Camino Ridge Post-Acute

Inspectors wroteBased on interview and record review the facility failed to follow its abuse policy to investigate and report any allegations of abuse to appropriate agencies within timeframes as required for one of two sampled residents (Resident 2). This failure resulted in an incident of abuse not being investigated and had the potential to compromise the safety of the residents in the facility. Review of Resident 2's clinical record indicated diagnoses that included mood disorder (a mental health condition that affects emotional state, causing persistent, extreme sadness, elation or anger), schizophrenia (a mental illness that is characterized by disturbances in thought) and schizoaffective disorder (a mental disorder that can affect thoughts, mood, and behavior). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide supervision to 1 out of 3 residents (Resident 1) from leaving the facility, when1. Resident 1 did not have an out-on-pass order (OOP, a temporary leave of absence for a resident, typically for family visits, holidays, or other events, which must be approved by the facility, the resident's physician, and often included in the individual's care plan) before he left the faciity on 9/14/2025.2. The facility did not implement Resident 1's care plan to provide one-person assistance during ambulation (the medical term for walking, which is the ability to walk from place to place) and locomotion (the act or power of moving from place to place).3. The facility did not report this incident to the California Department of Public Health (CDPH) as an unusual Occurrence. [...]

Inspectors wroteBased on interview and record review, the facility failed to prepare and ensure a safe and appropriate discharge for one of three residents (Resident 1) when:1. Resident 1's fall risk level was not updated;2. Resident 1's discharge minimum data set (MDS, a clinical assessment tool) was not accurately coded;3. The facility did not provide discharge notice (a written notice in advance to the resident and the resident's representative in a language and manner they understand and an opportunity to appeal) to Resident 1 and/or her son (Resident 1's co-health care decision maker). Resident 1 also did not have a discharge care plan and did not have discharge notes on the day of her discharge; and4. The facility did not verify the license and the care capabilities of the discharge placement facility. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to provide the residents with a safe environment when one of 8 resident beds was not stable; 5 of 8 toilet seats were not stable as it was wubly; 5 of 6 toilet-seat risers were not stable; and the toilet tank in room [ROOM NUMBER] did not have a proper size and shape lid. These failures had the potential to compromise the health and safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when:1. Certified nursing assistant B (CNA B) did not remove her gloves and carried Resident 3's soiled linen out of her room and in the hallway;2. A soiled pillowcase was left on the floor in room [ROOM NUMBER]; and3. Certified nursing assistant C (CNA C) did not put on a gown when doing incontinent care for Resident 4 who was on Enhance Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, a germ that is resistant to many antibiotics] in nursing homes). These failures had the potential to spread the infection to residents, staff, visitors, and throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment for self-administration of medications was completed for one of 3 residents (1) when Resident 1 administered lidocaine (used to relieve pain) liquid to his right hip himself and did not have a self-administration of medication assessment and did not have an order from the physician to do so. This failure resulted in duplication of administered medications and had the potential for improper, unsafe medication administration and not addressing the clinical condition of the resident.

Inspectors wroteBased on interview, and document review, the facility failed to ensure the designated Infection Preventionist (IP - infection control nurse) had completed the required specialized training in infection prevention and control. This deficient practice had the potential for inadequate infection control measures and could result in mismanagement of infections among residents, staff, and community.

Inspectors wroteBased on observation, interview, and facility's document review, the facility failed to maintain resident's rights to privacy and confidentiality to four of 18 sampled residents when Residents 35, 56, 91 and 2's personal information and care instructions were posted in the room visible to their roommate's visitors. This failure had the potential to compromise resident's rights.

Inspectors wroteBased on interview, and record review, the facility failed to complete a comprehensive minimum data set (MDS - a federally mandated resident assessment tool) admission assessment and the required discharge (DC) assessment in a timely manner for two of two residents (Residents 39 and 81). This failure resulted in Residents 39 and 81's admission and discharge assessment not completed within the time requirement and had a potential to result in inappropriate care planning and intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement individualized, resident-centered, care plans for seven of 18 sampled residents (Residents 62, 11, 68, 91, 40, 59, and 98) when: 1. Resident 62's diagnosis of Post Traumatic Stress Disorder was not addressed; 2. Resident 11's new diagnosis of closed nondisplaced supracondylar fracture of distal end of left and right femur without intracondylar extension (broken thigh bone [femur] just above the knee, where the bone is broken but remains in its normal alignment, and the fracture doesn't extend into the knee joint), was not developed and implemented since 1/17/2025, and fall care plan intervention was not implemented; 3. Bed rail (also known as side rail, a barrier attached to the side of bed, designed to prevent falls or assist with mobility) care plan used for Resident 68 was not developed; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice when: 1. Resident 89 did not have documentation for the care of her cast (is a device used to support healing by surrounding and immobilizing the area of the fracture) located in her extremity. 2. Resident 54 and Resident 156 did not have physician orders for PICC ((PICC, a thin, soft, long catheter [tube] that is inserted into a vein in arm, leg or neck and the tip of the catheter is positioned in a large vein that carries blood into the heart) line managment; 3. Residents 62, 73, 89, 153, and 156 did not have physician orders for use of side rails; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to inspect and ensure the Sharps container (a puncture-resistant container designed for the safe disposal of sharp medical instruments like needles, syringes, and scalpels, to prevent accidental injuries and ensure proper waste management.) were not overfilled for one of four medication carts (medication cart 4). When medication cart 4 was overfilled with syringes. This failure has the potential to cause injury to staff and residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the proper care and treatment services for oxygen (O2, a colorless, odorless gas) use was provided for four of seven sampled residents (Residents 42, 155, 303, and 40) when: 1. Resident 42's O2 concentrator's (a device which concentrates the oxygen from ambient air) filter had a grayish substance build-up and there was no Oxygen in Use/No Smoking sign posted at the entrance or door of Resident 42's room; 2. Resident 155's oxygen concentrator's filters were dusty; 3. Resident 303's door or entance there was no sign posted for Oxygen in Use/No Smoking; and 4. Resident 40's door or entance there was no sign posted for Oxygen in Use/No Smoking. These deficient practices had the potential for the residents to have complication related to improper treatment while receiving O2 therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 91) who received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with professional standards of practice when: 1. Staff did not follow Resident 91's fluid restriction (limiting liquids) order; 2. There was no documentation of Resident 91's fluid intake each shift for staff to determine if Resident 91 have met the fluid restriction order; and 3. There was no record of Resident 91's intake and output (I&O - the measurement of the fluids and food that enter [intake] and leave [output] the body) monitoring. [...]

Inspectors wroteBased on interview, and document review, the facility failed to ensure the licensed nursing staff employed at the facility had appropriate competencies, and skill sets related to intravenous (IV, to deliver a medication into a vein) therapy to ensure the residents with peripherally inserted central catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart, used for long term IV medication administration) lines received safe and appropriate medical care to attain or maintain the highest practicable physical, mental, and psychosocial well-being. There were 2 residents with PICC lines admitted to the facility at the time of the survey. This failure could compromise the safety and quality of care for the two residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled drugs (medications that can be easily abused and are under strict government control) and document medication administration in accordance with the facility policy and procedures (P&P) for three out of four residents (Resident 38, Resident 56, and Resident 59). This failure had the potential for medication errors and controlled drug abuse or diversion (when healthcare providers obtain or use prescription medicines illegally).

Inspectors wroteBased on interview and record review, the facility failed to act upon the facility's Consultant Pharmacist's (CP) recommendations during the Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to address the recommendation/ irregularities for the month of December 1, 2024 to January 31, 2025's MRR for 2 of 4 sampled residents (Resident 2 and 32). This deficient practice had the potential to result in adverse medication outcomes and for potential unnecessary medications for Resident 2 and Resident 32.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure two out of 18 sampled residents (Resident 68 and Resident 38) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. Insulated food covers used for food service were stacked and stored wet; 2. There were unlabeled and undated food items in the reach-in refrigerator. These failures had the potential to cause food contamination and food-borne illness to 89 of 90 residents who received their food from the kitchen.

Inspectors wroteBased on observation, interview and facility's document review, the facility failed to implement infection control measures when: 1. Resident 73's nebulizer equipment was left uncovered and undated; 2. Certified nursing assistant L (CNA L) was wearing gloves in the hallway after resident care; 3. Certified nursing assistant N (CNA N) was wearing gloves in the hallway after resident care; 4. Resident's used basins were unlabeled and stored on top of bathroom toilet's tank; 5. There was no enhance barrier precautions (EBP - an infection control strategy, focusing on the targeted use of gown and gloves during high-contact resident care activities [such as dressing, bathing, transferring, changing linens, etc.] to reduce the spread of multidrug-resistant organisms [MDROs] in nursing homes) signage by the door and no isolation cart right outside Resident 11's door entrance; 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and maintain resident dignity during mealtime for one out of two residents (Resident 49) when Certified Nursing Assistant B (CNA B) was standing while providing feeding assistance to Resident 49 during meal. This failure had the potential for violation of the resident's dignity. During an observation in Resident 49's room on 3/24/25 at 12:33 p.m., with Certified Nursing Assistant B (CNA B), during lunch, CNA B was observed standing while providing feeding assistance to Resident 49. Resident 49 was lying on his bed, the head of the bed was elevated, the meal tray was on top of bedside table across the bed, Resident 49 was not at eye level with CNA B. CNA B was standing, holding the spoon with food and bringing to Resident 49's mouth. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a significant change in status assessment (SCSA) was completed within 14 days after a significant change in the resident's physical or mental condition had been determined for one of 18 sampled residents (Resident 11). This failure had the potential of not providing the appropriate care and services to Resident 11.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission for one of two residents (Resident 50). This failure had the potential for the resident and/or responsible party (RP) to be unaware of the plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were reviewed and updated by the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward the common goal for the resident for two of 18 sampled residents (Residents 11 and 68) when: 1. Resident 11's fall, activity and pain care plans were not updated after a significant change in status; and 2. Resident 68's care plan for antipsychotic (a type of drug used to treat symptoms of psychosis) use was not updated. This deficient practice had the potential to compromise resident's health, safety and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 6.67% when two medication errors occurred out of 30 opportunities during the medication administration for two out of nine residents (Resident 26 and Resident 155). The failures resulted in the nursing staff not following physician's orders and the facility's policy and procedures (P&P), which had the potential for the residents not receiving the medications full therapeutic effects, and could also result to complications of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when one expired insulin vial was not removed from active stock and opened multi-dose vials/inhalers had no open date. These failures had the potential for residents to receive medications with reduced efficacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Antibiotic Stewardship Program for two of 18 sampled residents (Residents 68 and 301) when: 1. Resident 68 received two different antibiotics (medications that kill or inhibit the growth of bacteria) to treat pneumonia (an infection/inflammation in the lungs) and urinary tract infection (UTI- an infection in the bladder/urinary tract) without provider's full assessment and the diagnostic test performed indicated Resident 68 was negative for the mentioned infections; and 2. Resident 301 was prescribed with topical (medication or treatment applied directly to the skin or body surfaces) antibiotics without a stop date. These failures had the potential to increase the prevalence of multi-drug resistance organism or bacteria.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 91) received pneumococcal (common bacteria that can affect different parts of the body) vaccination. This failure resulted in Resident 91's positive chest x-ray (a diagnostic test used to generate images of tissues and structures inside the body) result of pneumonia (an infection/inflammation in the lungs) during the facility stay.

Inspectors wroteBased on interview and record review, the facility failed to ensure updated Coronavirus Disease 2019 (COVID-19, a highly contagious respiratory illness in humans capable of producing severe symptoms) 2024-2025 vaccination (a way to create immunity to [protection from] diseases) was offered to two of five sampled residents (Residents 15 and 35). This deficient practice placed Resident 15 and Resident 35 at risk for COVID-19 infection and had the potential to result in the spread of infection placing residents, staff, and visitors at risk to be infected with COVID-19.

Inspectors wroteBased on observation and interview, the facility failed to meet the requirement of having no more than four residents per room, when room [ROOM NUMBER] had six residents in the room. Having more than four residents in a room could potentially compromise the quality of life, care and services the residents receive.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy for five of seven allegations of abuse: 1. Resident 1 had altercations with three residents (Residents 2, 3, and 4) over a four-month period. After Resident 1 and Resident 2 had an altercation on 11/16/23, the residents' care plans were not revised and there were no documented interventions to prevent future occurrences. After Resident 1 and Resident 4 had a verbal altercation on 2/15/24, the residents' care plans were not revised and there were no documented interventions to prevent recurrence between the two residents. On 2/17/24, Resident 1 and Resident 4 had a physical altercation, which caused injury to Resident 4's leg. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services were provided to meet professional standard of practice for one of three residents (Resident 1) when: 1. Licensed nurse A (LN A) did not check the vital signs and document the characteristics of the pain for Resident 1's during pain assessment, 2. LN A did not follow-up with Resident 1's physician regarding request for the order for pain medication, 3. Facility LNs did clarify with physician regarding Resident 1's pain management plan, and 4. Resident 1's nursing weekly summaries were not done consistently. These failures had the potential to compromise Resident 1's health and safety.

Inspectors wroteBased on interview and record review, the facility failed to promote care in a manner that maintain resident dignity and respect for one of two residents (Resident 1) when certified nursing assistant C (CNA C) told Resident 1 to urinate in diaper instead of assisting her to the bathroom. This failure had the potential to affect Resident 1's self-esteem and feel less self-worth that may lead to emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party (RP, a person who makes healthcare decisions on patient's behalf) as soon as practicable of the hospital transfers due to fall for one of three residents (Resident 1). This failure resulted in Resident 1's RP not being informed and had the potential for Resident 1's RP's non-involvement in the urgent healthcare decision that may compromise Resident 1's health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's minimum data set (MDS, a resident comprehensive assessment and care screening tool) accurately reflected the actual resident's condition status for one of two residents (Resident 1) on two MDS assessments completed. This failure had the potential to affect the care provided for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to promote appropriate services to achieve or maintain as much as normal bladder function as possible when certified nursing assistant C (CNA C) encouraged one of two sampled residents (Resident 1) to urinate in diaper. This failure had the potential to result in losing and declining the current bladder function for Resident 1 that may lead to skin breakdown and urinary infection. (Cross reference to tag F550) Review of Resident 1's medical record indicated diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood), compression fracture of fourth vertebrae (one or more bones weaken and crumple in the spine), and radiculopathy of lumbar region (inflammation of the nerve root in the lower back). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a request for documents was fulfilled in a timely manner when the facility did not provide the requested documents to Resident 1's responsible party (RP, the individual that make medical and healthcare decision on behalf of the client) within the timeframes specified in their policies. This failure had the potential to cause undue concern and anxiety on behalf of the Resident 1 ' RP.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with the facility's policy and procedures (P&Ps) for four of 20 sampled residents (Residents 20, 34, 67, and 311) and four non-sampled residents (Residents 298, 305, 310, and 350) when: 1. Nursing staff failed to inform the physician when medications were not available for Resident 20 and Resident 298; 2. The nursing staff documented they administered the calcium acetate (medication to prevent high blood phosphate levels in patients who are on dialysis due to severe kidney disease) to Resident 20 when they did not have the medication available to administer; 3. For Resident 350, the nursing staff held the medication seven times while there was no physician's order to hold, and did not inform the physician of the held medication; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure routine medications were available for administration for two of 20 sampled residents (Residents 20 and 34) and one non-sampled resident (Resident 298); and failed to ensure accurate accountability of controlled medications (those with high potential for abuse and addiction) for three of four random sampled residents (Residents 39, 74, and 80), when: 1. Resident 298 did not receive three of her routine medications, as prescribed, for six days; 2. Resident 20 did not receive Creon (a pancreatic enzyme replacement therapy for patients with pancreatic problems) for 12 days, and calcium acetate (medication to prevent high blood phosphate levels in patients who are on dialysis due to severe kidney disease), as prescribed, for almost two months; 3. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure three of 20 sampled residents (Residents 20, 22, and 67) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors). Resident 67 received an antipsychotic medication and medication to treat high cholesterol without monitoring for lipid panel; Resident 22 received clozapine (an antipsychotic medication) which requires monthly blood count monitoring but did not get one for almost two months; and Resident 20 received medications for bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and depression without monitoring for specific target behaviors for these conditions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 15.22% when seven medication errors occurred out of 46 opportunities during the medication administration observation for three of seven residents (Residents 71, 298, and 350). Resident 298 did not receive three routine medications as prescribed, and a wrong dose of docusate sodium (DSS, medication to regulate bowel movement). Resident 350's spironolactone (a diuretic to remove fluid from the body) was held (not given) without a prescribed hold parameter, and received levothyroxine (a thyroid medication) not in accordance with the manufacturer's guidelines. Resident 71 received iron sulfate (to treat iron deficiency anemia) not in accordance with the doctor's order and accepted professional standards of practice. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and sanitary food service operations were carried out according to standards of practice when: 1. Expired foods were found in one of the kitchen refrigerators and the dry storage room; 2. The food preparation sink and the dishwashing sink drains did not have air gaps (an unobstructed vertical space between the water outlet and the flood level of a fixture), and food preparation sink drain was leaking; and 3. Multiple cutting boards with dust and stains stored under the food preparation sink. These failures had the potential to expose 96 of 97 residents to harmful contaminants that could cause foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. A Certified Nursing Assistant failed to perform hand hygiene when entering different residents' rooms to place and set up lunch trays, 2. A licensed nurse used unclean gloves to inject insulin for Resident 20, 3. A licensed nurses did not perform hand hygiene between glove changes during medication administration for Resident 34, These failures could result in the spread of infection and cross-contamination that could affect the 97 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy on self-administration of medication (resident takes medication without staff assistance) and bedside medication storage for two of 20 sampled residents (Resident 7 and 297) when: 1. For Resident 7, the facility did not ensure self-administered medications were stored in a safe and secure place; 2. For Resident 297 the facility did not determine that the resident was clinically appropriate and safe to self-administer medications; did not obtain a physician's order to self-administer medications; and did not develop care plans to address self-administration of medications or bedside storage of medications. These failures had the potential for unsafe and improper administration of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe and comfortable temperature of 71 to 81 degrees Fahrenheit for two of three common residents' area (Room A and B), one hallway and dining area. The failure resulted in the residents exposed to cold and uncomfortable environment.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to notify the Office of the State Long-Term Care Ombudsman (organization that advocates for the residents) when two of 20 sampled residents (Residents 6 and 67) were transferred to the acute care hospital from the facility without notifying the Ombudsman. This failure had the potential to compromise the residents' admission, transfer, and discharge rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure environment remains as free of accident hazards for one of 20 sampled residents (Resident 66) when Resident 66 was using an electric hot water kettle unsupervised inside his room. This failure had the potential to increase the risk for accident to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the correct enteral formula (liquid food products that are specially formulated to increase the amount of nutrients that will maintain proper function of the body) as prescribed by the physician for one of one sampled resident (Resident 2). This failure could result to resident's discomfort and further complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer parenteral fluids (the delivery of fluid or medication through an intravenous, subcutaneous, intramuscular, or mucosal route) consistent with professional standards of practice and in accordance with physician orders to one of one sampled resident (Resident 37) when: 1. The facility failed to clarify the physician order; 2. The facility failed to ensure Resident 37 received the Total Parenteral Nutrition (TPN) as ordered by the physician; 3. The facility failed to perform an aseptic technique during maintenance of the peripherally inserted central catheter line (PICC line, a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) during therapy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 20) received care and services for provision of hemodialysis (HD, the process of removing excess water, substances, and waste products from the blood in people whose kidneys could no longer perform these functions) consistent with the professional standards of practice, physician orders, and the facility's policies and procedures when 1. The facility failed to implement the physician order for fluid restriction; 2. The facility failed to monitor intake and output (I &O) measurements when Resident 20 was on fluid restriction. These failures had the potential for Resident 20 to have fluid overload and the possibility of medical complications.

Inspectors wroteBased on interview and record review, the facility failed to provide medically-related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) when 72 hour monitoring was not done after an abuse allegation incident for two of three residents (Resident 7 and Resident 397). The failure had the potential to affect the mental and psychosocial well-being of the residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure one non-sampled resident (Resident 298) was free from a significant medication error when Resident 298 did not receive her digoxin (medication to treat some heart problems, such as irregular heartbeats), as prescribed, for six days. The failure had the potential to cause complications, such as too fast heartbeats or worsening of heart failure, for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two insulin pens (pre-filled, multi-dose pens containing medication to lower blood sugar) and six (6) oral inhalers (medications to treat breathing problems) were dated with an open date in two of two medication carts inspected. The failure had the potential for these medications to be given beyond its expiration date, which would be ineffective for the residents.

Inspectors wroteBased on observation, interviews and facility document review, the facility failed to ensure the diet spreadsheet was followed for one of 44 residents (Resident 18) who received a controlled carbohydrate diet (CCHO, the focus of the diet is eating the same amount of carbohydrates every day. This helps keep the blood sugar, or glucose levels stable). This failure had the potential to result in the resident to not be able to maintain her blood sugar in the therapeutic range.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose the garbage and did not follow the facility's policy and procedures (P&P) for Covering receptacles when two of five dumpsters did not have lids closed properly. This failure had the potential to attract pests and rodents which could lead to unsanitary conditions and spread of disease.

Inspectors wroteBased on observation and interview the facility failed to meet the requirement of having no more than four residents per room when room [ROOM NUMBER] had six residents in the room. Having more than four residents in a room could potentially compromise the quality of life, and care and services the residents receive.

Inspectors wrote13. During an observation on 1/4/22 at 1:49 p.m., in Resident 82's room, the oxygen tubing currently in use was not dated or timed. During an interview on 1/7/22 at 1:49 p.m. with the assistant director of nursing (ADON), the ADON confirmed the oxygen tubing should be labeled, stating, if it is not labeled then we do not know when to change it. It is only to be used for 3 days. During a review of facility's policy and procedure titled, Oxygen Administration dated August 2014, it indicated .g. label humidifier with date and time opened. Change humidifier and tubing per facility procedure. 9. During an observation in the dining room on 1/4/22 at 11:53 a.m., the activities assistant (AA) assisted Resident 44 with her meals. At 11:56 a.m., the AA assisted Resident 3 with her meals without performing hand hygiene in between tasks. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual is incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) was available, completed, and accurate for 5 of 18 residents (18, 41,194, 52, and 54) reviewed under the advance directive care area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when: 1. Two refrigerators and one ice cream freezer had wire shelves with yellowish to orange color and; 2. the freezer and chest freezer had ice build-up. These failures had the potential to cause foodborne illness (illness resulting from contaminated food) for 82 of 85 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage was disposed properly when four of 5 facility dumpster lids were left opened. This failure had the potential to result in the spread of disease from vermin infestation and unsanitary environment for the residents.

Inspectors wroteBased on interview and record review, the facility failed to test three out of 4 unvaccinated staff (LN D, LN E, and CNA F) twice per week and when scheduled to work for Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) during the sampled period of 11/01/2021 to 12/30/2021. This deficient practice had the potential for unvaccinated staff, who are at higher risk for contracting COVID-19, to spread infection within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat four of 18 sampled residents (Residents 44, 31, 196, and 63) with respect and dignity when: 1. The activities assistant (AA) stood beside the residents to assist with their meals; 2. Resident 31's urine bag (bag that is attached to a tube that is connected to the bladder) was not covered. 3. A certified nursing assistant (CNA) stood while feeding Resident 196, and 4. Resident 63's indwelling catheter was not covered. These failures resulted in not ensuring residents' rights to be treated with respect and dignity and could potentially affect the residents' self-worth.

Inspectors wroteBased on interview and record review the facility failed to implement their abuse policy for one of 18 sampled residents (Resident 52) when the facility did not report a suspected financial abuse to the state agency. This failure had the potential to put the resident at risk for possible abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for five of 18 sampled residents (194, 84, 52, 54, and 344) when: 1. For Resident 194, facility staff failed to obtain an order for a peripherally inserted central catheter (PICC line, a long, thin tube inserted through a vein in the arm and passed through to the larger veins near the heart) management, there was no assessment of the PICC line upon admission, and the care plan was not implemented. 2. For Resident 84, facility staff failed to ensure oxygen (02, a colorless and odorless gas that people need to breathe) order was administered as specified in the physician's order and the order was not verified with the physician when Resident 84 had two active oxygen orders. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance to maintain an environment free of accident hazards for two of 18 sampled residents (Residents 68 and 56). 1. For Resident 68, the nursing staff allowed the resident to smoke outside the patio unsupervised, and without a smoking assessment. 2. For Resident 56, the sitter (person assigned to stay with the resident at all times to keep her safe) left the resident unattended and unsupervised. These failures had the potential to result in harm to residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 18 sampled residents (31, 54 and 72) with indwelling catheters (a small, flexible tube that can inserted through the bladder to drain into a urine bag) had an appropriate urinary management when: 1. For Resident 31, there was no documented foley catheter care; 2. For Resident 54, there was no care plan regarding the use of foley catheter and; 3. For Resident 72's suprapubic urinary catheter (a hollow flexible tube inserted through a cut in the abdomen that is used to drain urine from the bladder into a bag) had dark brown urine with sediments in his catheter and the physician was not notified of the resident's dark brown urine with sediments. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dialysis services consistent with professional standards and to ensure staff had coordinated residents' care with the dialysis facilities for two of five sampled residents (Residents 83 and 68) receiving hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte i.e., salts and mineral imbalances by using a machine and an artificial kidney) when: 1. Communication with the dialysis clinics were not properly coordinated when dialysis communication records (DCR) were not completed; 2. Staff were not trained on emergency care for residents with renal diseases, dialysis care and there was no emergency dialysis kit available; and, 3. The dialysis care plan was not resident-centered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient social services for one of the eighteen sampled residents (83) needing dental service. This failure had the potential to result in unmet care needs. During a concurrent observation and interview with Resident 83, on 1/4/22, at 12:24 p.m., Resident 83 stated that he told social services when he lost his upper and lower dentures sometime in October 2021. He further stated that his food has been chopped up because he has no teeth and no dentures. Review of Resident 83's Minimum Data Set (MDS, a clinical assessment tool) dated 12/21/21, indicated his BIMS score is 15 and is cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to reorder one of three emergency medication kits (E-kits) after medications were used. The facility also failed to ensure controlled medications (medications regulated by the government because they may be abused or cause addiction) for two of three residents (Residents 32 and 60) were accounted for. These failures had the potential to result in residents not receiving medications needed to maintain their health and well-being. Failure to account for controlled medications had the potential to result in diversion (transfer for illicit use) of the medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of 18 sampled residents (33 and 63) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior when: 1. For Resident 33, the facility failed to ensure there was a specific duration of use for a PRN (PRN as needed) psychotropic medication that exceeded 14 days and there was no specific target behavior for the use of Ativan (a medication for anxiety [feelings of worry and fears) and, 2. For Resident 63, the facility failed to obtain informed consent for the use of psychotropic medication. These failures could result in lack of adequate monitoring and had the potential for the residents to receive unnecessary medications

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were stored in a safe manner when: 1. The temperatures in two of two medication refrigerators were not within acceptable parameters; and 2. There was expired insulin (medication used to lower blood sugar) in one of three emergency medication kits (E-kits). These failures had the potential to result in residents receiving medications with reduced potency or efficacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food that conserved nutritive value and flavor when pureed, mechanical soft, and ground foods were prepared hours before serving. This failure had the potential for two residents who received a pureed diet out of 85 residents to receive food with reduced nutrients or flavor.

Inspectors wroteBased on observation and interview the facility failed to meet the requirement of having no more than four residents per room when room [ROOM NUMBER] had six residents in the room. Having more than four residents in a room could potentially compromise the quality of life and care and services the residents receive.