Camino Healthcare

Inspectors wroteBased on observation, interview, and record review, the facility failed to clarify physician's order on how to inspect the skin on one of four sampled residents (Resident 1), who has a knee immobilizer (a medical device designed to keep the knee joint in a fixed, straight position to promote healing and prevent further injury) for the management of right tibia and fibula (long bone in the lower leg) fracture (broken bone). This deficient practice resulted in Resident 1 to develop a pressure ulcer on her right leg.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive assessment (a nurse assesses a patient) was completed for one of three sampled residents (Resident 2) before Resident 2 left the facility out on pass ([OOP]- an approved temporary absence of an patient from a facility for a few hours) and after Resident 2 returned to the facility. This deficient practice had the potential to place Resident 2 at risk for the facility not being aware of any changes following her time outside of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure licensed nursing staff informed Residents 13 and 91 of the medications being administered prior to administration. 2. Ensure Residents 13 and 91 were given an opportunity to participate during medication administration. These deficient practices violated Residents 13 and 91's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of three residents (Resident 72) had a care plan for the residents' dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit (e-kit) not being kept in Resident 72's room. This deficient practice had the potential to delay immediate access to emergency supplies needed in case of unexpected complications such as bleeding from the dialysis shunt (access site for dialysis) or rapid evacuation from the facility.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Revise and update person-centered care plans to reflect current physician orders, oxygen flow rate and gastrostomy tube feeding rate for two of 20 sampled residents (Resident 30 and 53). This failure had the potential to result in implementation of incorrect care interventions and placed residents at risk for respiratory compromise and nutritional imbalance.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one of five sampled residents (Resident 7) the physician was notified when there was sediment (the solid matter that settles to the bottom of a liquid, such as urine or blood) in the indwelling catheter (a medical device inserted into the bladder to drain urine continuously) tubing. This deficient practice not notifying the physician of the sediment in the indwelling catheter tubing had the potential to cause a urinary tract infection ([UTI]- an infection in any part of the urinary system). During a review of Resident 7's admission Record (front page of the chart that contains a summary of basic information about the resident), indicated Resident 7 was admitted to the facility on [DATE] and readmitted [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Resident 30 received oxygen at the physician ordered flow rate of 2 liters/minute (L/min).2. Ensure Resident 34's oxygen tank was secured and properly stored. These deficient practices had the potential to result in adverse outcomes, including respiratory compromise, oxygen toxicity, carbon dioxide retention, or injury related to an unsecured oxygen tank.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 7) had followed recommended physician orders for Resident 7's foot care. This deficient practice of not following the physician's recommendation orders caused a delay in foot care treatment for Resident 7.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure one of five opened medication containers was dated with the open date. This failure had the potential to affect residents who receive medications requiring dating to ensure potency.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Dispose of an unlabeled and undated bag of spinach in the kitchen refrigerator.2. Dispose of cardboard boxes under the kitchen hand washing sink. 3. Cover the bulk container of oatmeal. 4. Ensure two bottles of Gatorade were not stored in the meat freezer. 5. Label the bottle titled, Spice with a list of ingredients and a use by date. These failures had the potential to expose residents to infectious microorganisms (germs), pests, and allergic reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure two of three outside trash bins properly contained with covers that were completely closed. This failure had the potential to attract pests and vermin to the area which is adjacent to the laundry room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a sign for Enhanced Barrier Precautions (infection control measure to stop germ spread), was displayed, for one of six residents, Resident 104, in Resident 104's room. This failure had the potential to expose staff and visitors to an infectious organism when touching or caring for Resident 104.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Perform hand hygiene before touching the forehead of Resident 1. This failure had the potential to result in exposing Resident 1 to harmful organisms on the hand of CNA1. During a review of Resident 1's Face Sheet, with an admission date of 4/9/2022, the Face Sheet indicated Resident 1 is diagnosed with Dementia, Alzheimer's Disease, and Dysphagia following nontraumatic intracerebral hemorrhage. During a review of Resident1's History and Physical, dated 1/2/2025, the History and Physical indicated Resident 1 does not have the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its infection prevention and control measures for one of four sampled residents (Resident 1) by failing to change gloves (type of personal protective equipment [PPE] that is worn or used to provide protection against hazardous substances and/or environments) and perform hand hygiene (washing hands or using an alcohol-based hand sanitizer) before administering a wound treatment to Resident 1. This failure had the potential to increase the risk of infection, spread germs and bacteria and impede the healing process for Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) had a comprehensive care plan in place to include in and out self-catheterization (a procedure where a thin tube (catheter) is temporarily inserted into the bladder to drain urine, then immediately removed). This deficient practice placed Resident 1 at risk for insufficient care and services related to self-catheterization.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) received their medication while being out of the facility on pass (permission to be able to leave the facility temporarily). This deficient practice resulted in Resident 1 not taking his prescribed antibiotics when it was due and could potentially lead to complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) temperature was reassessed after acetaminophen (a fever reducing medicine) was given. This deficient practice had the potential for nursing staff to delay care for Resident 1 if a given intervention was not effective.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate and complete documentation was done for one of one sampled resident (Resident 1) when going out of the facility on pass (permission to be able to leave the facility temporarily). This deficient practice had the potential for facility staff to not be aware of where a resident was when they were out of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and accident-free environment for one of three sampled residents (Resident 1), who had impaired functional mobility (a reduction in a person's ability to move independently and perform daily activities) by failing to: -Ensure Certified Nursing Assistants (CNAs) 1 and 2 transferred Resident 1 from the wheelchair to Resident 1's bed by using appropriate assistive device (any item, piece of equipment that are designed to help individuals with disabilities increase, maintain, or improve their functional capabilities) such as the Hoyer lift (a mechanical device used to safely transfer patients who have limited mobility from one surface to another, such as from a bed to a chair or wheelchair) as indicated in Resident 1's untitled care plan dated 2/1/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an unusual occurrence to the state agency.

Inspectors wroteBased on interview and record review, the facility failed ensure the Post Discharge Plan of Care was completed and contained the amount and lists of post discharge medications, for 1 of 4 sampled residents (Resident 1) who was discharged to a Board and Care facility ([B&C] a small residential facility, often referred to as a residential care facility for the elderly (RCFE) or assisted living facility, that provides room, board, and personal care services for a small group of individuals, typically 6 to 10 residents), as indicated in the facility ' s policy and procedure (P&P) titled Discharge Summary. This failure resulted in Resident 1 being discharged with 78 controlled medications (drug prescription specifically regulated by the government due to potential for abuse or harm) and placed the resident at risk for drug overdose, hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Norco (strong pain medicine) medication removed on 3/1 at 5 p.m., 3/13 at 4 p.m., 3/14 at 9 p.m., and the 2 tablets on 3/18 (no years indicated), as indicated in the Controlled Medication (drug prescription specifically regulated by the government due to potential for abuse or harm) Count Sheet dated 8/5/2024, for 1 of 4 sampled residents (Resident 1), were documented in the resident ' s e-MAR (Electronic Medication Administration Record) . This failure had the potential to cause drug diversion (unlawful use of drugs), healthcare personnel miscommunication and cause the resident, drug overdose.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled Infection Control Policy/Procedure, by failing to disinfect the wrist blood pressure monitor before and after use, by 1 of 4 sampled residents (Resident 2). This failure had the potential to spread germs and increase the risk of infections among residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to provide an environment free of accident hazards as possible for two of three residents (Residents 2 & 3), by failing to: 1. Ensure Resident 2 ' s care plan was individualized with interventions provided after the fall on 4/1/2025. 2. Conduct an Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) to discuss safety interventions after Resident 2 ' s fall on 4/1/2025. 3. Conduct an accurate fall risk assessment after Resident 3 ' s fall on 1/26/2027. Resident 3. 4. Implement the rehabilitation services recommendations after Resident 3 ' s fall on 2/7/2025 which indicated to apply bed railings, and cushion pad along the bedside to reduce the risk of falls and soften fall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe and hazard free environment for one of 9 sampled residents (Resident 1) by failing to: 1) Implement its Policy and Procedure (P&P) titled, Smoking Policy which indicated, no cigarette/tobacco products were allowed to be kept in the possession of the residents. 2) Review, update and document a quarterly Smoking Evaluation for the resident. 3) Ensure Resident 1's smoking Care Plan had current and accurate interventions. These failures had the potential to endanger the health and safety of residents, staff and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify one of three sampled residents ' (Resident 1) physician, for the resident ' s scratch marks on the left hand. This deficient practice had the potential to worsen the skin condition when left untreated.

Inspectors wroteBased on interview and record review, the facility failed to ensure, one of three sampled residents ' (Resident 1), urinalysis ([UA]- a laboratory test that examines a urine sample to detect a urinary tract infection [UTI, infection in the urinary system-kidneys, bladder, urethra]) order was carried out and sent to the laboratory (facility conducting the urine test) per the physician ' s order. This deficient practice had the potential for delayed treatment if Resident 1 had an unidentified UTI.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean air vent above Resident 15's bed and to ensure the room temperature was between 71- and 81-degrees Fahrenheit for Residents' 5, 38, and 301's rooms. These deficient practices had the potential for the resident to be exposed to dust and allergens affecting her respiratory health and the increased level of discomfort and to negatively impact the residents' quality of life.

Inspectors wroteBased on observation, and interview, the facility failed to ensure two sharps container (a puncture-proof container used to contain used and discarded needles and other sharp tools for patient care) on Medication Cart #2 and Medication Cart #4 were replaced with a new one when it reached the Full line. This deficient practice had the potential to result in staff or residents to sustain an injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] a resident assessment tool) was completed accurately for one of 21 sampled residents (Resident 20). This deficient practice had the potential to negatively affect the plan of care and delivery of care and services for Resident 20.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 21) received a Pre-admission Screening and Resident Review ([PASRR] a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) level II assessment. This deficient practice had the potential to result in Resident 21 not receiving the required services for her mental health condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to initiate a comprehensive care plan for one out of two sampled residents (Resident 20) who was non-compliant with fluid restriction (medical treatment that limits the amount of fluid a person can consume each day) as ordered by the physician. This deficient practice had the potential to place Resident 20 at risk for not receiving the appropriate interventions to prevent fluid overload (a condition where the body has too much water).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one resident, Resident 16, received grooming of his long fingernails. This deficient practice had the potential to cause the resident to scratch and cause skin break down, potentially causing skin infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 1 sampled resident, Resident 16, who had a 10 pounds weight loss within 30 days, was reported to the physician. This deficient practice had the potential to result in a delay in care for Resident 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a peripheral intravenous line ([IV] - a thin tube inserted into a vein for administration of medications, fluids and/or blood products) was removed after IV antibiotic (a drug used to treat infections caused by bacteria) was completed for one of two sampled residents (Resident 75). This deficient practice had the potential for the IV insertion site to develop infection and/or hospitalization for Resident 75.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 39) had her oxygen saturation ([O2 sat]- a measurement of how much oxygen the blood is carrying as a percentage) levels checked to keep the oxygen (O2) saturation above 90% as indicated in the physician's orders and care plan. This deficient practice had the potential to result in Resident 39 experiencing respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, two of three sampled residents (Resident 20 and 75), who received hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine) treatment, received care in accordance with professional standards of practice by failing to: 1. Implement Resident 20's fluid restriction (medical treatment that limits the amount of fluids a person can consume each day) order accurately. This deficient practice placed Resident 20 at risk for swelling, discomfort, and shortness of breath. 2. Collaborate and communicate with the dialysis center, which hypertensive medications (drugs that can lower blood pressure) were to be held for Resident 20 before dialysis treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 60) was provided necessary behavioral health care services for treatment of the residents mental condition by ensuring a psychiatrist (a physician who specializes in psychiatry - the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders) was notified when Resident 60 had episodes of refusal of care. This deficient practice had the potential to result in lack of interventions to Resident 60's refusal of care and worsening of his mental health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a follow-up appointment for urology (a medical and surgical specialty that deals with diseases of the urinary tract and male reproductive system in both men and women) evaluation/referral was completed for one of one sampled resident (Resident 80). This deficient practice had the potential to result in the delay of necessary care and services for Resident 80.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate pharmaceutical services to meet the needs of two of 7 sampled residents (Residents 3 and 55), by failing to ensure: a. Resident 3's jardiance (medication used to control high blood sugar), apixiban (medication given to thin the blood to prevent blood clots), breo ellipta (medication used to improve air flow in lung disease), metoprolol tartrate (medication used to lower the blood pressure), and sitagliplin (medication used to control high blood sugar) were ordered timely from the pharmacy to prevent outage. This deficient practice put Resident 3's health at risk due to missed doses of the medications. b. Licensed Vocational Nurse (LVN) 1 documented the administration of carvedilol (medication used to treat high blood pressure) in a timely manner. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Resident 3 received her Jardiance (medication used to control high blood sugar) dose as ordered by the physician. This deficient practice put Resident 3's health at risk due to a missed dose of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the medication refrigerator did not contain an emergency kit (a box that contains a small supply of medications) and three bags of ertapenem (medication given to treat infection) that were past the discard date. This deficient practice had the potential to result in harm to a resident if administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Resident 16 had a Complete Blood Count ([CBC] a blood test that measures the number and type of cells in your blood), Comprehensive Metabolic Panel ([CMP] a blood test that measures 14 substances in your blood to provide an overall picture of your body's chemical balance), Hemoglobin A1C ([HgA1c] a blood test that measures the average blood sugar level over the past two to three months), Thyroid Synthesizing Hormone ([TSH] a blood test used to determine the level of hormones being produced by the thyroid), and Lipid panel (a blood test that determines the level of fat in the blood) completed on 11/4/2024 per physician's order. This deficient practice had the potential to result in a lack of required monitoring of Resident 16's health conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the hospice (compassionate care for people who are near end of life) services meet professional standards for one of one sampled resident (Resident 71) by failing to: 1. Ensure hospice representative participates with facility interdisciplinary team ([IDT] - team members from different disciplines who come together to discuss resident care) care conference meeting.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 3 residents' (Resident 2) low air loss mattress (LAL, a medical mattress that uses air to prevent and treat pressure wounds, also known as bed sores) was set in the appropriate mattress setting. This deficient practice had the potential to delay wound healing process and risk for further skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 3 residents' (Resident 2) urinal containing urine was not placed on the bedside table when meal tray was served. This deficient practice had the potential for food cross contamination.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one out of four residents (Resident 1), had telephone orders for Hydroxyzine given by the ordering provider entered into the electronic medical record ([EMR]- a digital version of a resident ' s medical history). This deficient practice had the potential for Resident 1 not being able to receive the medication if they ask for it.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and services for one out of four residents (Resident 3) by failing to: 1. Administer continuous oxygen (O2) 2 liters per minute (L/min) to Resident 3 via nasal cannula ([NC] a small plastic tube, which fits into the person ' s nostrils for providing supplemental O2) according to the physician ' s orders. 2. Ensure Resident 3 ' s O2 equipment was labelled and dated according to its Policy and Procedure (P&P). These failures had the potential to lead to respiratory distress and infection for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure an abuse allegation was reported to the State Survey Agency in a timely manner for one of 3 sampled residents (Resident 1). This deficient practice had the potential to result in further abuse to Resident 1.

Inspectors wroteBased upon interview and record review, the facility failed to: 1. Ensure a new prescription order for Bethanechol (a medication used to relieve, prevent, or lowers the incidence of urinary muscle spasms) was carried out for one of 3 sampled residents (Resident 1). This deficient practice has the potential to result in developing complications of illness and delay of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) discharge planning was developed and implemented per the facility ' s policy and procedure by failing to: 1. Ensure Resident 1 ' s discharge needs were identified on admission. 2. Ensure the Interdisciplinary Team (IDT) was involved in developing Resident 1 ' s discharge plan. 3. Ensure Resident 1 ' s discharge plan was developed and implemented timely. These deficient practices had the potential to result in psychological stress, ineffective discharge planning, and can lead to delay and unsafe discharge.

Inspectors wroteBased on observation and interview the facility failed to ensure three of 18 sampled residents (Residents 236, 46 and 20) call light device were placed within reach at all times. This deficient practice had the potential to result in a delay in the residents to obtain necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for five doses of controlled medications (medications with a high potential for abuse) affecting Residents 17, 22, 25, 46, and 133 in one of two inspected medication carts (Station 2 Cart 2) This deficient practice increased the risk that Residents 17, 22, 25, 46, and 133 could have received too much or too little medication due to lack of documentation potentially resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the indwelling urinary catheter drainage bag (a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) for one of one sampled resident (Resident 236) was not touching the floor. This failure placed the patient at risk for acquiring urinary tract infections. 2. Ensure a correct stocking process was folllowed when restocking supplies in the red zone (COVID-19 [a virus to potentially cause severe respiratory illness] confrmed area). This failure placed the residents and staffs at risk for contracting COVID-19 and the spread of COVID-19 the entire facility 3. Ensure laundry personnel wore a gown (personal protective equipment) while handling contaminated linen and failed to change soiled gloves after handling contaminated linen that had feces and body fluid. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to notify one of five Residents (Resident 133) of the room change on 12/13/2023 per the facility's policy. This deficient practice resulted to Resident 133 feeling frustrated with the room change.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of 10 sampled residents (Resident 52) medical records were updated to show documentation that 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) were discussed and written information was provided to the residents and/or responsible parties. 2. Ensure the Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) was completed for one out five Residents (Resident 133). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a preadmission screening and resident review Level I screening document (PASRR) was completed accurately for one of one residents (Resident 2) who was diagnosed with a mental illness prior to admission in the facility. This deficient practice had the potential to result in Resident 2 not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive and resident centered care plan for three of nine sampled resident (Residents 52, 283 and 4) by failing to: 1. Develop a care plan to address Resident 52's behavior of changing the amount of oxygen infused from 2 liters to 3.5 liters which was not consistent with the physician's order. 2. Ensure Resident 283 had a plan of care and a physician's order to receive continuous oxygen at 2 liters per minute. 3. Develop a care plan to address Resident 4's bilateral great ingrown toenail. This deficient practice had the potential to a poor quality nursing care provided to Residents 52, 283 and 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 52 and Resident 283) received respiratory care consistent with professional standards of practice by failing to: 1. Ensure the oxygen (air) nasal cannula (a device used to deliver supplemental oxygen) tubing, storage bag and humidifier (liquid that moistens the air) bottle were changed after seven days from 11/29/2023 and the oxygen nasal cannula tubing, storage bag, and humidifier bottle was labeled with the date of change to be used as reference for changing humidifier bottles in seven days for Resident 52. 2. Ensure Resident 283 received the correct amount of oxygen ordered at 2 liters per minute as by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their Infection prevention and control policy and procedure (P&P) by failing to report the facility ' s Coronavirus Disease ([Covid-19] a highly contagious infection caused by a virus that could easily spread from person to person) outbreak (at least one confirmed case of Covid-19 who had resided in the facility for at least 7 days) to the California Department of Public Health (CDPH) District Office. These deficient practices had the potential to result in the spread of Covid-19 and infections to residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who receive dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) was provided proper transportation to and from hemodialysis appointments at a dialysis facility for Resident 1. This deficient practice had the potential for delayed dialysis treatments and safety issues.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the floormat (a material placed on the floor to protect the resident from injury during a fall) as indicated in the comprehensive person-centered care plan, for one of 3 sampled resident's (Resident 2), who had episodes of fall, was implemented. This deficient practice had the potential that Resident 2 will not be protected during another fall and placed the resident at risk to sustain severe injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan for 1 of 3 sampled residents (Resident 2), who had a recurrent fall and a status post fall episode dated 9/1/2023, was reassessed and revised. This deficient practice placed the resident at risk to sustain severe injuries and affect the highest practicable physical, mental and psychosocial well-being of the affected resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1), who did not have a mental health disorder diagnosis, was not prescribed Seroquel medication, an antipsychotic medication to treat mental health conditions including schizophrenia and bipolar disorder. This failure resulted to Resident 1's unnecessary use of the antipsychotic medication and placed the resident at risk for life-threatening adverse reactions which could lead to serious injury or death.