Canyon Oaks Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review the facility failed to ensure a safe and appropriate discharge for one of three sampled residents (Resident 1) by failing to ensure that only medications ordered by the physician for continued use after discharge were provided to Resident 1 upon discharge when on 6/16/2026 Resident 1 was discharged with a vial of Humulin Regular Insulin (medication used to assist with controlling blood sugars) that was not included on the physician-ordered discharge medication list. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to dispose garbage and refuse properly when the dumpster (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts) surroundings had sticky black spills. This failure had potential to attract birds, flies, insects, pests and possibly spread infection to 152 of 152 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards for three of seven residents (173, 160, and Resident 2) investigated under the accident care area by failing to: a. Provide upper bed rail padding for a resident with a history of seizures (a sudden surge of abnormal electrical activity in the brain, leading to a range of symptoms like muscle spasms, loss of consciousness) to Resident 173. This deficient practice placed Resident 173 at an increased risk for injuries. b. Ensure that vitamin A&D ointment (a topical skin protectant and moisturizer) and unknown white paste in an unlabeled medicine cup was not left at the Resident 160's bedside. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Administer a form of multiple vitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) to one (1) of six (6) observed residents (Resident 69) during medication administration task, as ordered by Resident 69's physician. 2. Replace one open used medication emergency kit ([ekit] - storage container for emergency use medications) within 72 hours of opening the kit on 4/27/2026, in one (1) of three (3) inspected medication carts (Medication Cart 1 Station 2.) 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: a. Not store food items with medications in the medication refrigerator for one (1) of two (2) inspected medication rooms (Medication Room Station 4.) b. Label the Neosporin (over-the-counter triple antibiotic ointment used to prevent infections in minor cuts, scrapes, and burns) ointment and properly store the ointment for resident self-administration in accordance with the facility policy and procedure on Medication Labeling and Storage, for one (1) of one (1) sampled resident (Resident 160). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Oranges, tomatoes, broccolis and prepared juice were labeled with incorrect date. 2. Prepared juice was left stored in the refrigerator beyond the for-use date. 3. Surfaces of the cutting boards were scratched and had gouges along the edges. 4. Temperatures of food items on the tray line (a system of food serving in which a tray is moved along an assembly line to ensure a resident gets their prescribed diet) were not obtained in accordance with the facility policy and procedure on Meal Service, by failing to ensure: a. [NAME] 1 obtained the temperature of all food on the tray line. b. Dietary Aide 1 (DA 1) recorded the temperature of all food items on the breakfast/lunch Food Temperature monitoring log. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe storage (refrigerator) designated for residents' food coming from outside sources. This failure had the potential to result in consumption of food that is unsafe and cause foodborne illness in residents who receive food from outside sources.

Inspectors wroteBased on observation, interview, and record review, the facility's interdisciplinary team (IDT - a coordinated group of experts from several fields who work together) failed to ensure a resident's self-administration of medication was appropriate and safe for one of one sampled resident (Resident 160) by failing to conduct the Self-Administration Safety Screen for Resident 160, who was self-administering a medication. This deficient practice placed resident at increased risk for negative outcome from potential improper use of medication, inappropriate treatment and medication mismanagement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for two of seven sampled residents (Resident 60, Resident 144) investigated under the environment task. This deficient practice had the potential to result in Resident 60 and Resident 144 not being able to call for facility staff assistance and delay in the provision of necessary care and services which could negatively affect the residents' comfort and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of four sampled resident rooms (Resident 105 and 174's shared room) was within a comfortable temperature range of 71 degrees Fahrenheit ( F) to 81 F. This deficient practice placed Residents 105 and 174 at risk for being uncomfortable due to the low temperature in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Licensed Vocational Nurse (LVN 5) maintained a current CPR (cardio-pulmonary resuscitation - an emergency, life-saving technique performed when someone's breathing or heartbeat has stopped) certification from a CPR provider whose training includes a hands-on session in accordance with accepted national standards for one of five staff members investigated in the staffing facility task. The deficient practice had the potential for staff to perform substandard life-saving measures to residents which could result in negative outcomes including death.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI/PU injuries to the skin and underlying tissue resulting from prolonged pressure) by failing to ensure the bilateral heel protectors were on and the heels were floated (when the lower leg is elevated with a pillow, leaving the heel floating to air) according to the doctors order for one of three sampled residents (Resident 7) investigated under pressure injuries. This deficient practice had the potential for the worsening of or the development of PI/Pus in Resident 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the intravenous (IV - into the vein) insertion site (site on the body where IV is inserted through the skin) and the label indicating the date of insertion were visible and not covered with white tape for one of one sampled resident (Resident 172). This deficient practice had the potential to delay the identification of complications, including pain/redness, and infection at the IV insertion site.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's hand-held nebulizer (a device that turns liquid medicine into mist you breathe in) and tubing was dated for one of one sampled resident (Resident 172) investigated under respiratory care area. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an environment free from accident hazards for one of seven residents (Resident 22) investigated for accidents when there was no informed consent obtained prior to the installation of left and right upper side rails (adjustable rigid plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides). This deficient practice had the potential to result in adverse effects from the side rails including restriction of physical movement and entrapment (becoming caught between the rails and the mattress).

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a resident's comprehensive care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) addressing incontinence (the inability to control urination [the act of passing urine] or bowel movements) for three of five sampled residents (Resident 2, 3, and 4) when licensed nursing staff did not identify the type of bowel and bladder retraining program (a planned routine to help a resident regain or improve control of urination and bowel movements) to be implemented and failed to include specific approaches or interventions detailing how the B&B retraining program would be carried out based on the resident's assessment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of five sampled residents (Resident 2, 3 , and 4) who were incontinent (having no or insufficient voluntary control) of bladder (a hollow, muscular organ that stores urine before it is expelled from the body) and bowel (the long tube that carries solid waste from the stomach out of the body) function, received the appropriate services and assistance to maintain or restore continence for by failing to implement its policy and procedures (P&P) on the assessment and management of urinary and fecal incontinence. This deficient practice had the potential to result in residents not receiving the necessary services and assistance to maintain or restore continence, which could lead to ongoing incontinence and negatively affect self-esteem and dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care and services in accordance with professional standards of practice by failing to administer Resident 1's insulin (hormone that regulate the amount of glucose [sugar] in the blood) as prescribed by the physician. This deficient practice resulted in the omission of insulin which could have resulted in a hyperglycemic (a condition where the blood sugar levels are abnormally high) episode. [...]

Inspectors wroteBased on observation, interview and record review, facility failed to ensure residents that are diabetic (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) were served sugar free gelatin and sugar free pudding for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to experience hyperglycemic (occurs when glucose [sugar] levels in the blood become too high) episodes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure clear storage cups of gelatin were dated and labeled according to the facility's policy. This deficient practice had the potential to place 142 out of 148 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). During an observation of the facility's kitchen refrigerator on 8/25/2025 at 1:45 p.m., observed open food items not in its original packaging and placed in clear storage cups. Observed several clear storage cups labeled SF and several clear storage cups with no labels. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of three sampled residents Resident 2 and Resident 3) received care and services to promote wound healing by:1. Failing to ensure Resident 2's low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure injuries [PI - an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) was properly set to the correct setting.2. Failing to ensure licensed nurses obtained clarification from the physician regarding Resident 2 and Resident 3's LAL mattress order. 3. Failing to ensure licensed nurses were knowledgeable on how to check for functionality of Resident 2 and Resident 3's LAL mattress. These failures had the potential to place the residents at risk of developing or worsening pressure ulcers. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that two of three sampled residents (Resident 3 and Resident 4) received the necessary treatment and services to promote healing and/or prevent pressure ulcer or injuries (PU/Is- injury to skin and underlying tissue resulting from prolonged pressure on the skin) when on 7/24/2025 staff placed multiple layers of linen over the residents' low air loss mattresses (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts), compromising the effectiveness of the pressure-relieving support surfaces. This deficient practice placed the residents at increased risk of pressure ulcers/injuries worsening or developing further and delayed wound healing. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent (having no or insufficient voluntary control) of bladder and bowel (B&B) function, received appropriate care and services for one of four sampled residents (Resident 1) by failing to implement its policy and procedures (P&P) on Perineal (the area of the body between the anus and the genitals) Care when Certified Nursing Assistant (CNA 3) used a soiled towel to wipe the perineal area and did not rinse the perineal area while providing perineal care. This deficient practice had the potential to result in urinary tract infection (UTI- an infection in any part of the urinary system), skin irritation, and unpleasant odor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure one of four sampled staff (Certified Nursing Assistant 3 [CNA 3]) performed hand hygiene (HH -cleaning hands by either washing with soap and water, or by using a hand sanitizing [removing germs] gel) after providing Resident 1's perineal (the area of the body between the anus and the genitals) care and before touching Resident 1's body to change the resident's clothing and position while in the bed. These deficient practices had the potential to result in the spread of infection placing residents, staff, and visitors at risk of being infected with germs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from unnecessary psychotropic drugs (medications capable of affecting the mind, emotions, and behavior) by failing to evaluate and summarize Resident 1's behavioral symptoms from 1/1/2025 to 5/31/2025 for Seroquel (a medication used to treat mental health conditions such as schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions] and bipolar disorder [a mental illness characterized by extreme shifts in mood, energy, and activity levels]). This deficient practice had the potential to result in Resident 1 receiving unnecessary psychotropic drugs potentially increasing Resident 1's risk of adverse reactions (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate documentation in the Medication Administration Record (MAR - a document used to track and record the administration of medications and treatments to a resident) for one of four sampled residents (Resident 1) by failing to document observed episodes of physical aggression on 5/21/2025. This deficient practice had the potential to result in inaccurate behavior information, inappropriate medication management, hinder evaluation of treatment effectiveness, and negatively impact the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure residents are provided with a call light (a device used by a patient to signal his or her need for assistance from a professional staff) that the resident can use and within the resident's reach for two of three (Resident 34 and Resident 395) sampled residents reviewed under the environment task. 2. Ensure that a call light was answered by any staff member walking by the room for 1 of three sampled residents (Resident 134) reviewed in environment task. These deficient practices had the potential to result in the residents unable to call health care workers for assistance and delay in the provision of necessary care and services that can negatively affect resident's comfort and well-being.

Inspectors wrote2. During a review of Resident 27's admission Record, the admission Record indicated that the facility originally admitted the resident on 12/17/2024, and readmitted on [DATE], with diagnoses including acute respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing, often caused by a disease or injury), type 2 diabetes (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) injection sites to two of two sampled residents (Resident 76 and Resident 111) reviewed under the insulin care area. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat), bruising and pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Replace one open used medication emergency kit ([ekit]-storage container for emergency use medications) within 72 hours of opening the kit on 2/13/2025, in one (1) of two (2) inspected medication rooms (Medication Room Station 2.) 2. Account for one (1) dose of Controlled Medication (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Resident 25 in one (1) of four (4) inspected medication carts (Station 2 Medication Cart 1.) 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident's drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) by failing to discontinue an antipsychotic [drug that affects brain activities associated with mental processes and behavior] medication for one (1) of one (1) sampled residents (Resident 76) reviewed for unnecessary medication care area. As a result, Resident 76 continued to receive aripiprazole (an antipsychotic medication used for schizophrenia [a mental disorder involving thought, emotion and behavior,]) between 1/24/2025 and 2/18/2025 without documentation indicating to do so. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that medication error rate was less than five percent (%). Six medication errors out of 25 total opportunities contributed to an overall medication error rate of 24% for one of four residents (Resident 95) observed during medication administration. Resident 95 received six medications in a form that was not ordered by Resident 95's physician. The deficient practice of medication administration without the physician's orders increased the risk for Resident 95 to experience medication adverse reactions (unwanted, uncomfortable, or dangerous effects that a medication may have) and potential complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber ' s order, manufacturer ' s specifications, and accepted professional standards) by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a medication that regulates sugar in the blood) injections sites to two of two sampled residents (Residents 76 and 111) reviewed under the insulin care area. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat), bruising and pain. 2. a. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label one (1) Forteo (a medication used for osteoporosis [a condition in which bones become weak, brittle, making them prone to breakage) pen (an injection device containing the medication) for Resident 295 with an open date in accordance with the manufacturers' requirements in one (1) of two (2) inspected medication rooms (Medication Room Station 2). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items on the tray line (a system of food serving in which a tray is moved along an assembly line to ensure a resident gets their prescribed diet) provide a record of food temperatures when the Assistant Dietary Supervisor (ADS) failed to document the temperature all foods on the tray line. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 143 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a leftover blueberry muffin from the previous day was removed from the resident`s bedside for one of one (Resident 96) sampled resident. This deficient practice had the potential to result in contamination of the blueberry muffin which could lead to foodborne illness (also called food poisoning, illness caused by eating contaminated food) if the blue berry muffin is ingested (consumed). 2. Follow their Oxygen Administration, policy and procedure by failing to label an oxygen tubing with the date and time of when it was last changed for one of two sampled residents (Resident 345) reviewed under oxygen. This deficient practice had the potential to place Resident 345 at increased risk of infection and cause complications associated with oxygen therapy. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement their policy and procedure for Advanced Directive (AD-a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themselves) for one (1) of 13 sampled residents ( Resident 11) by not obtaining a copy of the resident`s Living Will (a document that specifies a residents preferences about measures that are used to prolong life when there is a terminal prognosis) and maintain it in the resident`s medical record. This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment.

Inspectors wroteBased on interview, and record review, the facility: 1. Failed to notify the resident's representative when the resident's medication Gemtesa (medication for overactive bladder [an organ that holds urine]) was no longer covered by insurance and before it ran out on 2/11/2025, for one of five sampled residents (Resident 112) reviewed under unnecessary medications. This deficient practice had the potential to negatively affect Resident 112 and their representative's right to be informed of a change in their medication. 2. Failed to notify the resident's representative of a change of condition for one of one resident (Resident 27) reviewed under Notification of Change care area when Resident 27's family member (FM 2) was not notified when Resident 27 had a diagnosis of Methicillin- Resistant Staphylococcus aureus (MRSA- type of bacteria that is resistant to the antibiotic). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one (1) out of one (1) sampled residents (Resident 30). This deficient practice had the potential to result in delayed services to Resident 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a resident's care plan to reflect the use of floor or landing mats (a cushioning pad placed by a resident's bed to absorb the force of a resident falling) for a resident who was at high risk for falls for one out of three sampled residents (Resident 1) investigated for accidents and hazards. This deficient practice had the potential to increase the resident's risk for injury in the event of a fall.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to maintain or improve the resident's ability to carry out the activities of daily living for one (Resident 48) of two residents investigated under vision and hearing by failing to ensure Resident 48's hearing aid was functioning to allow the resident to better hear and improve her ability to communicate. This deficient practice had the potential to prevent the resident from communicating with staff and had the potential for the delay of providing the resident the necessary care, treatment or services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 98) reviewed under the Activities care area was provided activities according to his/her activity preferences. This deficient practice violated the resident`s right to have access and receive activity services important to the resident which had the potential to affect the resident`s sense of self-esteem and self-worth.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident received care consistent with professional standards of practice to promote healing, prevent infection and prevent new pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure) from developing by failing to notify the physician prior to the treatment stop date that the treatment needed to continue, as the resident's pressure ulcer had not fully healed for one of one resident (Resident 98) reviewed under the Pressure Ulcer/Injury care area. This deficient practice had the potential for worsening of the pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a resident, who was assessed as unsafe to self-administer medications, was not left unattended with a Diclofenac Gel 1% (also known as Voltaren, a medication applied to the skin to reduce pain by reducing inflammation [swelling]) at the bedside one of one sampled resident (Resident 1). This deficient practice had the potential for other residents to enter the room and take the medication or for Resident 1 to apply too much of the medication too often. 2. Ensure a resident who was at high risk for falls had floor mats (a cushioning pad placed by a resident's bed to absorb the force of a resident falling) as ordered by the physician for one out of three sampled residents (Resident 1) investigated for accidents and hazards.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents who needed respiratory care (the health care discipline that specializes in the promotion of optimum cardiopulmonary function and health and wellness) were provided such care, consistent with professional standards of practice to one out of two sampled residents (Resident 136) by failing to administer oxygen (a colorless, odorless, and tasteless gas, that supports life) to Resident 136 as per the physician's order. These deficient practices had the potential to negatively impact Resident 136's respiratory well-being.

Inspectors wroteBased on interview, and record reviews, the facility failed to follow their policy and procedure for pain assessment and management for one of one sampled resident (Resident 38) reviewed under pain by failing to: 1. Conduct pain assessments after Resident 38`s change of conditions (a deviation from a resident`s normal state of health that can be physical, mental, or behavioral) on 12/8/2024 and 2/13/2025. 2. Thoroughly complete Resident 38`s Pain Risk Evaluation form on 12/30/2024. 3. Monitor Resident 38 for presence of pain on 2/7/2025 and 2/23/2025. These deficient practices had the potential to negatively affect Resident 38`s psychosocial well-being and quality of life.

Inspectors wroteBased on interview and record review the facility failed to complete the Hemodialysis (HD, the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) Communication Record with information including post dialysis assessment of the access site (locations on the body where a needle or catheter can be inserted to provide access to the bloodstream for hemodialysis treatment) and post dialysis vital signs for one of one resident (R108) investigated under the dialysis care area. This deficient practice placed the resident at risk for delayed detection of potential complications after dialysis treatment such as blood clot formation and bleeding which could lead to hemorrhage.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Consultant Pharmacist`s (CP) recommendation for 12/2024 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 and potential risks associated with medication) to give Ferrous Sulfate (iron supplement) was discussed with the physician and acted upon for one of eight (Resident 48) sampled residents. This deficient practice has placed the resident at an increased risk for untreated anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body) which could result to complications such as fatigue, weakness, and shortness of breath.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain electronic medical administration records (EMAR) in accordance with accepted professional standards and practices by failing to ensure all licensed nurses charted accurately the administration of the medication Gemtesa (medication for overactive bladder [an organ that holds urine]) from 2/11/2025 to 2/19/2025 to one of three sampled residents (Resident 112) reviewed during the unnecessary medication task This deficient practice resulted in inaccurate documentation in Resident 112's medical record.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan (a document designed to facilitate communication among members of the care team that the summarizes a resident ' s health conditions, specific care needs, and current treatments) for one of three sampled residents (Resident 1) to address Resident 1 ' s gastrointestinal atony (inability of the stomach to contract normally, causing a delay in the movement of food out of the stomach). This deficient practice had the potential to result in a delay or lack of delivery of care and services and placed Resident 1 at risk for hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report the initial report of the physical abuse allegation was made within two (2) hours of the incident for one of five sampled residents (Resident 1). This deficient practice had the potential to result in delay of necessary actions to oversee the protection of the residents in the facility by the State Survey Agency (SSA).

Inspectors wroteBased on interview and record review, the facility staff failed to notify the physician immediately of a change in condition (when there is a sudden change in a resident's health) for one of six sampled residents (Resident 1) when Resident 1 had an episode of elevated blood pressure (pressure of circulating blood against the walls of blood vessels, normal range less than 120/80 millimeters of mercury [mmHg - unit of measure]) result of 193/93 on 3/28/2024. This deficient practice had the potential to cause a delay of obtaining appropriate medical treatment and interventions for the resident which could have resulted in a negative impact to his overall physical well-being.

Inspectors wroteBased on interview and record review, the facility staff failed to re-check and monitor a change in condition (when there is a sudden change in a resident's health) for one of six sampled residents (Resident 1) when Resident 1 had an episode of elevated blood pressure (pressure of circulating blood against the walls of blood vessels, normal range less than 120/80 millimeters of mercury [mmHg - unit of measure]) result of 193/93 on 3/28/2024. This deficient practice placed Resident 1 at risk for further episodes of elevated blood pressure due to not receiving appropriate medical treatment and intervention immediately (with no delay).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper storage, preparation, and distribution of food in accordance with professional standards for food service safety for 142 of 146 residents by failing to: 1. Ensure food items were labeled and dated. 2. Ensure food items were not stored and readily available to be served past the discard date. 3. Ensure temperatures were being monitored for two reach-in refrigerators. These deficient practices had the potential to place residents at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks).

Inspectors wrote1.b. A review of Resident 8's admission Record indicated the facility admitted the resident on 6/4/2011 and re-admitted on [DATE] with diagnoses that included acute (sudden) and chronic respiratory failure with hypoxia (a long-term condition in which the respiratory system is unable to adequately exchange oxygen to the body), acute and chronic respiratory failure with hypercapnia (respiratory failure with a buildup of carbon dioxide [waste product that your body gets rid of when you exhale] in the blood, and dependence on supplemental oxygen. A review of Resident 8's MDS dated [DATE], indicated Resident 8 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of verbal and financial abuse within two hours for one of three sampled residents (Resident 136). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan (a written document that summarizes a patient's needs, goals, and care) for one of two sampled residents (Resident 31) by failing to develop a comprehensive care plan for Resident 31's seizure (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain) precaution. This deficient practice had the potential to result in a negative impact on residents' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who required assistance with nail trimming is provided care and services to maintain good personal hygiene for one of one sampled resident (Resident 45) investigated under activities of daily living (ADL- activities related to personal care). This deficient practice had the potential to result in a negative impact on the resident's self- esteem due to an unkempt appearance.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure an inhaler (handheld device that delivers medication directly to your lungs) of albuterol budesonide (medication used to prevent and treat difficulty breathing) was not left at the bedside dresser for one of six sampled residents (Resident 81). 2. Ensure that facility staff monitored a resident's bed alarm (a device that alerts staff when a patient stands up or attempts to leave their bed) for placement and functionality for one (Resident 65) of four sampled residents. These deficient practices had the potential to place the resident at increased risk of sustaining a fall with injuries, and placed residents at risk for theft and loss of medication and increased risk for drug overdose and or medication errors.

Inspectors wroteBased on interview and record review, the facility failed to complete a post-hemodialysis (HD, the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of two sampled residents (Resident 118) investigated addressing the dialysis care area. This deficient practice placed Resident 118 at risk for complications of dialysis such as redness at the catheter site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions).

Inspectors wroteBased on interview, and record review, the facility failed to monitor a resident's lipid panel (a measure of cholesterol [a waxy, fat-like substance found in the blood] and other fats in the blood) who was on a hyperlipidemic medication (medication used to lower cholesterol) for one of five residents (Resident 12) investigated for unnecessary medications. This had the potential to place a resident at risk for having high cholesterol levels that are not controlled which can result in blocked arteries (blood vessels that transport blood away from the heart).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from significant medication error by failing to administer two doses of ceftriaxone sodium (an antibiotic [treats bacterial infections]) as ordered by the physician for one of one sampled resident (Resident 31) investigated under Unnecessary Medications. This deficient practice placed the resident at risk for developing an antibiotic resistance to the bacteria and causing reinfection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with a nourishing, palatable, well-balanced diet to meet the daily nutritional needs by failing to ensure fortified (foods with nutrients added to them to increase the nutritional value) mashed potatoes were included on the lunch tray per the dietary order and as indicted on the lunch meal ticket for one of eight sampled residents (Resident 26) investigated under the Dining Task. This deficient practice had the potential to result in unwanted resident weight loss.

Inspectors wroteBased on interview and record review, the facility failed to develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report an alleged allegation of abuse on 8/27/2023 within two hours of being made aware of the allegation to the State Survey Agency (SSA) for one of three sampled residents (Resident 1). These deficient practices had the potential to result in unidentified abuse in the facility and failure to protect other residents from further abuse.