Chatsworth Park Health Care Center

Inspectors wroteBased on interview and record review the facility failed to implement the facility's policy titled, Water Shut Off and Water Supply Interruption, last reviewed on 1/2026, by failing to provide documented evidence of staff's annual training on water outage response. This failure had the potential to place residents' safety, health, and well-being at risk during any planned or unplanned interruptions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident room temperatures within the required range of 71 degrees Fahrenheit ( F - a scale of temperature) to 81 F for one of five sampled residents (Resident 1) room. This deficient practice violated the resident's right to a comfortable, homelike environment and had the potential to adversely affect the resident's quality of life. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement policies and procedures (P&P) for monitoring air temperatures and Heating, Ventilation, and Air Conditioning (HVAC - controls indoor climate by managing temperature, humidity, air movement, and air purity) units by failing to establish written procedures that directed how room temperatures were to be measured, documented, and monitored and how HVAC units were to be inspected, monitored and documented. This failure had the potential to result in maintenance personnel monitoring air temperatures and HVAC systems in an inconsistent and inaccurate manner, potentially affecting the facility's ability to maintain a safe and comfortable environment for residents. During a record review of the facility's Weekly Air Temperature Record, the Weekly Air Temperature Record indicated the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the Heating, Ventilation, and Air Conditioning (HVAC - a system that controls indoor climate by managing temperature, humidity, air movement, and air quality) unit in functioning condition to provide a comfortable environment for one of five sampled residents (Resident 1). This failure resulted in Resident 1 expressing that it felt like roasting in my own skin and had the potential to create an uncomfortably hot environment for the residents, staff, and visitors. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when two of 29 sampled residents (Resident 117 and Resident 79) repeatedly refused prescribed medications. This failure placed Resident 117 and Resident 79 at risk for delayed care and worsening health conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents' (Resident 69) drug (medication) regimen was free from the use of unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure (P&P) by failing to provide a detailed clinical rationale documented for continuing olanzapine (a psychotropic medication used to treat behaviors related to psychosis [disconnection from reality]) as originally prescribed on 2/25/2025 without attempting Gradual Dose Reduction ([GDR] - stepwise tapering of a medication dose to determine if symptoms or conditions can be managed by a lower dose, or if the drug can be safely discontinued). [...]

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 three (Resident 8, Resident 30, and Resident 117) of 29 sampled residents by failing to: a. Indicate that Resident 8 was receiving restorative nursing program including passive range of motion exercises. This failure had the potential to negatively affect Resident 8's plan of care and the delivery of necessary care and services. b. Accurately assess Resident 30's fall risk evaluation dated 6/5/2026. This failure had the potential to affect the provision of Resident 30's care and provided inaccurate information to the Federal database. c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan (CP - a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide) for six of 29 sampled residents (Resident 108, 1, 117, 90, 48) by failing to: a. Develop a CP to address positioning Resident 108's bed against the wall. This failure had the potential to negatively affect the delivery of care and services to Resident 108. b. Develop a CP to identify the goals of treatment and the interventions necessary for Resident 1's use of oxygen therapy. This failure had the potential to result in failure to deliver the necessary care and services to Resident 1. c. Ensure Resident 117's CP included interventions to address the resident's repeated medication refusals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmaceutical services were provided for 3 out of 29 sampled residents (Residents 60, 90, and 112) by failing to: 1. Ensure to obtain a physician's order and conduct a self-administration evaluation for the use of hydrocortisone 1% cream (topical medication used to temporarily relieve itching, redness, swelling, and irritation) which was found at Resident 60's bedside. This failure had the potential to result in Resident 60 to administer the medication incorrectly leading to either overuse or underuse resulting in not treating the condition and adverse consequences. 2. Ensure to accurately document medication administration, assessment, and medication effectiveness for Resident 90 in the electronic medication administration record (eMAR). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Remove and discard from use, two (2) expired insulin (medication used to regulate blood sugar levels) Novolog (rapid-acting insulin) Flexpens (an injection device containing insulin) for Resident 88 and 105, in accordance with manufacturer's requirements and facility policy and procedures (P&P) in one (1) of three (3) inspected medication carts (Medication Cart Station 2 Middle). 2. Ensure eye drop medication was stored separately from orally administered medications, in one (1) of three (3) inspected medication carts (Medication Cart Station 2 Middle). These failures increased the risk that Residents 88 and 105 could have received medication that had become ineffective or toxic due to improper storage.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a physician's order for double portions (double the portions of a meal for a resident with high caloric needs who are eating well and for whom large portions are inadequate) for a resident on a renal diet (specialized diet for residents with kidney problems) for one of 29 sampled residents (Resident 60). This failure had the potential for Resident 60 to have increased work on their kidneys and experiencing fluid retention causing edema (swelling) to the arms and legs.

Inspectors wroteBased on observation, interview, and record review, a resident had to wait ten minutes to go to the restroom when Certified Nursing Assistant 1 (CNA 1) who was aware of the resident's request from the beginning, did not provide assistance or seek help from other staff for one (Resident 36) of 29 sampled resident. This failure had the potential for Resident 36 to be at risk for urinary incontinence (the involuntary loss of bladder control, resulting in the accidental leakage of urine), urinary tract infection (UTI, an infection in the bladder/urinary tract), and re-opening of her pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the resident's Advance Directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) acknowledgment form was kept in the resident's medical record and easily retrievable for two of 29 sampled residents (Resident 30 and Resident 63) reviewed under Advanced Directive care area. This failure had the potential to create confusion which could lead to conflict with the resident`s wishes regarding their health care preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal privacy or confidentiality of personal and medical records for two (Resident 69 and Resident 48) of 29 sampled residents by failing to: 1. Ensure Resident 69's diet ticket (or tray ticket, a paper meal ticket that travels with a resident's food tray from kitchen to dining room that lists the exact dietary orders, food textures, and food preferences prescribed for that specific patient) containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) was shredded prior to disposing in a waste container. As a result of this failure, Resident 69's confidential medical record was not securely maintained. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one of one sampled resident (Residents 108) investigated during review of physical restraints care area by: 1. Failing to complete an assessment for risk of entrapment prior to placement of bed against the wall. 2. Failing to ensure the informed consent was obtained from Resident 108 prior to placement of bed against the wall. 3. Failing to ensure an order was obtained from the physician prior to placement of bed against the wall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 48), was turned and repositioned in accordance with professional standards of care practice. This failure had the potential to result in Resident 48's increased risk of new pressure ulcer development and worsening of present sacral (the area between the lower back and buttocks) pressure ulcer/injury (also known as pressure sore and decubitus ulcer, localized damage to the skin and/or underlying tissue caused by prolonged pressure or friction, often over bony areas).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' medication, who had no physician's order for the medication that indicated the frequency in which to give the medication, was not left unattended at the bedside for one (Resident 60) of seven sampled residents investigated for accidents. This failure had the potential for other residents to enter the room, take another resident's medication and suffer adverse side effects. This deficient practice also had the potential for Resident 60 to take the medication more than its intended purpose.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident who was taking Levofloxacin (an antibiotic that that may be used to treat different types of bacterial infections) which carries a black box warning (a black box warning is the strictest safety alert required by the U.S. Food and Drug Administration [FDA]. It appears as a bold, black-bordered notice at the top of a drug's package insert to alert healthcare providers and patients to serious, life-threatening, or permanently disabling risks) was monitored for serious adverse reactions for one of two sampled residents (Resident 14) reviewed under the Urinary Tract Infection (a bacterial infection causing painful, frequent urination, pelvic pressure, and cloudy or bloody urine) care area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care consistent with professional standards of practice for two of two residents (Resident 104 and Resident 56) reviewed under respiratory care area by failing to ensure Resident 104 and Resident 56 received oxygen as ordered by the physician. This failure had the potential to cause Resident 104 and Resident 56 to have shortness of breath that could lead to hypoxemia (a low level of oxygen in the blood).

Inspectors wroteBased on interview and record review, the facility failed to assess the dialysis (a treatment that filters waste and excess fluid from your blood when your kidneys are failing) access site post-dialysis for signs and symptoms of infection for one of one sampled resident (Resident 8). This failure placed the resident at risk for delayed detection of potential complications after dialysis treatment such as blood clot formation and bleeding which could lead to hemorrhage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection control practices for two (Resident 74 and Resident 56) of 29 sampled residents by failing to: 1. Ensure Resident 74's urinal (a container used to collect urine) was labeled with Resident 74's identifier. 2. Ensure Resident 56's oxygen nasal canula tubing (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not touching the floor. These failures had the potential to result in contamination of the residents' care equipment and risk of transmission of bacteria that can lead to infection.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1's) Responsible Party (RP 1) was provided the facility's form titled Resident's Right to Choose a Physician (a from used by the facility for the resident or responsible party to provide information regarding their request of using their own physician). This deficient practice resulted in Resident 1 not having the opportunity to choose Resident 1's own physician and had the potential to delay the provision of necessary care and services, which could adversely affect Resident 1's overall health status.

Inspectors wroteBased on interview and record review, the facility failed to notify a physician regarding a resident's fluid intake that was below the Registered Dietitian's (RD's) estimated fluid needs for one of four sampled residents (Resident 1). This deficient practice placed the resident at risk for worsening dehydration (a condition that occurs when your body loses or uses more fluids than it takes in, leaving it without enough water to function normally), increased risk of hospitalization and related complications, and a decline in the resident's overall health status. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a resident's comprehensive care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) to address residents' food preferences and dislikes related to fish for two of four sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to result in the residents not receiving appropriate nutritional services and accommodations consistent with their dietary preferences and needs. a. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor residents' documented food preferences by continuing to serve fish to two of four sampled residents (Resident 2 and Resident 3) despite the residents' expressed dislikes. This deficient practice had the potential to result in decreased meal intake which could lead to weight loss and malnutrition (a serious condition resulting from an imbalance between the nutrients the body needs to function and the nutrients it receives).a. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 1) that adequately addressed the resident's individual care preferences. This deficient practice had the potential to negatively affect the delivery of care and services provided to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for two of three sampled residents (Resident 1 and Resident 3) by failing to ensure residents' fingernails were properly trimmed. This deficient practice resulted in Resident 1 and Resident 3 having long, untrimmed fingernails which had the potential to negatively impact the residents' self-esteem and sense of self-worth.a. [...]

Inspectors wroteBased on interview and record review the facility failed to implement its policy on skin and wound monitoring and management by failing to ensure the treatment nurse (a specialized nurse who focuses on providing direct, hands-on clinical care, such as wound care) measured the area of skin redness on 2/5/2026 for one of three sampled residents (Resident 1). This failure had the potential to place Resident 1 at risk for worsening of skin redness due to lack of proper assessment and monitoring.

Inspectors wroteBased on interview and record review the facility failed to implement its employee handbook by failing to ensure direct resident care staff maintained fingernails that did not extend beyond the end of each finger for two of three sampled staff (Certified Nursing Assistant 3 [CNA 3] and Licensed Vocational Nurse 1 [LVN 1]). This deficient practice had the potential to contribute to the spread of infection and cross contamination (the transfer of harmful bacteria, viruses, or allergens from one person, surface, or object to another, facilitating the spread of infection) among residents.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report an allegation of staff to resident physical and verbal abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) immediately but no later than two hours to the State Agency (California Department of Public Health [CDPH]) and the local law enforcement for one of four sampled residents (Resident 1). This deficient practice had the potential to result in the delay in implementing necessary actions to oversee the protection of the residents in the facility by the State Survey Agency (SSA).

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a 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) for three out of four sampled residents (Residents 81, 17, and 301). This deficient practice had the potential for: 1. Resident 81 to not receive the necessary care and services to prevent complications of antibiotic therapy such as nausea, vomiting, diarrhea, abdominal pain, loss of appetite, and bloating. 2. Resident 17 to receive oxygen therapy inconsistent with physician's orders. 3. Resident 301 to be unable to make his needs known, understand staff, or receive adequate care due to a language barrier.

Inspectors wroteBased on interview and record review the facility failed to reconcile (the process of comparing transactions and activity to supporting documentation) eight (8) medication emergency kit (eKIT) containing Controlled Medications ([CM] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Drugs or Controlled Substances [CS]) for 4/2025, in one (1) of one (1) inspected medication room (Medication room [ROOM NUMBER].) As a result, control and accountability of medications and CMs did not follow state and federal regulations and facility policy and procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI/PU, injuries to the skin and underlying tissue resulting from prolonged pressure) by failing to follow physician's order to apply heel protectors while in bed for one of one sampled resident (Resident 4). This deficient practice had the potential for the worsening of or the development of PI/PU.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the safety of residents by failing to ensure Resident 1's bed brake lock was engaged. This deficient practice placed Resident 1 at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's indwelling catheter (a tube that is inserted into the bladder, allowing urine to drain) did not have a loop or kink (unwanted twist or bend) for one of one sampled resident (Resident 15). This deficient practice had the potential for the resident to develop a urinary tract infection (UTI- an infection in any part of the urinary system).

Inspectors wroteBased on observation, interview and record review the facility failed to follow professional standards of practice by failing to administer an intravenous (IV - into or through the vein) antibiotic (a medication that kills or stops the growth of bacteria) at the rate ordered by the physician for one of one resident (Resident 57) during a random observation. This failure had the potential to increase the risk of Resident 57 experiencing adverse (undesirable outcome) effects such as fluid overload (too much fluid volume in the body), infiltration (an IV fluid or medication leaks from the vein into the surrounding tissue), pain and phlebitis (inflammation of the vein).

Inspectors wroteBased on interview and record review, the facility failed to ensure the hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) center completed a post-dialysis assessment (evaluation done after hemodialysis by the hemodialysis licensed nurses) by failing to: 1. Follow up with the dialysis center when there was no documentation of the resident's post dialysis weight. 2. Follow up with the dialysis center when a resident's weight is staying the same or increasing after dialysis treatments (it is usual for a resident's weight to be slightly reduced after dialysis since some fluid is removed). for one (Resident 59) of two sampled residents upon returning to the facility from a dialysis session. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) alprazolam (medication used to treat anxiety disorder [intense, excessive, and persistent worry and fear about everyday situations]) to one of five residents reviewed for unnecessary medications (Resident 31). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from alprazolam.

Inspectors wroteBased on observation interview and record review the facility failed to ensure residents were free of any significant medication errors by failing to administer an intravenous (IV - into or through the vein) antibiotic (a medication that kills or stops the growth of bacteria) at the rate ordered by the physician for one of one resident (Resident 57) during a random observation. This failure had the potential to increase the risk of Resident 57 experiencing adverse (undesirable outcome) effects such as fluid overload (too much fluid volume in the body), infiltration (an IV fluid or medication leaks from the vein into the surrounding tissue), pain and phlebitis (inflammation of the vein).

Inspectors wroteBased on observation, interview, and record review the facility failed to store and label one (1) Aplisol (medication used to diagnose tuberculosis [infection in the lungs]) vial in the refrigerator, in accordance with manufacturer's requirements and facility policy and procedures in one (1) of one (1) inspected medication rooms (Medication room [ROOM NUMBER].) This deficient practice increased the risk to residents in the facility to receive medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to inaccurate treatment for tuberculosis (a contagious bacterial disease that's usually spread through the air when someone with tuberculosis coughs, sneezes, or spits) resulting in hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 66). This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection.

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship program by failing to conduct infection surveillance and complete the infection control reporting form once a resident was prescribed an antibiotic for one (Resident 57) of one resident investigated who was prescribed an antibiotic. This deficient practice had the potential for Resident 57 to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required room size of 80 square feet (sq ft - unit of measurement) per resident for six of 60 multiple resident rooms (Rooms 108, 109, 208, 209, 215, and 216). This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' attending physician documented residents' History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) in a timely manner per the facility's policy and procedure for three out of three sampled residents (Resident 2, Resident 4, and Resident 5). This deficient practice had the potential for inconsistent care coordination due to incomplete records for Resident 2, Resident 4, and Resident 5.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's theft and loss policy by failing to document a resident's lost jewelry on the facility's theft and loss report form for one of three sampled residents (Resident 1). This deficient practice violated the resident's right to have Resident 1's property protected and conserved.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Discharge Summary was accurate and complete for one of three sampled residents (Resident 2). This deficient practice had the potential to lead to confusion about Resident 2's discharge status and a delay in attaining services needed for Resident 2 after discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide pain medication as ordered by the physician and follow the physician's order for pain medication parameters (a set of defined limits) for one (1) of three (3) sampled residents (Resident 2). This deficient practice had the potential to result in Resident 2 being overmedicated and experience an adverse reaction (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident received their prescribed amoxicillin-pot clavulanate (antibiotic- used to treat many different infections caused by bacteria) in a timely manner as ordered by the physician for one of three sampled residents (Resident 2). This deficient practice resulted in the delay of medication administration of an antibiotic which had the potential to cause bacteria to reproduce.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received treatment and care in accordance with the physician's order by failing to continue Resident 2's daily probiotic (live microorganisms intended to maintain or improve the good bacteria in the body) as ordered by the physician. This deficient practice resulted in Resident 2 not receiving their probiotic as ordered by the physician and had the potential to affect Resident 2's health.

Inspectors wroteBased on interview and record review, the facility failed to provide one of three sampled residents (Resident 1) copies of Resident 1's clinical records to Resident 1's representative upon written request. This deficient practice violated the rights of Resident 1's representative to obtain copies of Resident 1's clinical records when requested.

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/her need for assistance from staff) was within reach for one of three sampled residents (Resident 2). This deficient practice had the potential to delay the provision of services and residents' needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and revise a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of three sampled residents (Resident 3) by failing to ensure Resident 3 was provided with bilateral (both sides) floormats (padding placed on the floor to help prevent injuries related to falls) and was monitored for placement. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 3 and miscommunication among the care team regarding the resident ' s needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility provided transportation for one of two sampled residents (Resident 4) who had an appointment on 10/28/2024. This deficient practice resulted in Resident 4 missing his scheduled appointment on 10/28/2024 and had the potential for Resident 4 to not attain his highest practicable physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis (the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) residents received care in accordance with standards of practice for two of three sampled residents (Resident 2 and Resident 3) by: 1. Failing to complete a post-dialysis assessment for Resident 2 on 10/28/2024. 2. Failing to assess Resident 3's dialysis access site (way to reach the blood for dialysis) after returning from dialysis on 10/28/2024 and 11/4/2024. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) within two (2) hours of the incident for one of four sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure that one of four sampled residents ( Resident 2), who was experiencing significant weight loss (when a resident experiences unplanned and undesired weight loss of five percent [%-unit of measure] total weight in a one-month period) and severe weight loss(when a resident experiences unplanned and undesired weight loss of 10% in six months), was weigh weekly as per facility policy and procedure. This deficient practice placed Resident 2 at increased risk for undetected weight loss.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Notify the physician for one of four sampled residents (Resident 1) when Resident 1 verbalized getting skin reaction from the blood pressure cuff (a medical device used to measure blood pressure by wrapping it around the upper arm and inflating it). 2. Notify the physician for one of four sampled residents (Resident 1's) refusal to take her Furosemide (a medication used to treat fluid retention and swelling caused by certain disease or medical conditions) medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services that assured the accurate administration of Sinemet (medication used to treat symptoms of Parkinson's disease [a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination]) and Midodrine (used to treat low blood pressure when standing up from a sitting position or when already standing) for one of eight sampled residents (Resident 1). This deficient practice had the potential to result in ineffective treatment and management of Resident 1's Parkinson's disease and hypotension (low blood pressure).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent (having no or insufficient voluntary control) of bladder and bowel (B&B) function, receives appropriate care and services to prevent urinary tract infection (UTI- an infection in any part of the urinary system) for one of seven sampled residents (Resident 3) by failing to implement its policy and procedures (P&P) on Perineal (the area of the body between the anus and the genitals) Care when two Certified Nursing Assistants (CNA 2 and CNA 3) used a soiled towel to wipe the perineal area and did not rinse the perineal area while providing perineal care. This deficient practice had the potential to result in urinary tract infection, skin irritation and unpleasant odor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure two of two sampled staff (Certified Nursing Assistant 2 [CNA 2] and CNA3) performed hand hygiene (HH - cleaning hands by either washing with soap and water, or by using a hand sanitizing [removing germs] gel) after providing Resident 3's perineal (the area of the body between the anus and the genitals) care and before touching Resident 3's body to fix the resident's position while in the bed. These deficient practices had the potential to result in the spread of infection placing residents, staff, and visitors at risk to be infected with germs.

Inspectors wroteBased on interview and record review, the facility failed to obtain a written order from a physician to provide Physical Therapy (PT- used to preserve, enhance, or restore movement and physical function impaired or threatened by disease, injury, or disability and that utilizes exercise, physical modalities [uses transmission of energy to or through the resident], assistive devices [tools, products or types of equipment that help a resident perform tasks and activities], and resident education and training) for one of six sampled residents (Resident 1). This deficient practice had the potential to result in negative physical outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure Licensed Vocational Nurse 1 (LVN 1) performed hand hygiene (HH- washing of hands with water and soap or applying an alcohol-based hand rubs) for one of four sampled residents (Resident 1) on 6/27/2024 after touching Resident 1 with bare hands to check the resident's identification band and blood pressure (the pressure of circulating blood against the walls of blood vessels). This deficient practice had the potential to spread the infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among residents.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 100) when on 4/7/2024, Resident 106 pulled the hair of Resident 100 causing Resident 100 to fall on the floor. This deficient practice resulted in Resident 100 being subjected to physical abuse by Resident 106 while under the care of the facility. Resident 100 sustained bleeding to the scalp (skin on top of a resident's head where hair grows) and pain to the left ankle.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that six of six residents (Residents 123, 102, 60, 32, 48, and 67) interviewed during the Resident Council Meeting (a group of nursing home residents who meet regularly to discuss their rights, quality of care, and quality of life) were aware of how to contact the State Survey Agency (the department) to file a complaint. This deficient practice had the potential to deprive the residents of assistance from resident advocacy groups should unresolved issues arise in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) for one of two sampled residents (Resident 69) investigated under insulin. The deficient practice had the potential for adverse effects (undesired harmful effect resulting from a medication or other intervention) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 67) received morning medications scheduled for 9 a.m. on time and not given at 11:15 a.m. These deficient practices resulted in the omission of medications, receiving medications before they are due, or giving medications after they are due which could have resulted in severe health complications. 2. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) for two of five sampled residents (Resident 44 and 48). These deficient practices had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug).

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were not used unnecessarily for one of six sampled residents (Resident 56) when receiving a duplicate therapy of Zyprexa (antipsychotic- a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) at nighttime for 41 days. 2. [...]

Inspectors wrote3. A review of Resident 106's admission Record indicated the facility admitted the resident on 12/25/2023 with diagnoses that included hyperlipidemia (abnormally high concentration of fats in the blood), dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), and difficulty in walking. A review of Resident 106's MDS dated [DATE], indicated Resident 106 had severely impaired cognition. A review of Resident 106's Change in Condition Evaluation, dated 4/7/2024 at 7:55 a.m., indicated the resident was verbally and physically aggressive and Resident 106's primary physician renewed Resident 106's previous Haldol order. A review of Resident 106's discontinued physician orders indicated the last order for Haldol injection solution for agitation manifested by physical and verbal aggression was ordered on 3/12/2024 for 14 days. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of four sampled residents (Resident 12) by failing to document wound care treatments conducted on Resident 12 in Resident 12's Treatment Records (TAR, a legal document indicating the dates a treatment was conducted for a resident) for 1/2024. This deficient practice had the potential to result in confusion regarding Resident 12's condition and what care and services were provided to Resident 12.

Inspectors wroteBased on interview and record review, the facility failed to rightfully inform in advance of the risks and benefits of the proposed plan in medication for two of eight sampled residents (Resident 106 and 56) by failing to: 1. Obtain an informed consent (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) when Resident 106's Seroquel (antipsychotic- a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) dosage was increased. This deficient practice violated the resident's and his/her representative's right to make an informed decision regarding the use of an antipsychotic medication. 2. Obtain an informed consent when Resident 56's Zyprexa (antipsychotic medication) dosage was increased. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan (a written document that summarizes a patient's needs, goals, and care) within 48 hours of admission for one of one sampled resident (Resident 378) who tested positive for coronavirus disease -2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection). 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 develop a comprehensive person-centered care plan (a plan for a resident's specific health needs and desired health outcomes) related to constipation (a bowel dysfunction that makes bowel movements [BM] infrequent or hard to pass) for one of four sampled residents (Resident 408); when Resident 408 was first identified as being at risk for constipation on 5/19/2024. This deficient practice had the potential to result in failure to deliver necessary care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a medicine cup of diclofenac sodium gel (gel used to relieve pain) was not left at the bedside table of one of three sampled residents (Resident 330). This deficient practice had the potential to place residents at risk for theft and loss of medication and increased risk for drug overdose and or medication errors.

Inspectors wroteBased on interview and record review, the facility failed to the facility failed to ensure effective pain management was done by failing to administer pain medication for the appropriate pain scale as indicated by the physician's orders for one of two sampled residents (Resident 100). This deficient practice had the potential to result in confusion on the delivery of care and services rendered and may lead to inadequate management of residents' pain.

Inspectors wroteBased on interview and record review, the facility failed to complete a post-hemodialysis (HD, the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of two sampled residents (Resident 38) investigated addressing the dialysis care area. This deficient practice placed Resident 38 at risk for complications of dialysis such as redness at the dialysis access site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR - review of a resident's drug therapy to assure appropriateness of medication usage completed each month by the consultant pharmacist) was acted upon for one of five residents (Resident 67) by failing to act upon the facility consultant pharmacist's recommendation for Resident 67's prednisone (a medication used to treat many conditions associated with inflammation) to give with food. This deficient practice has placed the resident at an increased risk of experiencing adverse side effects (unwanted undesirable effects that are possibly related to a drug) and had the potential for the resident to experience stomach irritation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from any significant medication errors for one of five sampled residents (Resident 67) by failing to ensure Licensed Vocational Nurse 6 (LVN 6) checked Resident 67's blood pressure before giving a blood pressure medication. This deficient practice had the potential to cause complications such as low blood pressure, resulting in hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure that food found inside a refrigerator designated for residents were labeled with the date they were placed in the refrigerator. This deficient practice had the potential to place 111 out of 117 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required room size of 80 square feet (sq ft - unit of measurement) per resident for six of 59 multiple resident rooms (Rooms 108, 109, 208, 209, 215, and 216). This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a post fall risk evaluation (form completed after a resident has fallen to determine risk factors related to falls) was completed after a fall for one of two sampled residents (Resident 3). This deficient practice placed Resident 3 at risk of not receiving the needed care and services and had the potential to result in undetected pain or injury after a fall incident.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Medication Administration- General Guidelines by not informing the physician for one of three sampled residents (Resident 1), who refused Zyvox (an antibiotic [medication that inhibits the growth of or destroys microorganism] medication used to treat bacterial infections) for more than two consecutive doses. This deficient practice resulted in Resident 1 ' s physician not being informed of Resident 1 ' s continued refusal of Zyvox which placed Resident 1 at risk for complications of untreated bacterial infections which can cause, sepsis (a serious condition in which the body responds improperly to an infection), hypotension (low blood pressure), and even death.

Inspectors wroteBased on interview and record review, the facility failed to inform one of six sampled residents (Resident 1) of the results of their urinalysis (involves checking the appearance, concentration, and content of urine) and urine culture test (a test to check urine for germs that cause infections). This deficient practice had the potential for the resident to not be well-informed of the urine test result and help identify the cause of their symptoms. This deficient practice also had the potential to cause a delay in care and services if the resident decided to seek further alternatives in treatment or diagnostic tests.

Inspectors wroteBased on interview and record review the facility failed to implement and follow its policy and procedure (P&P) titled Medication Administration and failed to ensure Licensed Vocational Nurse 1 (LVN 1) administered and documented accurately the medication Midodrine (a medication that works by constricting the blood vessels and increasing blood pressure) as ordered, for one of three sampled residents (Resident 1). This deficient practice had the potential to result in medication errors, had the potential to result in confusion on the delivery of care and services, and had the potential to result in ineffective management of Resident 1's blood pressure.

Inspectors wroteBased on interview and record review the facility failed to follow its policy and procedure (P&P) titled Release of Information and failed to provide copies of medical record in a timely manner (within 48 hours as per the P&P) for one of three sampled residents (Resident 1). This deficient practice violated the right of Resident 1 to obtain a copy of the requested medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's written notice of the proposed discharge was provided to the State Long-Term Care (LTC) Ombudsman (assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) as soon as practicable for eight of nine sampled residents (Resident 6, 8, 9, 10, 11, 12, 13, and 14). This deficient practice violated the resident ' s rights to appeal the discharge and resulted in the State LTC Ombudsman being unaware of the residents ' status and whereabouts; placing the residents at risk for being inappropriately discharged from the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 6 and Resident 7) were provided a discharge summary with a complete reconciliation of medications (a process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over-the-counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care) by failing to document what post-discharge medications the residents were to take and were provided and the amount of medications provided upon discharge to the residents or responsible party (RP). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a facility policy and procedure (P&P) for a resident's written notice of the proposed discharge to be provided to the State Long-Term Care (LTC) Ombudsman (assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) as soon as practicable for facility-initiated transfers/discharges (transfers or discharges which the resident objects to, or did not originate through a resident ' s verbal or written request). This deficient practice resulted in the State LTC Ombudsman being unaware of the facility ' s residents ' status, whereabouts, and placed the residents at risk for being inappropriately discharged from the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered plan of care (a plan for an individual's specific health needs and desired health outcomes) for four of four sampled residents (Resident2,3,4 and 6) by: 1. Failing to develop a care plan related to Coronavirus Disease 2019 (COVID-19 - a highly contagious respiratory illness) for Resident 2, 3 and 4. 2. Failing to develop a care plan related to Clostridioides difficile (C-Diff - a germ that causes diarrhea) and peripherally inserted central catheter line (PICC line-type of catheter that is placed in a large vein that allows for medications to be given intravenously) for Resident 6 . This deficient practice can result to a delay in providing intervention if the residents signs and symptoms worsens and could potentially result in a delay in or lack of delivery of care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control practices by: 1. Failing to ensure one of five sampled staff (Certified Nursing Assistant 2 [CNA 2]), performed hand hygiene (washing of hands) after disposing a bag of soiled linen after leaving Resident 10's room and before entering Resident 12's room. 2. Failing to ensure that one of five sampled staff (Treatment Nurse 1 [TN 1]) performed hand hygiene after providing wound treatment to Resident 10. 3. Failing to ensure that one of five sampled staff (TN 1) disinfected Wound Medication Cart 1 (Med Cart 1) before gathering supplies to start wound treatment to Resident 9 and failed to perform hand hygiene entering Resident 9's room and returning to Med Cart 1 to gather additional wound care supplies. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one of three sampled residents (Resident 6), with a peripherally inserted central catheter line (PICC line-a long, flexible catheter [thin tube] that's put into a vein) was provided with a PICC line dressing change (a PICC line requires that the dressing be changed every seven (7) days or as needed due to the high risk of infection) as ordered by the physician on 9/25/2023. This deficient practice placed Resident 6 at increased risk for sepsis (the body's extreme response to an infection. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 6), when Registered Nurse 1 (RN 1) falsely documented that she provided a peripherally inserted central catheter (PICC line-a long, flexible catheter [thin tube] that's put into a vein) dressing change (a PICC line requires that the dressing be changed every seven [7] days or as needed due to the high risk of infection) on 9/25/2023 as ordered by the physician. This deficient practice had the potential to result in confusion regarding Resident 6's condition and what care and services were provided to Resident 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) positive resident (Resident 4) was kept separated from COVID-19 negative residents (Residents 1, 2, and 3) while in the smoking area for three out of four sampled residents. This deficient practice had the potential to place COVID-19 negative residents at increased risk of contracting COVID-19.