Cerritos Vista Healthcare Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 6) who had behaviors of getting up unassisted, was not restrained in a Trendelenburg (a specific body position where the patient lies flat on their back with their feet elevated higher than their head) like position, while seated in a Geri-chair. This deficient practice resulted in Resident 6's inability to get out of the Geri-chair unassisted and frustration when he wanted to get up but could not do so himself. This deficient practice had the potential for Resident 6 to act out and move in ways that could cause him injury.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one resident's (Resident 1) Minimum data Set ([MDS] resident assessment tool), dated 5/8/2026, was coded correctly. This failure resulted in an inaccurate assessment of Resident 1's current health status and Resident 1's inaccurate MDS indicated that Resident 1 did not have broken teeth and abnormal gum tissue in the mouth.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident's (Resident 1) Enteric coated ([EC] a pill with a protective layer that won't dissolve in the stomach but will be released once in the small intestines) Aspirin ([ASA] nonsteroidal anti-inflammatory drug) was not crushed and administered through the gastrostomy ([G-tube] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This failure had the potential to result in severe stomach irritation or reduced medication effectiveness.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders for an orthopedic surgeon (specialist in bones, joints, and muscles) and vascular specialist (specialist in blood vessels and circulation) was carried out and/or follow-up was made for one of four sampled residents (Resident 1) who had dry gangrene (tissue death caused by loss of blood supply) of the left finger. These failures resulted in a two-week delay in obtaining Resident 1's ordered consultations and placed Resident 1 at risk for worsening gangrene, auto-amputation (dead portion may fall of on its own due to lack of blood supply) of the left finger, and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when:There was trash of paper, plastic and soiled gloves left in the bottom of 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)One trash can was not covered and has no lid near the residents' refrigerator in Hall 1 when actively not used. These failures had potential to attract birds, flies, insects, pests and possibly spread infection to 129 of 129 facility residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care in a manner that promoted dignity and respect by failing to ensure residents were served in China wares during lunch time. This deficient practice had the potential to affect 116 of 129 residents' self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to formulate Advance Directives ([AD]-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) correctly in the medical records for three of 14 sampled residents (Resident 7, 15 and 126) by not:Completing the AD form for Resident 7Completing the AD form for Resident 15Providing written information to Resident 126 and/or responsible parties and had a completed AD Acknowledgement/Physician Orders for Life-Sustaining Treatment ([POLST]- a medical order that helps give people with serious illness more control over their care during a medical emergency)These failures had the potential for delay of care and treatment and/ or inadvertently missed health care wishes/ decisions of the residents during emergencies, end of [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (meal tickets) containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were not shredded prior to disposing in the waste container. This failure had the potential to violate 116 of 129 residents' rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of six sampled residents (Resident 9, Resident 46 and Resident 56)'s Preadmission Screening and Resident Review (PASARR, a screening that helps decide whether a person moving into a nursing home has a serious mental illness, an intellectual disability, or another condition that needs special care.) was complete correctly. This failure had the potential to affect Resident 9, 46 and 56's care and treatment.

Inspectors wroteBased on interview and record review the facility failed to to ensure:a. Residents' care plans were implemented for two of four sample residents (Resident 9 and 46).b. Ensure resident's request for hospice (end of life care ensuring the person feels comfortable and supported) care for one of four sampled residents (Resident 89). These deficient practices resulted in Resident's 9 and 46 not receiving person centered care and Resident 89 not receiving necessary comfort-focused interventions, pain management supports, and coordinated end of life services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 10 sampled residents (Residents 9, 6, and 136) received appropriate services to prevent a decline in joint range of motion (ROM, full movement potential of a joint) and mobility by failing to:1a. For Resident 9, put on right and left ankle foot orthosis (AFO, an orthotic device designed to correct or address problems with the ankle and foot) during Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment for no more than three hours, as ordered by a physician.1b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and appropriate management of enteral tube feeding (a method of delivering liquid nutrients, fluids, and medications directly into the stomach or small intestine via a flexible tube) and hydration bag for two of five sampled residents (Resident 11 and 129) by failing to:Ensure Resident 11's hydration bag did not run for more than 24 hours against the physician's order. Ensure Resident 129's tube feeding was labeled including date and time the formula was hung/administered. These deficient practices had the potential to increase the risk of infection prevention and compromised resident health.a. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide medically related social services (professional interventions provided by social workers to help residents manage the emotional, social, and financial impacts of illness) for two of five sampled residents (Resident 2 and Resident 8) as evidence by:A. Failing to initiate conservatorship [ a court-ordered arrangement where a judge appoints a responsible person or organization (conservator) to manage the financial affairs and/or daily care of an adult (conservatee) who is unable to do so themselves due to physical or mental limitations] or public guardian (a court-appointed official or agency that acts as a conservator for individuals unable to care for themselves or manage their finances due to age, illness, or incapacity) to protect Resident 2 who had no mental capacity (ability) to make decisions. B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when:The Dietary Supervisor (DS) was unable to verbalize the International Dysphagia Initiative/Level 4 ([IDDSI] level 4 testing process-cohesive, pudding-like foods and liquids that hold their shape on a spoon, require no chewing, and do not flow easily) diet. Cooks (Cook 1 and [NAME] 2) were unable to verbalize proper thawing of food in the sink. Dietary Aide (DA) 1 unable to verbalize Quaternary Ammonium Compounds (QUAT, a chemical used a disinfectant, sanitizer to kill bacteria and viruses) sanitizer ratio with water. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the methods that conserved appearance and temperature for lunch when hot food (chili) served on paperwares was not hot, cold foods were not served cold, and tossed green salad was watery. This failure had the potential to result in decrease in food intake to 116 of 129 residents on regular and therapeutic diets, resulting in unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when pureed chili was too sticky and left a thick film during a spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together) and pureed tossed salad was too watery. These failures had the potential to result in difficulty in swallowing, decrease in food and nutrient intake to 13 of 129 residents on puree diet, resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).

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:One (1) of four (4) racks in the walk-in refrigerator had rust and amber discoloration. Kitchen equipment and utensils were not free from dirt, dust and food debris. Vent in the walk-in refrigerator had dust buildup. Walk-in refrigerator wall had dressing spillsWalk-in freezer wall had a black dirt spill coming from the ceiling and the racks had dirt, dust, and food particles in the walk-in freezer. Corn starch spilled into the lentil's container. Pans had burnt plastic debris and sticker residue. Two (2) of three (3) food warmers had food and dirt debris. Six (6) of 6 dented cans were stored with non-dented cans. Pots and pans were stacked wet in the storage area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures by failing to:A. Ensure a visitor was wearing Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) properly for Resident 35 who was on Enhanced Barrier Precaution [EBP-an infection control measures, primarily in nursing homes, requiring staff to wear gowns and gloves during high-contact care for residents with multidrug-resistant organisms or increased risk factors like wounds/devices, expanding beyond Standard Precautions to prevent multidrug-resistant organism(MDRO) spread where direct contact is likely]. B. Ensure padded side rails that were wrapped with porous (having minute spaces or holes through which liquid or air may pass) foams were disinfected properly for Resident 59. [...]

Inspectors wroteBased on interview and record review, the facility failed to:Obtain an informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their authorized responsible party (RP - a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment with Abilify (a medication used to treat mental illness) for one of five residents sampled for unnecessary medications (Resident 2.)Obtain a new informed consent pursuant to a dosage increase for Cymbalta (a medication used to treat mental illness) for one of five residents sampled for unnecessary medications (Resident 111.)These deficient practices of failing to obtain informed consent prior to initiating treatment with psychotropic (medications that affect brain activities associated with mental [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor for adverse effects (unwanted or dangerous medication-related side effects) related to the use of Cymbalta (a medication used to treat mental illness) between 11/2/25 and 2/24/26 in one of five residents sampled for unnecessary medications (Resident 111.)The deficient practices of failing to monitor adverse effects related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) increased the risk that Resident 111 could have experienced adverse effects related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in his mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and report a change in condition for one of five sampled residents (Resident 89) when Treatment Nurse (TXN) 1 identified multiple open areas of skin breakdown on the resident's arm, did not complete an assessment or notify the physician. This deficient practice had the potential to delay medical evaluation and treatment and increased the risk of infection for Resident 89

Inspectors wroteBased on observation, interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS], a resident assessment tool) for one of three sampled residents (Resident 37) who had a suctioning machine (a medical device designed to remove obstructions such as mucus, blood, saliva, or vomit from a person's airway, for easier breathing) at the bedside. This deficient practice had the potential to result in inaccurate assessment and services for the residents due to inaccurate MDS assessment and care screening tool practices.

Inspectors wroteBased on observation, interview, and record review, the facility failedto develop communication barrier care plans for two out of four sampled residents (Residents 42, 112). to ensure residents' care plans were implemented for two of four sample residents (Resident 9 and 46). These failures affected Resident 9, 42, 46, and 112's care and safety.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the comprehensive person-centered care plan was revised to include the intervention no blood pressure on left arm after one of five sampled residents (Resident 16) received an arteriovenous (av) shunt (device that connects an artery and vein) for hemodialysis (dialysis treatment to clean blood and remove excess fluids because the kidneys failed). This failure had the potential to place the resident at risk for av shunt failure, clotting, and bleeding. During an observation on 02/23/2026 at 3:25 p.m., at Resident 16's bedside, Resident 16 was observed with dialysis access on the left upper arm and right chest. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 112) had a communication board (a tool that helps residents, especially those who have trouble speaking, share their needs. It usually has simple words, pictures, or symbols that residents can point to.) This failure had the potential to negatively affect Resident 112's care and treatment.

Inspectors wroteBased on interview, and record review, the facility failed to Identify and to intervene for one of three sampled residents (Resident 6) history of trauma and triggers which may cause re-traumatization (a person encounters a new event or stimulus that triggers them to re-experience the intense stress, emotional distress, and even flashbacks of a previous traumatic event as if it were happening again). This failure had the potential to result in Resident 6 experiencing re-traumatization.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 140)'s History and Physical (H&P) was completed within 72 hours per the facility policy. This failure had potential to affect Resident 140's care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for one dose of alprazolam (a controlled medication used to treat mental illness) 0.5 milligrams (mg - a unit of measure for mass) for one of one residents (Resident 117) in one of four inspected medication carts (Medication Cart 3.)This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations (medications with a high risk for diversion) and the risk that Resident 117 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. During a concurrent observation and interview on 2/24/26 at 11:45 a.m. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled resident's (Resident 1) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for a psychotropic (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication was obtained prior to administration of the medication to Resident 1. This deficient practice violated Resident 1 rights to receive information, in advance, of risks and benefits of proposed care, treatment, treatment alterative, and choose the alterative of choice which includes information for administration of psychotropic drugs.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one resident (Resident 1) was seen by a psychologist (medical doctor who can diagnose and treat mental health conditions) as physician ordered. The deficient practice resulted in Resident 1 not being assessed and treated (as needed) by a psychologist while in the facility, with the potential for untreated mental health decline.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one resident's (Resident 1) Permethrin shampoo (medication for head lice [tiny crawling insects]) ordered on 12/26/2025 was dispensed by the pharmacy and administered in a timely manner. The deficient practice resulted in a delay of care and Resident 1 was not treated for head lice until 12/29/2025, three days after head lice infestation was identified, which has the potential to cause uncomfortable itching and loss of sleep for the Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to ensure sanitary conditions were maintained by preventing a cockroach infestation in the facility. This deficient practice resulted in the facility's kitchen being closed for use to residents on 12/10/2025, and roaches being observed in the rooms of two of two sampled residents (Resident 1 and Resident 2). This deficient practice placed 135 residents, who resided at the facility and ate food from the facility's kitchen, at risk of contracting serious diseases and allergies.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was protected when Resident 1 reported to Certified Nursing Assistant (CNA) 4 that she had been struck/hit, after CNA 4 found Resident 1 with bruising to the right side of her chin. On 9/14/2025 during the 11 a.m. to 7 a.m. shift, while receiving care, Resident 1 told CNA 1 the guy had two fist towards her cheek. CNA 1 later that evening, observed Registered Nurse (RN) 1 rough handling Resident 1, while providing care, and later observed redness to Resident 1's left and right cheeks. These deficient practices resulted in Resident 1 being left unprotected after making an allegation of abuse and placed her at risk for continued abuse.

Inspectors wroteBased on interview and record review, the facility failed to report suspected abuse for one of three sampled residents (Resident 1) when Resident 1 was found with a bruise to her right and left cheek. This deficient practice resulted in the inability of the California Department of Public Health (CDPH) to conduct an effective investigation due to the potential for information to be lost and/or forgotten.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for one of three sampled residents (Resident 1) when Resident 1 was found with a bruise on her right and left cheek. This deficient practice resulted in the inability of the facility to determine how bruising on Resident 1's face occurred and placed Resident 1 at risk for continued injury/abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who displayed behaviors of uncontrollable singing, and was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment, was allowed to return to the facility once the GACH cleared her for discharge back to the facility. This deficient practice resulted in Resident 1 remaining in the GACH for 21 days after attempts to transfer her back to the facility were made by the GACH. This deficient practice placed Resident 1 at risk for disruption in her routine, anxiety and non-continuity of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care provided to one of three sampled residents (Resident 1) was completed in a timely manner and under appropriate conditions. This deficient practice resulted in rounds not being completed and care not being provided to Resident 1 until approximately four hours after the 11 p.m. to 7 a.m. shift began on 9/14/2025 and when care was provided at approximately 3 a.m., (9/14/2025), it was done with the lights off/dimmed with staff unable to determine Resident 1's status. This deficient practice placed Resident 1 at risk for an unrecognized change of condition (COC).

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown injury for one sampled resident (Resident 1) when Certified Nursing Assistant (CNA) 1 identified an area of discoloration on Resident 1's left lower jaw. This deficit practice resulted in a delayed investigation by the California Department of Public Health (CDPH) into Resident 1's injury of unknown origin and had the potential for information/facts to be lost and/or forgotten. Findings During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) physician progress notes were readily accessible. This deficient practice had the potential to result in a delay in the delivery of care and necessary services for Resident 1.

Inspectors wroteBased on observation, interview, and record review, The facility failed to respect residents' right to receive visitors without limitation. This failure has the potential to disrupt resident's psychosocial well-being, cause emotional distress, and negatively affect the quality of care provided. During an interview on 7/8/2025 at 7:25 a.m. with Receptionist 1, Receptionist 1 stated that they recommended two visitors per resident to prevent the room being crowded. During a concurrent observation and Interview on 7/8/2025 at 12:38 p.m. with Receptionist 2 at the facility entrance, observed one signage on the receptionist's desks stating, only two people allowed in residents room per visit. Receptionist 2 stated that the facility limits visitors to two people per visit and the facility remained the sign on the receptionist's desk for several years. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow facility's own restraint policy for one of three sample residents (Resident 2) by not:a. trying alternatives prior to use of abdominal binderb. completing the informed restraint consent.c. monitoring every 30 minutes while on use.d. developing a care plan for abdominal binder (a supportive garment that wraps around the abdomen and provides compression and support) restraint (limiting or controlling something, whether it's a person's actions, emotions, or physical movement). These deficient practices have the potential to place the residents at risk for unnecessary prolonged use of restraints and can lead to a decline in physical functioning, and residents not being treated with respect and dignity with the use of restraints. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- a resident assessment tool) related to restraints and alarms was accurately documented for one of two sample residents (Resident 2). This deficient practice had the potential to negatively affect Resident 2's plan of care and delivery of necessary care and services. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 5/9/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a common lung disease that makes it hard to breath), and dysphagia (difficulty swallowing) with gastrostomy (a surgically created opening into the stomach, often for the purpose of inserting a feeding tube). [...]

Inspectors wroteFacility failed to assess comprehensively one of three sampled residents (Resident 2) by not assessing and monitoring Resident 2's toenail detachment status after it began bleeding for five days. This failure had the potential to delay necessary medical intervention, leading to complications such as infection, pain, or further injury. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 5/9/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a common lung disease that makes it hard to breath), dysphagia (difficulty swallowing), type two diabetes mellitus (a condition where the body does not use insulin properly, and our blood sugar levels become too high), the admission record also indicated that long term use of anticoagulants (blood thinners). [...]

Inspectors wroteBased on interview and record review, the facility failed to turn and reposition two of three sampled residents (Resident 5 and 6) with pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) every two hours and/or as needed. These deficient practices placed Resident 5 and 6 at risk for poor wound healing.

Inspectors wroteBased on interview and record review the facility failed to complete and document a comprehensive assessment (a complete head to toe physical evaluation), blood pressure (measurement of amount of force your blood uses to get through your arteries), heat rate, temperature, and blood glucose (amount of sugar in the body) measurements after one of one sampled resident (Resident 1) vomited. These deficient practice had the potential to result in delay of care and services which can result in poor health outcomes.

Inspectors wroteBased on interview and record review the facility failed to ensure medication administration was documented in the Medication administration Record for one of two sampled residents (Resident 1). These deficient practice resulted in an incomplete depiction of care and services provided to Resident 1 which can result in poor health outcome.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident who was unable to carry out activities of daily living received care services to maintain good personal hygiene for one of three sampled residents (Resident 1) who was left with soiled gown and dry blood on her right nostril for long hours. This deficient practice had the potential to result in a negative impact on Resident 1's quality of life and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to effectively manage residents ' pain before wound treatment for one of four sampled residents (Resident 1) by: 1. Administer Tramadol ( medication used to relieve moderate to moderately severe pain) prior to wound care treatment on 5/28/2025 per physician order. 2. Failing to identify and assess the resident's pain level after the administration of routine medication for Resident 1. These deficient practices resulted in Resident 1 ' s experiencing unrelieved pain during wound treatment and personal care on 5/28/2025.

Inspectors wroteBased on interview and record review, the facility failed to ; A.Assess and fix a malfunctioning bed in a timely manner for one of one residents (Resident 114). This failure had the risk for fire and the potential to place all residents at risk for injury. B. Provide adult briefs (disposable absorbent underwear) that comfortably fit for one of three sampled residents (Resident 233). This failure had the risk for fire and the potential to place Resident 114 at risk for injury and result in skin breakdown and lowered self esteem for Resident 233.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accurate resident assessments, and that assessment status' were reflected on medical records for two of three sampled residents (Resident 130 and Resident 103) by: A. Failing to provide accurate information in the Minimum Data Set ([MDS], a resident assessment tool) assessment for one of three sampled residents (Resident 130) when resident was discharged to home. B. Failing to ensure the bowel and bladder assessment entries on the Minimum Data Set (MDS- a resident assessment tool) was accurately reflected and documented for Resident 103. These failures had the potential to result in a negative effect on Resident 130 and Resident 103's plan of care and delivery of necessary services, care, and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of five sampled residents (Resident 84 and Resident 17) had their Level 1 Preadmission Screening and Resident Review ([PASRR], is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) completed accurately. This deficient practice had the potential to delay care for Resident 84, and Resident 17 and had the potential that they would not receive the proper level of care or services they required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of five sampled residents (Resident 3 and Resident 40) as evidenced by: A. Failing to ensure a replacement tracheostomy (an incision in the trachea [windpipe] made to relieve an obstruction to breathing) tube, an inner cannula (a removable tube that fits inside the outer cannula of a tracheostomy tube, allowing for easy cleaning and replacement to maintain a clear airway), and an obturator (a thin, curved piece of hard plastic or rubber that is inserted into the tracheostomy tube [cannula] to help with placing the tube into the trachea) were available at the bedside for Resident 3. B. Failing to ensure there was a physician order to administer oxygen (life sustaining element of air) for one of three sampled residents (Resident 40). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of medication error rate of five percent (5%) or greater, as evidenced by the identification of two medication errors out of 26 opportunities (observations during medication administration), to yield a cumulative error rate of 7.69% for one out of five residents (Resident 186) observed during the medication administration facility task when: 1. Licensed Vocational Nurse (LVN) 2 did not monitor Resident 186 during two separate, breathing treatments of Ipratropium-albuterol solution inhalation solution and Budesonide inhalation suspension (medications to help control symptoms of lung diseases) via nebulizer (a device that converts liquid medication into a mist that can easily be inhaled to treat wheezing, shortness of breath, and other respiratory issues) . 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 71), was free of significant medication error. The facility failed to ensure Resident 71 was not administered three doses of expired Advair (fluticasone and salmeterol, is a combination inhaler medication used to treat asthma and chronic obstructive pulmonary disease (COPD) by opening airways and reducing inflammation) Diskus (a dry powder inhaler), by three different licensed nurses between [DATE] - [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 114 out of 130 total residents in the facility by not: A. Ensuring food Items were dated, labeled, and sealed properly. B. [...]

Inspectors wroteBased on observation. interview and record review, the facility failed to implement infection control measures by failing to: A. Ensure padded side rails (a padded side fitted to a bed for safety) that were wrapped with foam (a soft, porous material, and the degree of porosity can vary depending on the type of foam) and paper tape were disinfected (the process of cleaning something, especially with a chemical, to destroy bacteria) properly for one of three sampled residents (Resident 70). B. Ensure Treatment Nurse (TN)1 performed hand hygiene while she was checking lunch trays in dining room. C. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to treat one of eight sampled Residents (Resident 37) with dignity and respect while providing feeding assistance. This deficient practice had the potential for Resident 37 to feel rushed while eating, uncomfortable, and disrespected.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of eight sampled residents (Resident 87) was accurately screened for a level one Pre-admission Screening and Resident Review (PASRR, a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care). This deficient practice had the potential for Resident 87 not to receive the necessary care and services for mental health.

Inspectors wroteBased on observation, interview and record review, the facility failed to update the care plan when oxygen (life sustaining component of air) requirements changed for one of three sampled residents (Resident 40). This failure had the potential to result in Resident 40 receiving excessive oxygenation resulting in hypercapnia (elevated carbon dioxide (CO2 waste product of processed oxygen that must be exhaled) in the blood) which can lead to discomfort, difficulty breathing, and causing injury to the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 35) medication was ordered appropriately for their diagnosis who was on quetiapine fumarate ([Seroquel], medication used to treat the symptoms of schizophrenia, bipolar disorder and depression, which are mental illnesses that cause disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) for schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder). This deficient practice had the potential to result in Resident 35 to experience adverse (unwanted or dangerous medication side effects) effects of Seroquel and to continue receiving medication that was not ordered appropriately for the diagnosis.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a.the facility failed to ensure one of one (Resident 114) did not store TUMS (over- the-counter (OTC) antacids [medication used to relieve heartburn and indigestion) at bedside in accordance with the facility's policy. This failure had the potential for Resident 114 to be at risk for medication interactions, Resident 114's physician missing symptoms that the resident is self-treating, abusing the medication, and possible overdose. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Dental services, revised 12/2016, which indicated routine and emergency dental services were available to meet residents' oral health services in accordance with the resident's assessment and plan of care by not replacing missing dentures and following up after a dental visit for one of three sampled residents (Resident 66). This deficient practice had the potential to result in Resident 66 having discomfort while eating or chewing foods that could lead to unintended weight loss and lower self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Store two of three sampled residents' (Resident 4 and 6) discontinued orders for controlled substances securely in the Director of Nursing's (DON) office as required by the facility's policy and procedure. 2. Maintain documentation and accuracy of Resident 4's controlled dug record. The deficient practice of failing to accurately account for controlled substances increased the risk that may have received controlled medications more often than prescribed possibly causing medical complications. The deficient practice of failing to store discontinued orders for controlled substances securely per facility policy increased the risk of diversion (when medications are obtained or used illegally).

Inspectors wroteBased on interview, and record review, the facility failed to ensure a care plan was developed for one of three sampled residents (Resident 1) who was prescribed Lidocaine patches (a medicated patch used to relieve pain) for pain to her left knee and left shoulder. This deficient practice resulted in the facility's inability to determine the need to adjust Resident 1's Lidocaine administration and had the potential for mismanagement of Resident 1's pain regimen.

Inspectors wroteBased on interview and record review, the facility failed to follow up and accurately assess the Preadmission Screening and Resident Review ([PASARR]- a comprehensive evaluation that ensures people who have been diagnosed with serious mental illness, intellectual, and/or developmental disabilities are able to live in the most independent settings while receiving the recommended care and interventions to improve their quality of life) Level I and Level II evaluation for eight of nine sampled residents (Resident 4, Resident 117, Resident 32, Resident 54, Resident 66, Resident 29, Resident 71 and Resident 113) to determine the facility's ability to provide the special need of the residents.] This deficient practice placed (Resident 4, Resident 117, Resident 32, Resident 54, Resident 66, Resident 29, Resident 71, and Resident 113 at risk of not receiving necessary care and services they [...]

Inspectors wroteBased on interview and record review the facility's Quality Assessment and Assurance (QAA) Committee, (group of staff which is responsible in identifying and responding to quality deficiencies throughout the facility) failed to implement corrective action (a written and implemented plan of action for correcting or improving performance in response to an identified quality deficiency) to the systemic problems identified: 1. Weight loss, treatment/wound care. 2. Residents food preferences. 3. Pain medication orders not being followed. 4. Staffing hours posting. 5. Basic life support training/certificate taken online. 6. Preadmission Screening and Resident Review (PASARR) 7. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 2/27/24 when: 1. Faciltiy failed to ensure four residents on dysphagia mechanical soft diet (food that are moist, mechanically altered and forms a cohesive bolus requiring little chewing and not fall apart when swallowed, ground the meat or fish and serve with gravy or sauce, vegetables should be cooked soft to a mashable texture) received fish italiano texture in form that meet their needs instead they received flaked fish italiano instead of ground fish italiano according to the dysphagia mechanical soft diet spreadsheet (food portion and serving guide) and menu. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four of four sampled residents (Resident 66,82,111 and 53) were served the food preference listed on the lunch meal ticket (physician ordered diet with resident food preferences) and received substitute meal options of similar nutritive value when: 1. Two residents (Resident 66 and Resident 82) food preference were not honored when fish was served during lunch, despite fish being listed as a dislike on resident's lunch meal ticket/tray card. 2. One resident (Resident 111) who was on pureed diet (food that is blended to a pudding consistency, no chewing required) and dislikes fish, received only puree spinach and puree mashed potato with no alternate protein choice. 3. [...]

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. Several food items were not dated in the reach in refrigerator, five ham and cheese sandwich, two tuna salad, two egg salad, three chicken salad and two peanut butter and jelly sandwiches were stored in the reach in without dates. One cottage cheese and fruit plate were stored in the reach in refrigerator with a date of 2/24/24 exceeding storage periods for ready to eat food. Nutrition supplement labeled store frozen with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster (a movable waste container) areas was maintained in sanitary manner when two of three garbage dumpsters had the lids open, one dumpster was propped open with a stick and one trash dumpster was overfilled with cardboard boxes and uncovered. This deficient practice had the potential for harborage and feeding of pests.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident and/or responsible party were informed of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) prior to initiating administration for one of four sampled residents (Resident 81). This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 25 sampled residents was treated with dignity by requiring the resident wear a diaper when the Resident does not have a history of incontinence. This failure resulted Resident 85 felt embarrassed and sad.

Inspectors wroteBased on interview and record review, the facility failed to address a complaint about noise coming from Resident 87 on one of five residents (Resident 2) who had a diagnosis of circadian rhythm sleep disorder(conditions that disrupt or affect your body's natural sleep-wake cycle). This failure resulted in Resident 2's inability to sleep at night and caused a feeling of anxiety every time Resident 2 thought about the return of the discharged resident (Resident 87).

Inspectors wroteBased on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and a care screening tool) related to urinary and bowel continence status was accurately documented to reflect the resident's continence for one of 24 sampled residents (Resident 85). This deficient practice had the potential to negatively affect Resident 85's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 25 sampled (Resident 55) had a baseline care plan developed and implemented for incontinence of bowel and bladder. This failure resulted in Resident 55 not receiving the necessary care and services needed for bowel and bladder training.

Inspectors wroteBased on interview and record review the facility failed to ensure assistance was provided to maintain continence and implement a bowel and bladder program for two of 25 sampled Resident (Resident 55 and Resident 85). This deficient practices resulted in declining in bowel and bladder function for Resident 55 and Resident 85.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure was served food that was appetizing, not bland and tasteless, and assess for food preferences and provide supplements for two of 25 sampled resident (Resident 29 and Resident 71). These deficient practices had the potential for further weight loss for Resident 29 and Resident 71 and continue to have poor food intake of less than 50% for multiple meals.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five nursing staff had specific competency and skill necessary to care for residents' needs by failing to: a. Ensure Certified Nursing Assistant (CNA 4) was up to date and current with Basic Life Support Certification (BLS- training to equip healthcare professionals the necessary skills to respond to life threatening or emergency situations). This deficient practice had the potential for CNA 4 unable to help residents in the facility whose wish to have full code (full support which includes cardiopulmonary resuscitation (CPR), if the patient has no heartbeat and/or is not breathing) during a life-threatening situation, where these skills are needed to be applied.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was posted and placed in a visible and prominent place in the facility. This failure resulted into the total number of staff and actual hours worked by staff not readily accessible to residents and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen staff were competent in safe and effective food preparation and handling practices when: One cook did not monitor cooked roast beef for safe cool down process and storage (hot food cooled down within a certain time frame to prevent harmful bacterial growth). This deficient practice had the potential to result in unsanitary food production and storage that could lead to foodborne illness (infectious organisms or their toxins are the most common causes of food poisoning with symptoms that may include cramping, nausea, vomiting (throwing up) or diarrhea (loose stool) including death) of 115 out of 125 residents who received food from the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures on two of six sampled residents (Resident 5 and Resident 117) by failing to: a. Practice hand hygiene during wound care treatment (procedure that involves assessing, cleaning wounds, performing dressing change and implementing interventions to promote wound healing) on Resident 117. b. Dispose isolation gowns (garment that protects healthcare worker against potential contamination from bodily fluids and infectious materials) properly that were used on Resident 5 and Resident 117 during wound care treatment. These deficient practices had the potential to spread infection among residents and staff. a. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for antibiotic stewardship (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use ) for one of two sampled residents (Resident 39) by prescribing antibiotic ( drug that treats infection) without meeting the criteria (checklist used for infection surveillance), for urinary tract infection ([UTI]an infection in any part of the urinary system). This deficient practice had the potential for Resident 39 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide physician ordered pressure ulcer (skin injury from prolonged pressure on the skin and tissue underneath) treatments for two of three sampled residents (Resident 1 and 3) when Licensed Vocational Nurse 1 (LVN 1): a. used wound cleanser spray (medication to allow fast, thorough, and gentle cleansing of wounds) instead of normal saline (a liquid mixture of sodium chloride (salt) and water) during wound care for Resident 1 and 3. b. failed to apply betadine (topical antiseptic [substance that stops or slows the growth of germs]) directly to both heels for Resident 3. This deficient practice had the potential to result in a delay in wound healing and increased risk of infection for Resident 1 and 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nine medication tubes were labeled according to the facility ' s policy and one container of Hydrogel 110 grams (unit of measurement) (aloe-based product designed for advanced wound care and relief) was not stored after the container ' s expiration date in one of two treatment carts (treatment Cart 2). This deficient practice had the potential to cause medication administration errors and possible administration of expired medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures by: a. Failing to ensure Certified Nursing Assistant (CNA) 1, CNA 2 and Licensed Vocational Nurse (LVN) 1 donned (put on) an isolation gown while providing direct care for two of three sampled residents (Resident 1 and 2) who were on enhanced precautions (an approach of gown and glove use during high contact resident care activities, designed to reduce transmission of infections). b. Failing to ensure LVN 1 followed infection control process while providing wound treatments for two of three sampled residents (Resident 1 and 3). These deficient practices had the potential to increase the risk of infection for Residents 1, 2, and 3. Findings a. [...]