, G and H). 1. Facility failed to ensure the window frame in Room G, the top part of the frame was not damaged and the paint and [NAME] (a construction material that coats and protects the inside walls and ceilings) was not peeling off from the wall. 2. Facility failed to ensure there was hand soap in Room G's bathroom. 3. Facility failed to ensure that there was no used urinal on top of the bathroom sink in Room H. 4. Facility failed to ensure that the cabinet in Room E was not chipped off and free of sharp edges. 5. Facility failed to ensure that the corner of the linoleum on Room F floor has missing portion exposing the cement base. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device (one of the major communication technologies that link nursing home staff to the needs of residents) was within reach for one of 21 sampled residents (Resident 31). This had the potential to result in a delay in care for Resident 31 not to receive the necessary care and services which can lead to illness or serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's order for the use of physical restraints (means of purposely limiting or obstructing the freedom of a person's bodily movement) for one of one sampled resident (Resident 28) for restraint care area. This deficient practice had the potential to place the resident at risk for unnecessary prolonged use of restraints and could lead to further decline in physical functioning and skin injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's tracheostomy (a surgically created hole [stoma] in the windpipe (trachea) that provides an alternative airway for breathing) was reflected on the Minimum Data Set (MDS, an assessment and care screening tool) care for one of two residents (Resident 33) for Resident Assessment care area. This deficient practice had the potential to not develop and implement an individualized care plan, which could negatively affect the Resident 33's overall wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure the preadmission screening assessment (PASRR, Preadmission Screening and Resident Review [a federal requirement to ensure that every person entering a Medicaid Certified Nursing Facility [NF] receive a Level I screening and if necessary a Level II evaluation to ensure that resident's NF stay is appropriate and to identity what specialized services the resident may need]) form was fully completed for one of two sampled residents (Resident 13) for PASRR care area, when resident's diagnosis of mental illness was not reflected on the PASRR. This deficient practice had the potential for Resident 13 not to receive the necessary and appropriate treatment and evaluation in the facility or the risk for inappropriate placement if the facility is unable to provide the treatment and services necessary for the resident's wellbeing.

Inspectors wroteBased on interview and record review, the facility did not develop a care plan for isolation precautions (measures to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) for one of 21 sampled residents (Resident 121) who had a history of Klebsiella Pneumonia (a gram-negative bacteria that can cause different types of healthcare-associated infections including pneumonia [lung inflammation caused by bacterial or viral infection], bloodstream infections, wound or surgical site infections and meningitis [a disease caused by the inflammation of the protective membranes covering the brain and spinal cord]) and Methicillin-resistant Staphylococcus aureus (MRSA, staph [a type of bacteria found on people's skin] infection that is difficult to treat because of resistance to some antibiotics). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain good grooming by failing to keep the resident's toenails short for one of 21 sampled residents (Resident 21) for Activities of Daily Living (ADL, activities related to personal care) care area. This failure had the potential to result in Resident 21 experiencing pain or discomfort from potentially scratching himself with his toenails and negatively impacting his self esteem by causing him embarrassment.

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to ensure the safety of one (1) of four (4) sampled resident (Resident 54) for the accidents care area by not ensuring that Resident 54's bed alarm (used to alert nursing staff when at-risk patients attempt to get up without assistance in order to prevent falls) was in place. This failure placed Resident 54 to have accident such as fall (suddenly go down onto the ground or toward the ground without intending to) which can lead to serious injury or illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's tracheostomy tube (a surgical opening creating through the neck into the trachea [windpipe] to allow air to fill the lungs with a tube inserted through it to provide an airway and to remove substances such as saliva and mucus from the lungs) was free of visible debris for one of one sampled resident (Resident 43) for tracheostomy care area. This failure had the potential to lead to respiratory infection if the debris entered the Resident 43's airway.

Inspectors wroteBased on interview and record review the facility failed to revise and update the care plan addressing the ventilator (vent-a machine that helps with breathing) settings to reflect the new ventilator settings for one (1) of four (4) sampled residents (Resident 4) in accordance with the resident's physician order. This deficient practice had the potential in Resident 4 to not receive the correct ventilator setting and had the potential to negatively affect Resident 4's physical well-being by not receiving the required amount of oxygen.