Chapman Global Medical Center D/P SNF

Inspectors wroteBased on observation, interview, medical record review, and facility's P&P review, the facility failed to provide a homelike, clean and comfortable environment for five of ten residents rooms. * The facility failed to ensure Resident 8's room was free with water mark discoloration in the ceiling. In addition, the facility failed to ensure the window blinds for rooms [ROOM NUMBER] were not missing panels. * The facility failed to ensure Resident 9's privacy curtains were well maintained and not off the hook. * The facility failed to ensure Resident 23's GT feeding pole stand was clean and free from brownish, dirt like particles. * The facility failed to ensure the window blinds for room [ROOM NUMBER] were not missing panels. These failures had the potential for the residents to not have a clean, comfortable, homelike environment and could negatively affect the residents' well-being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure three of five licensed nurses (LVNs 7, 8, and 10) demonstrated the competencies needed to provide safe nursing care. * LVNs 7, 8, and 10 failed to disconnect the residents from the GT extension tubing when the residents' GT feeding reached the formula dose limit or after the feeding formula was completed. These failures had the potential to put the residents at risk for enteral feeding care not provided in a safe and competent manner. Findings Review of the facility's P&P titled Enteral Feeding revised 12/2020 showed to review the order for feedings such as formula, dose limit, rate, and number of hours for infusion per physician orders. In addition, to check the GT placement by auscultating air and to check feeding residual by aspirating stomach content. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services for five of 12 final sampled residents (Residents 3, 12, 13, 20 and 21), five nonsampled residents (Residents 5, 9, 10, 16, and 18) and for three of seven medication carts (Medication Carts A, C, and D) to ensure proper storage and labeling of the medications. * Medication Cart A had multiple colored stains, dust and rust-like particles. Additionally, there were expired wound supplies and culture and sensitivity tests. * Medication Cart C had internal and external medications stored together in the same drawer. Additionally, Resident 3's Lantus medication was expired. * Medication Cart D had rust on the mid-base of the first drawer. [...]

Inspectors wroteBased on interview and facility P&P review, the facility failed to ensure safe food handling of the food brought for the residents from outside sources. * The facility failed to ensure the facility staff members who handled the outside food demonstrated competency on safe food handling procedures. This failure posed the risk of food contamination which could lead to food borne illness for three residents who consumed food by mouth.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to implement the infection control surveillance program for the months of October 2025 through March 2026. The facility conducted surveillance of the residents infections only when the residents were prescribed an antimicrobial medications and/or if the residents were diagnosed with an infection. * The facility failed to determine whether the residents who exhibited signs and symptoms of infection and were not prescribed antimicrobial medications, or had not been diagnosed with an infection, met the facility's criteria for infection (utilizing McGeer's Criteria). [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the dignity was maintained for one of 12 final sampled residents (Resident 6) and one nonsampled resident (Resident 14). * The facility failed to ensure Resident 6's and 14's indwelling urinary catheter drainage bag was covered. This failure had the potential to affect the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility's P&P review, the facility failed to ensure one of five residents (Resident 7) reviewed for the unnecessary medications was free from the unnecessary psychoactive medications. * The facility failed to ensure an informed consent was completed prior to Resident 7's use of valproic acid (mood stabilizer) as manifested by angry outburst and duloxetine (antidepressant) medications. These failures had the potential for the resident to receive unnecessary medications and negatively affect the resident's health. Findings Review of the facility's P&P titled Psychoactive/Chemical Restraint dated 3/2026 showed the residents will receive psychoactive medications only when they are necessary to treat medical, mood, behavioral or psychiatric symptom. To obtain informed consent from resident's rep if resident lacks decisional capacity. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure privacy was provided during care to one of 12 final sampled residents (Resident 12) and two nonsampled residents (Residents 9 and 23). * The facility failed to ensure the privacy curtains were fully closed during the medication administration to Resident 9. * The facility failed to ensure the privacy curtains were fully closed during the tracheostomy care and suctioning to Residents 12 and 23. These failures had the potential to negatively affect the dignity of the residents and violate the residents' rights to privacy.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for one of 12 final sampled residents (Resident 2). * The facility failed to ensure Resident 2's injection sites were rotated for the administration of the Lovenox (blood thinner medication) and insulin medications. This failure had the risk for lipodystrophy (buildup of fatty lumps) and decreased the medication absorption.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the risk and development of pressure injuries for two of 24 (Residents 2 and 20) residents in the facility. * The facility failed to ensure Resident 2's low air loss mattress setting was accurate and failed to obtain a physician's order for the low air loss mattress setting. * The facility failed to ensure Resident 20's low air loss mattress setting was accurate per the physician's order. These failures placed Residents 2 and 20 at risk for the development or worsening of pressure injuries.

Inspectors wroteBased on interview, observation, and medical record review, the facility failed to provide the appropriate restorative care and services for one of 12 final sampled residents (Resident 24). * The facility failed to provide a left soft hand roll to Resident 24 as per the physician's orders. This failure posed a risk for Resident 24 to have decreased range of motion and mobility.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of 12 final sampled residents (Resident 4). * The facility failed to ensure Resident 4's upper side rail pads were in place as per physician's order for safety/seizure precautions. This failure had the potential to put the resident at risk for serious injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for the use of an indwelling urinary catheter for one of three final sampled residents (Resident 3) reviewed for indwelling urinary catheter care. * The facility failed to ensure Resident 3's indwelling urinary catheter had no sediments in the tubing. In addition, the facility failed to notify the clinician when Resident 3 had sediments in the indwelling urinary catheter. These failures had the potential for Resident 3 to develop complications associated with the use of indwelling urinary catheter.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for the use of the GT (Gastrostomy Tube) for two of 21 residents (Residents 3 and 20) with GT feedings. * The facility failed to ensure Resident 3's GT extension feeding tube was disconnected after their tube feeding formula was completed. * The facility failed to ensure Resident 20's GT extension feeding tube was disconnected after their tube feeding formula was completed. These failures posed the risk of tube clogging, leaking, not functioning properly, and for developing bacterial growth (infection) for Residents 3 and 20.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management was provided for one of five final sampled residents (Resident 3) reviewed for unnecessary medications. * The facility failed to assess Resident 3's pain prior to the administration of morphine (pain medication). In addition, the facility failed to reassess Resident 3's pain after the administration of morphine. These failures had the potential to put the resident at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to two of 12 final sampled residents (Residents 2 and 7). * The facility failed to monitor for adverse effects for Resident 2's anticoagulant medication and failed to obtain a physician's order to monitor the anticoagulant medication use. * There was no evidence nonpharmacological interventions were ordered, performed and documented for Resident 7's use of psychoactive medications. These failures had the potential to result in unnecessary use of, ineffective and/or lack of monitoring or interventions for psychotropic and anticoagulant medications that could negatively affect the residents highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for one of 12 final sampled residents (Resident 3). * The facility failed to ensure the physician's orders for Resident 3's code status was accurate. Resident 3's code status showed full code status; however, Resident 3's POLST showed she was a DNR status. In addition, the facility failed to ensure the physician's order for precautions for Resident 3 was accurate. A contact precaution was ordered; however, Resident 3 no longer needed contact precautions. These failures had the potential for the residents' care needs not met as the medical record was inaccurate.

Inspectors wroteBased on interview and medical record review, the facility failed to provide necessary care and services to ensure the residents maintained their highest physical well-being for five of five sampled residents (Residents 1, 2, 3, 4, and 5). * Resident 1 had fracture of the right upper arm. There was no monitoring for pain, redness, swelling and warmth of extremities. * The facility failed to follow the physician's order for PT and OT treatment for Resident 1 and OT treatment for Resident 4. * The facility failed to follow the physician's order for daily RNA services for Residents 1, 2, 3, and 5. These failures had the potential for delayed medical interventions and could negatively impact the residents well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of two sampled residents (Residents 1 and 2) who were dependent on the ventilator with tracheostomy for breathing. * The facility failed to ensure Resident 1's ventilator circuit was effectively monitored. As a result, the resident experienced the respiratory arrest. * The facility failed to ensure the P&Ps for respiratory care and services were followed for Resident 2 when the oxygen therapy and a part of the disposable ventilator circuit was replaced and rinsed by a non-qualified personnel. These failures posed the risk of delayed care and interventions for the residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to promote healing of the pressure injuries for one of two final sampled residents (Resident 18) reviewed for pressure injuries. * The facility failed to ensure Resident 18's air mattress was set at the alternate mode (setting where mattress inflates and deflates with air cyclically to redistribute pressure on the body) as ordered by the physician. This failure had the potential to inhibit the pressure injury healing.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure two of two final sampled residents (Residents 9 and 11) reviewed for RNA services received the RNA services as ordered. * The facility failed to ensure Residents 9 and 11 received the RNA services daily as ordered by the physician. This failure had the potential for the residents to have a decline in ROM function, which could lead to worsening of contractures or muscle weakness.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for three of 12 final sampled residents (Residents 12, 13, and 21). * The facility failed to ensure the low air loss mattress pump of Residents 13 and 21 was placed in a safe area as per the manufacturer's recommendation. * The facility failed to implement the floor mats to both sides of Resident 12's bed for safety, in accordance with the physician's order. These failures put the residents at high risk of serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of GT were provided for two of 12 final sampled residents (Residents 3 and 13). * The facility failed to ensure Resident 3's HOB was elevated at a 30 degree angle or higher when Resident 3 was receiving the enteral feeding via GT. * The facility failed to ensure Resident 13's HOB was elevated at a 30 degree angle or higher when Resident 13 was receiving the enteral feeding via GT. These failures posed the risk for complications related to use of the GT for Residents 3 and 13.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of 12 final sampled residents (Resident 21). * The facility failed to obtain a physician's order for the care and maintenance of the IV access and develop a plan of care for Resident 21's IV access to the lower extremity. These failures had the potential to delay identification of intravenous access to lower extremity related complications for the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to dispose the unused medication in accordance with the facility's P&P. * LVN 4 disposed Resident 18's unused half tablet fludrocortisone (corticosteroid medication) in a sharps container (container used for the disposal of sharp medical equipment) instead of the pharmaceutical waste container as per the facility's P&P. This failure posed the risk for improper management of pharmaceutical waste.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations from the MRR were acted upon for one of five final sampled residents (Resident 13) reviewed for the unnecessary medications. * The Pharmacy Consultant's recommendation to discontinue the chlorhexidine (antiseptic medication) and perform a hemoglobin A1c level (a blood test that measures the average blood sugar level over the past two or three months) for Resident 13 were not acted upon. These failures had the potential to put the residents at risk for adverse consequences related to the medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8%. * The facility failed to administer Resident 18's lactulose (laxative) and clonidine (antihypertensive) medications as ordered by the physician. These failures had the potential to negatively affect the resident's health.

Inspectors wroteBased on observation, interview and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling and disposal of the medications for two of four medication carts (Medication Carts A and B). This failure posed the risk for the occurrence of errors in medication administration.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure the food preparation utensils and equipment were in good, sanitary, and cleanable working conditions. * The facility failed to ensure the staff's personal food items were not placed in the kitchen refrigerator. * The facility failed to ensure the kitchen staff wore hair restraint. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. Resources necessary to care for residents including weekends; 3. Include a plan to maximize recruitment and retention of direct care staff; and 4. Include a contingency plan for staffing needs. This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices were implemented. * The facility's infection control committee did not meet for one quarter in 2024 to discuss infection control within the subacute unit. This failure posed the risk for transmission of diseases-causing microorganisms and resulted in the committee not being able to discuss quarterly infection control statistics within the subacute unit.

Inspectors wroteBased on interview and facility document review, facility failed to have a full-time, dedicated IP. This failure had the potential for the Infection Prevention and Control Program not being implemented without proper oversight.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the resident's protected health information was utilized in a confidential manner for one of 12 final sampled residents (Resident 10). * Resident 10's protected health information was displayed on a staff computer screen located in the residents' hallway. The facility staff left the computer unattended on two occasions, while Resident 10's protected health information was displayed. This failure had the potential to violate the resident's right to protected health information privacy.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment for four of 12 final sampled residents (Residents 10, 14, 18, and 23). * Resident 23 resided in Room A and Residents 10, 14, and 18 resided in Room B. The walls behind the residents' beds were observed in disrepair as evidenced by holes, scratches, unfinished patchwork, and/or peeled paint. This failure had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the facility's garbage and refuse was properly disposed as evidence by: * The facility failed to ensure two of eight waste dumpsters were properly closed and not overfilled with trash. This failure had the potential to cause unsafe sanitary conditions and potential to harbor pests and rodents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the RNA services were provided as ordered to one of three sampled residents (Resident 3) to prevent a decline in the ROM functions. * The facility failed to follow a physician's order for the RNA to apply the bilateral hand splints, bilateral PRAFOs the to lower extremities, and provide the ROM exercises daily to Resident 3. This failure had the potential for Resident 3 to sustain a decline in the ROM functions, which could lead to the worsening of contractures and muscle atrophy.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure nine of 12 final sampled residents (Residents 3, 7, 11, 12, 13, 15, 19, 20, and 23) remained free from accident hazards. * The facility failed to ensure the residents' side rail paddings were properly placed as ordered by the physicians and residents' care plans for Residents 3, 7, 11, 12, 13, 15, 19, and 20. * The facility failed to ensure an informed consent was obtained, conduct an assessment, and implement the least restrictive measures prior to utilizing the enclosed bed (Posey Bed - a hospital bed with canopy and mattress designed to help provide a safe, controlled environment for residents at extreme risk of injury from a fall. It is a restraint and must be prescribed by a licensed physician) for Resident 23. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 7) was free from the physical restraints. * The facility failed to conduct an assessment and implement the least restrictive measures prior to applying a mitten (mitten which look like boxing gloves with a Velcro or tie at the wrist to hold them in place and immobilize the resident's fingers) to Resident 7's left hand. In addition, the facility failed to obtained the physician's order and informed consent from the responsible party. These failures posed the risk of compromising the residents' independence and psychosocial well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan for one of 12 final sampled residents (Resident 8) and one nonsampled resident (Resident 9). * The facility failed to develop a care plan problem for Resident 9's use of adaptive device (a beige colored velcro strap that was used to assist in holding utensils during meal times). * The facility failed to develop a care plan problem to address the use of peripheral IV (peripheral intravenous access for IV fluids and/or medications) for Resident 8. These failures posed the risk of not providing the appropriate, consistent, and individualized care to the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of 12 final sampled residents (Resident 7) attained and maintained their highest practicable well-being. * The facility failed to ensure Resident 7 was provided with the heel protectors while in bed as per the physician's order and resident's care plan. This failure had the potential for the resident to not receive appropriate care and treatment to prevent a skin problem.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure injuries and promote the healing of the existing pressure injuries for two of 12 final sampled residents (Residents 8 and 12). * The facility failed to ensure the LAL mattress setting was consistent with Resident 8's weight and the service light on the LAL mattress unit was addressed; and failed to ensure Resident 8 was administered wound treatments as per the physician's orders. These failures put Resident 8 at higher risk for developing new pressure injuries and worsening of the existing pressure injury on the left buttock. * The facility failed to ensure the LAL mattress setting was appropriate for Resident 12's weight. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the residents with limited ROM functions consistently received the treatments and services. * All 23 residents with orders for RNA services (including the ROM exercises and application of splints) did not consistently receive their treatments on multiple occasions. This failure had the potential for the residents to develop further decrease in ROM functions.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) care and services for five of 12 final sampled residents (Residents 3, 14, 15, 19, and 20) and one nonsampled resident (Resident 2). * The facility failed to ensure Residents 3, 14, 19, and 20's enteral feeding bottles were completely labeled to include the time and rate. * The facility failed to ensure the medications were administered via GT by gravity for Residents 2 and 15. These failures posed the risk for complications related to the use of the enteral feeding for Residents 2, 3, 14, 15, 19, and 20.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for IV therapy (the administration of fluids or medications through an IV line) for one of 12 final sampled residents (Resident 8) and one nonsampled resident (Resident 5). * The facility failed to change Resident 8's IV tubing per the date on the label; and the facility failed to ensure Resident 8 had an order for TKO. * The facility failed to label Resident 5's IV tubing with the date to be changed; and the facility failed to ensure Resident 5 had an order for TKO. These failures had the potential for complications related to IV therapy and negative effects related to the residents' medical condition.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide safe respiratory care to meet the needs for one of 12 final sampled residents (Resident 13). * The facility failed to ensure Resident 13 was placed on the correct ventilator settings ordered by the physician. In addition, the ventilator machine alarms were not set for high pressure alarms. These failures had the potential to result in poor health outcomes to the resident and posed the risk of delayed intervention in the event of an emergency.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the appropriate use of side rails for two of 12 final sampled residents (Residents 8 and 12). The facility failed to ensure the informed consents for side rail use matched the indications for side rail use ordered by the physician for Residents 8 and 12. This failure had the potential to put the residents at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. * The facility's medication error rate was 48%. Two of three licensed nurses (LVNs 3 and 5) were found to have made errors during the medication administration. These failures resulted in the residents not receiving the prescribed medications as ordered by the physician, which posed the risk of adverse effects for the residents.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly in two medication carts (Medication Carts A and B) and failed to ensure an expired medication was not stored in Medication Cart A. * Three medications in Medication Cart B and one medication in Medication Cart A did not have clear labels and were unreadable. * Five medications in Medication Cart B and five medications in Medication Cart A did not have no open dates. * One expired medication was found in Medication Cart B. * One drawer from Medication Cart B contained 3 containers of protein powder stored with alcohol gel and hydrogen peroxide 3% in the same drawer. [...]

Inspectors wroteBased on observation, interview, facility document review, and P&P review, the facility failed to ensure food safety and sanitation in the kitchen as evidenced by: * The FSS did not perform hand hygiene after removing the gloves and touched the food with the dirty gloves during the food preparation. * Resident 9's culinary utensil was not washed and sanitized as per the facility's P&P. * A handwashing sink was used for purposes other than hand washing when the CNA used hand sink to wash the spoon. * The food contact surfaces were not clean. * A hair restraint was not worn during food preparation, * The following nonfood contact surfaces were not clean. * The nonperishable food brought from the outside was not labeled or dated. * The can opener blade was worn. * The test strips used to test the dish machine sanitizer were expired. [...]

Inspectors wroteBased on interview and facility P&P review, the facility failed to ensure the staff and visitors who brought food from outside were educated on the safe food handling practices. This failure had the potential to cause the risk of safety of usage, handling, and consumption of foods brought to the residents by the resident's family and visitors.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented. * LVNs 3, 4, and 5 failed to perform hand washing prior to the administration of medications via GT to three nonsampled residents (Residents 2, 4, and 17). * The trash can in Resident 4's room was overfilled with yellow gowns which was used for contact precaution isolation. * The facility's infection control committee did not meet for one quarter to discuss the residents who did not meet McGeer's criteria in November 2023. These failures posed the risk for transmission of disease causing microorganism, and resulted for the committee not able to discuss about the residents on antibiotics who did not meet McGeer's criteria.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in a safe operating condition. * The facility failed to ensure the ice machine located in the kitchen was cleaned and sanitized as per the manufacturer's guidelines. * The facility failed to ensure the medication refrigerator was maintained and the freezer compartment inside the medication refrigerator was free of ice buildup. These failures had the potential for the refrigerator not being maintained in a safe operating condition and posed the risk of ice contamination and equipment to function improperly.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to promote the dignity and respect for one nonsampled resident (Resident 9). * CNA 4 was observed standing over Resident 9 while assisting and feeding the resident with his lunch. This failure posed the risk of not treating the resident with respect.

Inspectors wroteBased on interview and facility document review, the facility failed to provide one nonsampled resident (Resident 526) with the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055). This failure had the potential of not allowing Resident 526 to make an informed decision regarding their Medicare services.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the personal privacy for two nonsampled residents (Residents 2 and 17) when the nurses failed to provide full privacy to the residents during the medication administration via GT. This failure had the potential to negatively affect the dignity of the residents and violate the residents' right to privacy.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to obtain the physician's order for an adaptive device for one nonsampled resident (Resident 9). This failure had the potential for Resident 9 to not receive the appropriate care and services in the facility.

Inspectors wroteBased on observation, interview, and USDA Food Code review, the facility failed to ensure the safe handling and collection of regular waste. This failure posed the risk for safety and pest contamination .

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the resident-centered activity programs to meet the residents' needs and interests for one sampled resident (Resident 2) and 22 nonsampled residents (Residents A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, and V). This failure had the potential to negatively affectthe residents' psychosocial well-being.