Capital Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received treatment and services in accordance with professional standards of practice when:1a. Resident 1's Midodrine (medication to increase blood pressure) order for orthostatic hypotension (a sudden significant drop in the blood pressure after standing up from a sitting or lying position causing symptoms like dizziness or lightheadedness) was not consistently followed; and, 1b. Resident 1's Midodrine PRN (given as needed or requested) order was not clarified and carried out as ordered. These failures increased the potential for Resident 1 to experience dizziness and lightheadedness and potentially increase incidents for falls due to low blood pressure. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program when pests were noted inside the rooms of two of three sample residents (Resident 1 and Resident 2). This failure had the potential to jeopardize the residents' living conditions, their health and safety. A review of Resident 1's clinical record indicated Resident 1 was admitted [DATE] with a diagnosis of encounter for surgical aftercare. A review of Resident 1's MDS (Minimum Data Set- an assessment tool) dated 2/5/26 indicated Resident 1 was cognitively intact. During an observation and interview on 4/29/26 at 11:08 a.m. with Resident 1 in Resident 1's room, a live roach was observed on the floor and a live brown spider 1 inch in length was observed on the sliding door in the resident room. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain proper infection prevention practices for one of three sampled residents (Resident 1) when a licensed nurse did not perform hand hygiene during wound care between changing gloves. This failure increased the potential to contaminate Resident 1's wound. A review of Resident 1's clinical record indicated Resident 1 was admitted in February 2026 with a diagnosis of aftercare following joint replacement surgery. A review of Resident 1's MDS (Minimum data set- an assessment tool) dated 2/16/26, indicated Resident had moderate cognitive impairment. During a concurrent observation and interview on 2/26/26 at 10:37 a.m. in Resident 1's room with Licensed Nurse (LN 1), Resident 1 was observed lying supine in bed with steri-strips to the left thigh. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nine residents (Resident 32, Resident 17, Resident 59, Resident 84, Resident 94, Resident 122, Resident 71, Resident 36 and Resident 126) out of 32 sampled residents were free from involuntary seclusion when resident room doors were left closed. This failure had the potential to increase the risk of psychosocial trauma and physical injury when residents were unable to exit their rooms independently or access staff during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four residents (Resident 139, Resident 96, Resident 116 and Resident 126) of 32 sampled residents were free of medication administration error rates of five percent or more, when 10 errors out of 28 opportunities for errors occurred during the medication administration to the residents. These failures resulted in medication administration error rates of five percent or more, which was 35.71 %.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for 116 out of 116 residents when: 1. Several metal sheet pans, serving utensils and scoop in clean and ready-to-use storage areas:Were stacked wet while stored awayThere was food debris in scoop and metal strainer [NAME] substance inside of the utensil holder.2. There were bags of food items in the walk-in freezer with issues:1 bag of unopened cream puffs, and two unopened bags of chopped green chilies have freezer burnsWalk in freezer had dark brown substances, white particles and an unknown plastic blue container at the back corner of the freezer floor. These failures had potential to cause food-borne illnesses in a highly susceptible population of 116 out of 116 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 116 when:1. Resident 54's nebulizer mask (a medical accessory that fits over a patient's nose and mouth to deliver medication directly into the lungs) had been sitting outside of the antimicrobial bag exposed for an unknown time; and,2. Staff did not follow enhance barrier precaution and did not perform hand hygiene when providing care for residents in Rooms 403, 404, 405 and 407.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse from one out of five sampled residents (Resident 89) when Resident 61 slapped Resident 89's right hand. This failure resulted in Resident 89 not being free from abuse by Resident 61, and Resident 89's right to be free from abuse not protected.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure an alleged violation involving elopement was reported to the State agency within the required time frames. The facility failed to report the elopement of one out of 32 sampled resident (Resident 138) whose whereabouts were unknown on 11/19/25. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure residents' safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of 32 sampled residents (Resident 38 and Resident 41) received assistance with their Activities of Daily Living (ADLs-normal daily functions required to meet basic needs) when Resident 41 and Resident 38 had long facial hair and long fingernails with blackish substance underneath. This failure had the potential to negatively affect their self-esteem, comfort, and personal hygiene.

Inspectors wroteBased on observation, staff interview, and record review the facility failed to provide for two residents (Resident 138 and Resident 139) out of 32 sampled residents:Adequate supervision when Resident 138 eloped the facility without staff being aware of Resident 138's whereabouts; and,No smoking assessment completed for Resident 139. These failures placed residents at risk for serious injury, harm, or death related to elopement and fire hazards.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe storage of medication for one (Resident 139) out of 32 sampled residents. This failure resulted in the facility's inability to monitor Resident 139's medication administration, placing Resident 139 at risk for improper dosing and non-therapeutic medication levels.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's food preference was honored for one of 32 sampled residents (Resident 5) when Resident 5's request for a diet upgrade was not followed. This failure had the potential to negatively impact the residents' food intake and well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure necessary treatment and care services was provided for one (Resident 118) of 32 sampled residents in accordance with professional standards of practice when rehabilitation referral for restorative nursing (RNA) was not started right away for Resident 118. This failure had the potential to place Resident 118 at risk for decline in functional ability, including decreased mobility and muscle strength.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident's (Resident 105) out of 32 sampled residents, call light was accessible to call for staff assistance, when call light was out of reach. This failure had the potential to result in Resident 105's inability to notify staff if there was an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 1), when the facility failed to identify, implement and monitor new interventions to prevent falls after Resident 1 fell at the facility on 1/4/26 and fell twice more on 1/10/26. These failures could have contributed to a fall on 1/13/26 that resulted in a broken clavicle (a break in the outer end of the collarbone, often caused by a direct fall onto the shoulder causing intense pain), pain, and a four-day hospitalization for Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to protect one of five sampled residents from abuse (Resident 1) when a Certified Nursing Assistant (CNA) hit Resident 1 on the head and the CNA, along with Witness 1 and Witness 2, physically restrained Resident 1 during care. This failure resulted in violation of Resident 1's right to be free from abuse of any type and had the potential to result in physical and psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 3) was free from abuse when facility staff witnessed Resident 4 hit Resident 3 with an object. This failure resulted in Resident 3 to feel unsafe in the facility and had the potential for Resident 3 to be harmed.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure Resident 1 was treated with respect and dignity for a census of 116. This failure had the potential for Resident 1 to not experience her highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when staff did not wear a gown when providing high contact care to three residents (Residents 1, 2, and 3) on Enhanced Barrier Precautions [EBP-set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDRO)] for a census of 116 These failures could lead to increased risk of infection spreading among residents. Findings 1. Resident 1 was re-admitted to the facility in March 2025 with multiple medical diagnoses which included anemia (a condition where the body does not have enough healthy red blood cells). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) to the State Survey Agency for one of nine sampled residents (Resident 4). This failure placed the residents at risk for continued exposure to potential abuse.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were secure for a census of 118 when a medication/treatment cart was unlocked and unattended with prescription medications in it. This failure had the potential to expose residents, staff, and visitors to unauthorized access to medications resulting in possible injury or drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage, handling, labeling, and delivery of respiratory care and equipment consistent with the facility's policy and procedures (P&P) for three out of 25 sampled residents (Resident 105, Resident 23, and Resident 88) when: 1. Resident 105's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) mask and tubing set was left on top of the bedside drawer, uncovered after use and was not changed after 72 hours; 2. Resident 23's nebulizer mask and tubing set was left on top of the bedside drawer, uncovered after use; and, 3. [...]

Inspectors wrote6. A review of Resident 63's clinical record indicated Resident 63 was admitted June of 2022 and had diagnoses that included hepatic failure (occurs when the liver is unable to perform its normal functions), chronic pain, diabetes mellitus (a chronic condition causing too much sugar in the blood that can affect nerves), and neuropathy (a nerve condition that can cause pain, numbness, tingling, or weakness in the body). A review of Resident 63's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 10/23/24, indicated Resident 63 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 63 had an intact cognition. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure dishes and utensils were cleaned in a sanitary condition for a census 112. This had the potential for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 112 when; 1. A shared glucometer (a device which measures blood sugar using blood from the fingertip) was not cleaned and sanitized properly after use and before storage; 2. A clean residents' personal items delivery cart was found with a thick layer of dust on its tray; 3. Shared glucometers (a device used to measure blood sugar) were not cleaned and sanitized based on manufacturer instruction when used for Resident 109 and Resident 315. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident's right to privacy and confidentiality of personal and medical records for one resident out of a census of 112 residents when a computer screen that showed a resident's photo and confidential personal and medical information was left unsecured and unattended. These failures had the potential to result in unauthorized access of residents' personal and medical information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, comfortable, and homelike environment for one of 25 sampled residents (Resident 70) when a hole was observed in the wall of Resident 70's room. This failure created a non-homelike environment for Resident 70.

Inspectors wroteBased on staff interview, record review and policy review, the facility failed to ensure an assessment accurately reflected the resident's status for one of 25 sampled residents (Resident 112). This deficient practice had the potential for inaccurate care.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one out of 25 sampled residents (Resident 105) when Resident 105's respiratory care and nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) treatment care plan was not developed. This failure placed Resident 105 at risk to not meet his medical needs and to not achieve the highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe Quality Control (or QC, proactive testing and calibration for accuracy of devices) and resident care practices with resident census of 112 based on standards of practice and facility's policy when: 1. The facility did not perform Quality Control (testing and calibration for accuracy) for glucometer (a machine that measures the blood sugar level) devices consistently based on facility's policy and the manufacturer recommendations. 2. Nursing care did not follow orders for checking feeding tube (surgically inserted tube into the stomach for feeding or medication administration when oral route not available) residuals (practice of checking volume of residue in the tube connected to stomach; [...]

Inspectors wroteBased an observation, interview and record review, the facility failed to ensure one out of 25 sampled residents (Resident 29) received treatment and care in accordance with professional standards of practice, and facility's policy and procedure (P&P) when Resident 29's physician's order for G-Tube Insertion Site (Gastronomy tube-a tube used to provide nutrition and medications) treatment was not followed. This failure had the potential for Resident 29's G-tube insertion site to become infected and for Resident 29 to not achieve their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure injury/ulcer (PI/PU, injury to skin and underlying tissue resulting from prolonged pressure) care and treatment consistent with professional standards of practice and facility's policy and procedures (P&P) for one of 25 sampled residents (Resident 89) when Resident 89's newly applied pressure ulcer dressing was not initialed and dated. This failure has the potential for Resident 89's stage 4 PU (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) to not get ordered care and treatment, to get worse, and/or develop complications, and for Resident 89 to not achieve the highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow a physician's order for care of a feeding tube (a tube placed in the gastrointestinal (GI) tract to deliver nutrition and calories (enteral nutrition) to your body if you can't safely chew or swallow), when a water flush (water given to hydrate patients via enteral feeding tube) volume and frequency received by Resident 107 was not consistent with the physician's order for one (Resident 107) of 25 sampled residents. This deficient practice placed Resident 107 in danger of receiving incorrect amounts of water flushes and may have resulted in depleted nutrition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident 94's medically related social services needs were met when, Social Services Assistants (SSA) did not clarify his surgery with his primary physician for one of 25 sampled residents, Resident 94. This failure had the potential to cause delay in Resident 94's healing and recovery.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with Resident census of 112. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 37 opportunities which resulted in a facility wide medication error rate of 8.11 % in two out of 10 residents (Resident 69 and Resident 105) observed for medication administration. These failures may result in unsafe medication use, medication error, and use of spoiled or ineffective drugs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices were maintained in the medication room and medication carts with the census of 112 when: 1. The Back Station medication room stored expired, unlabeled, and undated medications. 2. Medication Cart #2 found a pill in the pill cutter, and Pro-Stat AWC had yellow/orange streaks running down the bottle. 3. Hazardous medications (drugs that can cause harm to the body when handled unsafely) were stored in medication Carts # 1 and Cart #4 with no warning label on how to be handled by nursing staff. 4. Inhalation products called Ipratropium Bromide and Albuterol Sulfate (or DuoNeb, a breathing treatment) stored in medication Cart #1 and Cart #4 were not dated, and/or the beyond use date was not followed. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure accurate documentation of Resident 100's diagnosis in the medical records in one out of five residents. This failure of inaccurate documentation of resident's diagnosis may contribute to unsafe care and treatment by the facility and subsequent care providers.

Inspectors wroteBased on interview and record review, the facility failed to protect two residents (Resident 1 and Resident 2) of two sampled residents' right to be free from verbal and physical abuse when Resident 1 yelled racial slurs and Resident 2 slapped Resident 1 in the face. This deficient practice resulted in both residents feeling either discontent, pain, and concerns about safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored locked for a census of 119 when two bags of medications were left unlocked and unattended on top of a cabinet. These failures had the potential for medication misuse and drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the professional standards of practice for Resident 1 when the nasal cannula (a device used to deliver oxygen to the nose) was not labeled with an open date (start of use) and the nasal cannula replacement order was scheduled for a longer interval than indicated on the facility's policy. These failures decreased the facility's potential to prevent the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an incident of allegation of abuse for one of four sampled residents (Resident 1) as required by the regulations. This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect residents from physical and psychosocial harm.

Inspectors wroteBased on interview, record review and policy review, the facility failed to provide supervision and monitoring for one of three sampled residents (Resident 1) when Resident 1, after several attempts, eloped from the facility. This failure had the potential to result in serious injury or death for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1's) representative obtained a copy of Resident 1's record or any portions thereof upon request and of two working days advance notice to the facility. This failure resulted in the impingement of Resident 1's representative rights.

Inspectors wroteBased on interview and record review, the facility failed to observe professional standards of practice to meet the needs of one of three sampled residents (Resident 1), when the facility failed to carry out physician's order for management of shortness of breath as ordered upon discharge from a General Acute Care Hospital (GACH). This failure resulted in worsening of Resident 1's shortness of breath and subsequent need to be transferred to a hospital.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) on notification of changes for one of six sampled residents (Resident 1) when Resident 1's family member was not notified of Resident 1's change of condition and transfer to the hospital. This failure resulted in Resident 1's family member to be unaware and not involved with Resident 1's current medical status and transfer to the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notice of bed-hold was provided for 2 of 3 sampled residents (Resident 1 and Resident 3) or their representatives. These failures caused residents or their representatives to not be fully informed of bed-hold options and rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when there was no care plan, no wound assessment, and no monitoring for Resident 1's left middle toe wound. These failures contributed to Resident 1 being admitted to the hospital with osteomyelitis (serious infection of the bone from injuries that cause damage to deep tissues) and gangrene (tissue death often caused by lack of blood flow or infection) on his left second and third toes and, as a result; both toes were amputated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided to promote healing and prevent further progression of wounds for 2 residents (Resident 1 and Resident 2), for a census of 116, when: 1. Resident 1's open area on the coccyx (tailbone) and surgical wound on the posterior spine (backbone) were not assessed weekly; and 2. Resident 2 was not provided with a low air loss mattress (LAL, designed to distribute the body weight and help prevent skin breakdown) and heel suspension boots (removes pressure from the heel). These failures increased the risk for Resident 1 and Resident 2 to develop new pressure ulcers and the deterioration of existing wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement acceptable standards of practice in the use of controlled medications when Resident 1's unused narcotic was taped back into the peeled blister pack and Resident 2's discontinued narcotics were stored in the medication cart for available for use and, had a reconciliation discrepancy. These failures increased the potential for controlled medication diversion, loss, and medication errors for a census of 119.

Inspectors wroteBased on interview and record review the facility failed to implement its policy and protocols on abuse for one of six sampled residents (Resident 1), when: 1. The facility failed to provide a nursing assessment immediately after Resident 1 alleged he had been physically abused by a staff member, and 2. The facility failed to immediately place a staff member, who was accused of physically abusing a resident, on leave. These failures resulted in Resident 1 not receiving an immediate assessment and interventions to ensure safety.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse involving one of six sampled residents (Resident 1) to the California Department of Public Health (CDPH) within two hours after facility staff were made aware of the allegation of abuse. This failure decreased the facility's potential to protect vulnerable residents and provide a safe environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices for a census of 121 residents when a Certified Nursing Assistant (CNA) did not perform hand hygiene when entering and exiting multiple resident rooms before providing care to a resident during lunch. This failure decreased the facility's potential to prevent the spread of infection among the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received respiratory care in accordance with professional standards of practice when: 1. Resident 1's Bilevel Positive Airway Pressure (BiPAP, a machine that pushes pressurized air into the lungs to help with breathing) treatment was not signed as given for 63 days, and 2. Resident 1's nasal cannula (used to deliver oxygen to patients who need supplemental oxygen) and humidifier (adds moisture to the oxygen) were not dated, her BiPAP mask and tubing were found uncovered on top of the oxygen concentrator (a machine that delivers oxygen) ; and a used nasal cannula was found on the bedside table. These failures had the potential to result in Resident 1 developing hypoxia (low oxygen) and infections.

Inspectors wroteBased on interview, record review, and facility policy review, Licensed Nurse 1 (LN 1) failed to ensure the correct type and dose of insulin (a medication used to control blood sugar levels) was administered to one of three sampled residents (Resident 1). This failure had the potential to result in hypoglycemia (low blood sugar) for Resident 1.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure one of 3 sampled residents (Resident 1) was treated with respect and dignity when the staff did not provide privacy during care. This failure decreased the potential to ensure Resident 1's right to privacy was maintained.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmacy services timely for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when prescription medications were not available for administration. This failure resulted in Resident 1, Resident 2, and Resident 3 to not receive their routine medications as prescribed and placed the residents at risk for adverse consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) attained the highest mental and psychosocial well-being when the residents were concerned about their medication supplies after they missed their routine medications due to medication delivery delays. This failure resulted in Resident 1 to start keeping her own medication administration log to remind staff to reorder her medications timely and Resident 2 was more depressed and experienced uncontrolled pain, high stress, and anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident's right to privacy of personal and medical records when residents' meal tickets were discarded in the facility kitchen garbage bin for the 98 residents who ate facility prepared meals. This failure had the potential for unauthorized access of residents' personal and medical records.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired biological supplies found in Station 1 and 2 Medication Rooms (MR) were not available for use, and failed to ensure proper labeling of drug when, 1. Resident 47's oxycodone (an opioid, controlled medication used to treat moderate to severe pain) had no change in order label on the bubble pack; and 2. Expired medical supplies in the medication rooms were not removed and discarded, for a census of 111 residents. These failures placed Resident 47 at risk for receiving more than the prescribed dose of the opioid medication and had the potential for the expired biological supplies to be used for residents, compromising the accurate findings of their laboratory results, and may have subsequently led to misdiagnosis or prescribing wrong medications and treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve residents' therapeutic diet (a diet ordered as part of treatment for a disease or clinical condition, or to eliminate, decrease, increase, or provide specific nutrients in the diet) as prescribed by the physician when the prescribed controlled carbohydrate diet (CCHO- a diet focused on having the same amount of carbohydrates; fiber, starches and sugars, every day) for 14 out of 32 residents (Resident 81, Resident 78, Resident 33, Resident 52, Resident 10, Resident 121, Resident 171, Resident 114, Resident 97, Resident 107, Resident 570, Resident 122, Resident 44, and Resident 76) were not followed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 98 residents who ate facility prepared meals when: 1. A package of ground sausage with ice crystals built-up was found open and exposed to air in the freezer; 2. Two out of two dry storage logs were not filled in four out of 11 entries; 3. A food preparation sink lacked an air gap (a backflow prevention device that prevents contaminated water from re-entering the sink); 4. Five large steam table pans, three medium steam table pans, one small steam table pan (with food particles), two water pitchers and covers, and two medium measuring containers were all found stored wet; 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for the facility when two cockroaches were observed in the facility kitchen. This failure has the potential for contamination of resident's food, soilage of kitchen utensils and surfaces, and possible spread of disease or infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure smoking safety for one of 24 sampled residents (Resident 97) when the initial smoking assessment was delayed and the smoking care plan was inconsistent with the assessment. This failure placed the resident at risk for injuries related to smoking and had the potential for non-smoking residents to be exposed to smoking hazards.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards were met when two of 24 sampled residents (Resident 170 and Resident 173) received medications without identifying irregularities of the indications for use. This failure had the increased potential for medication errors and placed the residents at risk for erroneous diagnoses and inaccurate medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to; 1. Identify signs and symptoms of opioid (a controlled medication used to treat moderate to severe pain) overdose (a life-threatening condition characterized by lessened alertness and small pupils) and to develop a care plan to accurately assess and monitor one of three sampled residents (Resident 47), and 2. failed to ensure Licensed Nurses (LN) provided quality of care in accordance with professional standards of practice for Resident 171 when: a. No comprehensive person-centered care plan with interventions that reflected his Peripherally Inserted Central Catheter, PICC (a thin, soft, long catheter inserted into the arm, neck, or leg's vein); b. No physician order about routine care and maintenance of PICC line; and c. [...]

Inspectors wroteBased on interview and document review, Resident 44 failed to maintain his usual body weight, losing 38 pounds (lbs.) and 18% of his body weight since admission. This had the potential of leading to decreased independence due to muscle loss, as well as reduced ability to fight off infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with the facility policy for one of 24 sampled residents (Resident 12) when oxygen tubing, oxygen mask for nebulizer (to administer liquid medicine into a mist through a mask to inhale the medication) treatment and the Bi-pap (the machine supplies pressurized air into the lungs) bag were outdated or not dated at all. These failures increased potential for respiratory infection for Resident 12 who already had compromised lung function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care for one of three sampled residents (Resident 1) and failed to notify the physician immediately of Resident 1's change of condition (COC), when the resident complained of chest pain. In addition, the facility failed to assess Resident 1 and monitor him for his complaint of chest pain. These failures resulted in Resident 1's calling 911 due to the delay for needed medical attention and placed the resident at risk for harm when his condition was not evaluated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from neglect when Resident 1 did not receive incontinence care, was not turned and not repositioned for over five hours. This failure resulted in Resident 1's feeling uncomfortable, itching and had the potential to worsen his skin rash.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sufficient staff to provide nursing and related services to meet the residents needs for census of 116, when Resident 2 had to wait for over an hour to be assisted with cleaning, multiple residents complained of extended wait time for assistance with their needs, and the facility failed to meet State staffing requirements for Certified Nursing Assistants (CNAs) for 10 of 10 sampled days. These failures resulted in inadequate availability of CNAs to attend to Residents 2 and other residents requiring assistance needs, had the potential to place residents at risk for skin breakdown, and negatively affect residents' physical and psychosocial well-being.