Casitas Care Center

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) had accurate and complete documentation on the Fall Risk Assessment (a form used by the facility to assess a resident's risk for a fall) dated 6/30/2026. This deficient practice had the potential to place Resident 1 at greater risk for a fall and decreased supervision by facility staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Maintain a comfortable sound levels to promote a restful environment for two of three residents (Resident 3 and 89) investigated under the care area Safe/Clean/Homelike Environment. This deficient practice resulted in the residents feeling disrespected, annoyed and awaken unnecessarily. 2. Provide a safe, clean, comfortable, and homelike environment for one of three sampled residents (Resident 91) when there was dust buildup on the base of the resident's facility provided fan and wall. This deficient practice denied Resident 91 the right to a clean, comfortable, and homelike environment and had the potential to negatively impact Resident 91's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 2) was free from unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure Resident 2 did not have duplicate (more than one [1]) medication treatments with the use of quetiapine (antipsychotic [medication used to treat mental illness]) and clonazepam (a psychotropic drug used for agitation and as anxiolytic [reduce anxiety]) between 12/23/2025 and 3/24/2026. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) four (4) medication emergency kits (eKIT - kit containing medications needed to be used during emergencies) containing Controlled Substance-[CS, medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics or Controlled Medication, CM]) for March 2026, in one (1) of one (1) inspected Medication Rooms (Medication room [ROOM NUMBER].) 2. Reconcile two (2) medication eKITs containing CS for March 2026, in two (2) of three (3) inspected Medication Carts (Medication Cart 1 Station 1, Medication Cart AM Station.) 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 25 total opportunities contributed to an overall medication error rate of 8% affecting two (2) of four (4) residents observed for medication administration (Resident 18 and 57.) The medication errors were as follows:1. Resident 18 did not receive a form of aspirin (a medication used for cerebrovascular accident [CVA - an interruption in the flow of blood to cells in the brain, mainly caused by hypertension (high blood pressure)] prophylaxis [PPX - prevention]) as ordered by Resident 18's physician. 2. Resident 57 did not receive a form of aspirin as ordered by Resident 57's physician. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store medications in accordance with manufacturer specifications, professional principles and facility policy and procedures by failing to ensure eye drops were stored separately from orally administered medications, in one (1) of three (3) inspected Medication Carts (Medication Cart 1 Station 1.) This deficient practice increased the risk of contamination of medications and receiving medications via the wrong route (internal versus external routes,) for residents in the facility, possibly leading to adverse health consequences resulting in the negative impact to their health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident`s dignity and respect by failing to ensure a staff member knocked prior to entering a resident`s room for one of two residents (Resident 26) observed during dining observation. This deficient practice violated the resident's right to be treated with respect and dignity and had the potential to affect Resident 26`s sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) by failing to: a. Develop a care plan for a skin tear (a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers) sustained during a fall incident for one of five sampled residents (Resident 30) investigated under the Accidents care area. This deficient practice had the potential to result in failure to deliver the necessary care and services to Resident 30. b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly use the air redistribution mattress (a specialized mattress that continuously circulates air) when it was turned off for one of four sampled residents (Resident 54). This failure had the potential to result in development of pressure ulcers (localized pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), increased skin breakdown and slower healing.

Inspectors wroteBased on interview and record review, the facility failed to accurately document orthostatic blood pressure (taking blood pressure measurements when lying, sitting, and standing to detect for significant drop in blood pressure during each position change) measurements for one of five sampled residents (Resident 4). This failure had the potential to result in residents receiving the wrong treatments, physician miscommunication and inconsistent care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection control practices for one of four residents (Resident 26) reviewed during the Infection Control task by failing to ensure Certified Nursing Assistant 1 (CNA 1) performed hand hygiene (the process of cleaning hands with soap and water or alcohol-based sanitizer to remove germs and prevent the spread of infections) after handling a soiled meal tray and prior to delivering a meal to Resident 26. The deficient practice had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the double door exit in the middle station (MSDDE) was fully sealed when closed and did not have gaps, which created an opening from top to bottom measuring 72 inches in length and 1/3 of an inch in width for one of three doors in the facility. This deficient practice created an entry point and access for insects to get inside the building which could potentially transmit insect borne illnesses to the 94 out of 94 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to accurately measure the pressure ulcer/injuries (PU/ls - injury to skin and underlying tissue resulting from prolonged pressure on the skin) wound measurements for two of three sampled residents' (Resident 1 and Resident 2). This deficient practice had the potential to delay necessary treatments and services and to increase the residents' risk of further skin breakdown.

Inspectors wroteBased on interview and record review the facility failed to ensure that a 72-hour neurological check (neuro check- an assessment conducted to assess a person's brain and nervous system function by checking level of consciousness, behavior, pupils, movement, and vital signs to identify any changes in condition) was completed for one of three sampled residents (Resident 1) after Resident 1's unwitnessed fall on 12/18/2025. This deficient practice had the potential to result in delayed identification of changes in Resident 1's condition, which could affect the timely delivery of appropriate care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the admission Coordinator (AC) was aware that residents and their representative can rescind the facility's arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) agreement (a written contract in which two or more parties agree to settle a dispute out of court) within 30 days after obtaining the signature for two of three sampled residents (Residents 2, and 5 ). These failures could potentially result in the residents and residents' representatives not knowing or understanding what an arbitration agreement is and potentially causing feelings of doubt and confusion.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Notify one of four sampled residents (Resident 1) physician and Resident 1 regarding the missed dose of Levothyroxine Sodium (levothyroxine - a medication used to treat an underactive thyroid gland [a gland that makes and stores hormones that help regulate the heart rate, blood pressure, body temperature, growth development and energy]) scheduled to be given on 1/15/2025 at 6:30 a.m. 2. Notify one of four sampled residents (Resident 1) physician of Resident 1's refusal to allow body weight monitoring for a duration of 58 days (2/6/2025 to 4/4/2025). These deficient practices may result in worsening symptoms, increased risk of hospitalization or complications and health decline.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered 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) and implement care plan interventions for one of four sampled residents (Resident 1) to address Resident 1's refusal to allow body weight monitoring. These deficient practices had the potential to negatively affect the delivery of care and services and placed Resident 1 at risk for impaired nutrition and decline in well-being.

Inspectors wroteBased on interview and record review, the facility failed to conduct a nutritional assessment upon admission for one of four sampled residents (Resident 1), as per the facility's policy and procedure (P&P) titled, Nutritional Assessment. This deficient practice had the potential to place Resident 1 at risk for undetected nutritional status and at risk for medical complications related to impaired nutrition.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure that the on-coming nurse (Licensed Vocational Nurse 1 [LVN 1]) signed the Narcotic (a controlled medication or substance with a high potential for abuse that in moderate doses dulls the senses, affects mood or behavior, relieves pain and induces sleep) Count Sheet (NCS- a form used to account all controlled medications, and to transfer accountability from the out-going nurse to the on-coming nurse) on 4/24/2025 for 7 a.m. to 3 p.m. shift after counting the controlled medications with the out-going nurse (Licensed Vocational Nurse 2 [LVN 2]). 2. Ensure that the on-coming nurse (Licensed Vocational Nurse 3 [LVN 3]) signed the NCS on 4/9/2025, 11 p.m. to 7:00 a.m. shift in one of two inspected medication carts (MC 3) at the Nursing Station (NS). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS - a resident assessment tool) Assessment Section K (Swallowing/Nutritional Status) dated 4/14/2025 under Section K0200 (the section for a resident weight) and Section K0300 (the section for weight loss) by failing to indicate the resident's body weight based on most recent measure in last 30 days which then led to an inaccurate assessment data entered under Section K0300 for one of four sampled residents (Resident 1). This deficient practice had the potential to negatively affect Resident 1's plan of care and delivery of services.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure titled Wandering (to walk around without any clear purpose or direction) and Elopement (leaving the facility without notice or permission) and failed to ensure one of three sampled residents (Resident 1), who was observed with periods of confusion, agitation (a condition in which a person is unable to relax and be still) and was observed wandering and entering other resident rooms on 4/7/2025 was kept free from accidents and hazards by: 1. Failing to ensure Certified Nursing Assistant 1 (CNA 1) followed the facility's policy and procedure titled Wandering and Elopement to attempt to prevent Resident 1, who was at risk for unsafe wandering, from leaving the facility premises. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt attempts were made to resolve the grievance of one of three sampled residents (Resident 1). This deficient practice violated the residents' right to have his grievance addressed.

Inspectors wroteBased on interview and record review the facility failed to ensure the facility ' s intravenous (IV -fluids given directly into the blood stream) administration policy was implemented to prevent complications from intravenous therapy by failing to monitor a resident receiving intravenous hydration for Intake & Output (I&O- the careful tracking and recording of fluids a patient consumes [intake] and eliminates [output] to monitor fluid balance and overall hydration status) and failed to assess a resident prior to the administration of IV fluids for one of three sampled residents (Resident 1) This deficient practice had the potential to place Resident 1 at risk for developing complications such as inflammation of the vein, fluid overload (a medical condition characterized by having too much fluid volume in the body, potentially leading to health complications like swelling, high blood [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy on quality of life by failing to ensure three of four sampled residents (Resident 2, Resident 3 and Resident 4) were assisted by staff to participate in activities. This deficient practice had the potential to affect the resident's sense of well-being, self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure titled Activity Programs by failing to incorporate at least one activity a month held away from the facility and offer at least one evening activity per week to 93 residents residing in the facility for two of three sampled months (January 2025 and February 2025). This deficient practice had the potential to result in psychosocial decline and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services (refers to the collection, testing. and analysis of a resident's specimen [such as blood, urine or stool] for health-care professionals to make decisions on the diagnosis and treatment of their residents) were provided to one of three sampled residents (Resident 1) timely per physician's order. This deficient practice resulted in the delay of necessary care and services for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within residents' reach while in bed for three of three sampled residents. (Resident 5, Resident 44, and Resident 45) This deficient practice had the potential to delay the provision of services and residents' needs not being met.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident`s needs for four of four sampled residents (Resident 287, Resident 36, Resident 37, and Resident 20) by failing to: 1. Develop and implement a comprehensive person-centered care plan addressing Resident 287`s intravenous catheter (IV- a thin flexible tube inserted into a vein to allow for administration of fluids or medications). This deficient practice had the potential to result in Resident 287`s inadequate care of IV site. 2. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe environment for three out of six residents (Resident 70 and Resident 37) investigated under the care area of accidents when: 1. The facility failed to place a landing mat to Resident 70's right side of the bed while Resident 70 was in bed as indicated in the care plan and physician's order. This deficient practice placed the resident at risk for avoidable pain and/or injury in an event of Resident 70 experiencing an actual fall. 2. The facility allowed Resident 37 to keep an electric tea kettle in his room. This deficient practice had the potential to result in injuries to Resident 37.

Inspectors wroteb. During a review of Resident 287's admission Record, the admission Record indicated that the facility initially aditted Resident 287 on 4/27/2024 and readmitted the resident on 3/3/2025 with diagnoses including pneumonitis (lungs tissue inflammation, swelling, and irritation), urinary tract infection (an infection in any part of the urinary system), and type 2 diabetes mellitus (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). During a review of Resident 287's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/12/2024, the MDS indicated that the resident had severely impaired cognition (a severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure licensed nurses did not leave medications at residents' bedside unattended by a licensed nursed for one of three sampled resident (Resident 57) This deficient practice increases the risks of harm to the resident from omitting the dose, double dosing, and mixing the medications that could cause adverse (unfavorable) or even fatal effects on the resident 2. Ensure a resident was given the first dose of antibiotic timely for one of three sampled residents (Resident 60) This deficient practice resulted in the delay of medication administration of an antibiotic which has a potential to cause bacteria to reproduce.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure leftover food brought from outside by residents' family and visitors were labeled with a resident identifier and use-by-date in one of one resident refrigerator (Refrigerator 1). This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for the residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the facility had arranged provisions of hospice services by failing to: 1. Ensure the contracted hospice agency provided training programs to facility staff as per contractual agreement. 2. Ensure there is a designated staff to coordinate care and services provided by hospice and the facility. 3. Ensure documented evidence was provided to validate hospice staff was physically in the facility to provide hospice related services to one of three sampled residents (Resident 70) These deficient practices has the potential to negatively affect the resident's physical comfort, psychosocial well-being, and has the potential to delay or have a lack of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a resident's nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was not touching the floor for one of one sampled resident (Resident 137). 2. Ensure a resident's nasal cannula was labeled with the date when it was last changed for one of three sampled residents (Resident 287). These deficient practices 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 provide dignity to a resident by failing to ensure an indwelling urinary catheter (a flexible tube inserted into the bladder [organ that stores urine] and left in place to continuously drain urine) collection bag (attached to the catheter tube for the purpose of collecting urine) was covered with a privacy bag (dignity bag- a bag that conceals urine in the collection bag) for one of one sampled resident (Resident 238). This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan (a document that summarizes a resident's needs, goals, and care/treatment) within 48 hours of admission and/or readmission for three of four sampled residents (Resident 21, 59, and 62) by failing to: 1. Develop a baseline care plan that addressed Resident 21 and 59's antibiotic (medication used to treat bacterial infections) use. 2. Develop a baseline care plan that addressed Resident 62's insulin (a hormone that works by lowering levels of glucose [sugar] in the blood) use. These deficient practices had the potential to result in failure to deliver the necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to update and revise a resident's care plan (a document that summarizes a resident's needs, goals, and care/treatment) after the resident's physician discontinued administration of Januvia (a medication that helps control blood sugar levels) on 10/25/2024, for one of two sampled residents (Resident 20). This deficient practice had the potential to result in confusion regarding the care and services Resident 20 received at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with a communication board (a device that can help patients communicate with care providers and family using symbols, photos, or illustrations) for one of two sampled residents (Resident 20) whose primary and preferred language was not English. This deficient practice has the potential to prevent the resident from communicating with the staff and had the potential to delay receiving care/treatment the resident needed.

Inspectors wroteBased on interview and record review, the facility failed to provide religious services to one of one sampled resident (Resident 10) investigated under Activities. This deficient practice violated the resident's right to have access and receive religious services 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 one of one sampled resident (Resident 62) with an indwelling catheter (a hollow tube inserted into the bladder [organ that stores urine] to drain or collect urine) received proper care and services by failing to monitor the resident for signs and symptoms of urinary tract infection (UTI- an infection in the bladder/urinary tract) and pain associated with the catheter as indicated in the resident's care plan (a document that summarizes a resident's needs, goals, and care/treatment). This deficient practice had the potential to result in Resident 62 receiving inadequate care and monitoring at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the pharmacy's medication recommendation label of discarding two opened eye drop bottles after 28 days of opening from one in five medications carts (Medication Cart 1 3-11 shift) This deficient practice had the potential to compromise the therapeutic effectiveness of the medication and increase the risk of contamination, which could result in a negative impact to the health, and well-being of the residents.

Inspectors wroteBased on interview, and record review, the facility failed to conduct an accurate Minimum Data Set (MDS- a resident assessment tool) assessment, reflecting a resident's status at the time of assessment for one of two sampled residents (Resident 62) by failing to indicate that the resident was receiving insulin (a hormone that works by lowering levels of glucose [sugar] in the blood) since his admission to the facility. This deficient practice had the potential to negatively affect Resident 62's plan of care and the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were updated to indicate that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for three of nine sampled residents (Resident 24, 53 and 67). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Resident 24, 53 and 67.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure blood glucose (the amount of sugar in the blood) monitoring (measure and display the amount of sugar in your blood) was done as per the physician orders for one of two sampled residents (Resident 46). 2. Ensure that one of three sampled residents (Resident 64) was provided with bilateral (both sides) upper bed side rails as ordered by the physician. These deficient practice resulted to inappropriate management of Resident 46`s type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) which could potentially result to hypoglycemia (blood sugar level goes below the standard range) and hyperglycemia (high blood sugar) episodes which could lead to complications such as a condition called diabetic ketoacidosis (diabetic coma) and even death; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a comfortable home-like environment by not providing an adequate and comfortable lighting per the facility's policy for one of six sampled residents (Resident 293). This deficient practice had the potential to negatively impact the quality of life and increased risk for discomfort for Resident 239.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure for the use of restraints (a device that restricts movements) by: a. Failing to ensure a consent (the legal approval that a resident gives to a physician regarding health care decisions) was first obtained prior to utilizing bilateral (both sides) bed side rails for one of three sampled residents (Resident 77). b. Failing to ensure licensed nurses obtained a physician's order for the use of bilateral bed siderails for one of three sampled residents (Resident 77). This deficient practice placed Resident 77 at increased risk for complications of restraint use such as decline in functioning, injury, and entrapment (event in which a resident is caught, trapped, or entangled in a space where they are being restrained).

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 three sampled residents (Resident 77) by failing to develop a comprehensive care plan for use of Resident 77's bilateral bed siderails. 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 interview and record review, the facility failed to renew and revise a resident's comprehensive care plan (a care plan is a form where you can summarize a person's health conditions, specific care needs, and current treatments) for high risk for fall for one of two residents sampled residents (Resident 40) investigated under Care Planning. This deficient practice resulted in Resident 40 not being evaluated if the desired outcome or care plan goals have been met or if the plan of care needs to be updated with new interventions to prevent a fall incident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards by failing to: A. Ensure the electrical extension cord that was connected to an electrical outlet was secured to the wall for one of 21 sampled residents (Resident 9). B. Ensure the electrical power strip (a length of electrical sockets attached to the end of a flexible cable that plugs into an electrical receptacle) was not wrapped around the bed siderail while attached to another power strip for one of 21 sampled residents (Resident 48). These deficient practices had the potential to place Resident 9 and Resident 48 at increased risk of electrical accidents which could then result in injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to post in a visible and prominent place the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift for two of three sampled days (2/23/2024 and 2/24/2024). This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) was acted upon for one of six sampled residents (Resident 21) investigated under the care area of unnecessary medications by failing to act upon the facility's consultant pharmacist's recommendation for Resident 21's Ambien (medication used to treat insomnia [sleep disorder that can make it hard to fall asleep or stay asleep] as needed order. This deficient practice had the potential to cause adverse side effects from the continued use of these medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was monitored for complications that included signs and symptoms of bleeding and side effects related to anticoagulant (medications that help prevent blood clots) use for one of two sampled residents (Resident 190) investigated under Unnecessary Medications. This deficient practice placed the resident at risk for undetected bleeding which could lead to blood loss and hemorrhage (loss of blood from a damaged blood vessel).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 48) reviewed for unnecessary medications, was free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) by failing to ensure Resident 48 was adequately monitored for the amount of hours of sleep for the use of Trazodone (medication used to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest]). These deficient practices had the potential to place residents at risk of receiving unnecessary medications and/or overuse of medication and adverse consequences while using the medications.

Inspectors wroteBased on interview, and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for two of nine sampled residents (Resident 24, and 58) by failing to ensure the resident's Coronavirus Disease 2019 (COVID-19)- a deadly respiratory disease transmitted from person to person) and influenza (Flu-common viral infection that can be deadly, especially in high-risk groups) vaccination (A preparation that is used to stimulate the body's immune response against diseases) consents (the legal approval that a resident gives to a physician regarding health care decisions) contained the residents name. This deficient practice had the potential to result in confusion regarding Resident 24 and Resident 58's condition and what care and services were provided to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control measure and prevention by failing to ensure there was a personal protective equipment (PPE- specialized clothing or equipment worn by an employee for protection against infectious materials) cart outside of a resident's room and ensure staff wear full personal protective equipment (PPE- specialized clothing or equipment worn by an employee for protection against infectious materials) before entering and providing care to one of nine sampled residents (Resident 64) who had an order for enhanced standard precaution (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that have become resistant to certain antibiotics] in nursing homes). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident ' s call light (a device used by a resident to signal his or her need for assistance from healthcare workers) was within reach for two of six sampled residents (Resident 2 and 3). This deficient practice had a potential for the residents not able to call for assistance needed.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of three sampled residents (Resident 1) by: 1.failing to develop a comprehensive care plan for Resident 1's incontinence (inability to control both bowel and bladder). 2. failing to ensure Resident 1's care plan for pain medication therapy included the reason the resident was on pain medication therapy. These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement infection control practices by: 1. Failing to ensure one used commode (a type of chair with an opening to a large pot used by residents as a toilet) containing soaked toilet papers with yellow substances were not left in the courtyard of the facility that is used by residents during smoking breaks and leisure time. 2. Ensure 13 empty trash bins and liners (plastic bags) used for disposal of Coronavirus disease -2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) waste were not scattered in the vacant spaces between resident ' s room windows and the facility ' s fence. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a homelike environment was provided by: 1. Failing to ensure that the window screen was not torn and had no cobwebs (a web spun by spiders) accumulating on the screen for one out three residents (Resident 2) investigated for clean and homelike environment. 2. Failing to ensure that room [ROOM NUMBER] and room [ROOM NUMBER] of the facility did not have torn window screens. 3. Failing to ensure that Rooms 1,2,3,4 and 5 did not have missing vertical window blind louvers (slats- a type of window covering). These deficient practices violated the residents ' rights to a safe, clean, comfortable, sanitary, and homelike environment.