Clara Baldwin Stocker Home for Women

Inspectors wroteBased on observation, interview and record review the facility failed to ensure renovations for two of four sampled residents' rooms (Resident 1's and Resident 2's shared room) followed State regulations when: 1. Facility did not obtain prior written approval from Department of Healthcare Access and Information (HCAI, state agency that regulates the design, seismic [refers to earthquakes] safety, construction of hospitals and skilled nursing facilities) and from the California Department Public Health (CDPH, the Department) prior to initiating facility renovations. 2. Facility assigned residents in a renovated room prior to written approval from HCAI and CDPH. [...]

Inspectors wroteBased on interview, and record review, the facility (Skilled Nursing Facility [SNF] 1) failed to ensure one of three sampled residents (Resident 1) was permitted for readmission to the first available private room on 4/13/2026 after Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 3/21/2026 and transferred to Long-Term Acute Care Hospital (LTACH) 1 on 3/26/2026, in accordance with SNF 1's policy and procedure (P&P) titled, Bed-Holds and Returns, dated 3/2017. This deficient practice resulted in Resident 1 remaining in LTACH 1 on 2/4/2026 following an inquiry from LTACH 1 for Resident 1 to be transferred back to SNF 1 and had the potential to cause Resident 1 distress from not being able to return to Resident 1's previous living arrangement. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a copy of a maintenance schedule for the facility's two of two air conditioner units and the facility's preventative maintenance program failed to include testing water valves (regulate or shut off water flow in plumbing systems) and pneumatic controls (utilize compressed air to measure, transmit, and actuate control signals in systems like HVAC [heating, ventilation, and air conditioning]). This failure had the potential for residents (in general) not to have a comfortable environment while at the facility.

Inspectors wroteBased on interview and record review, the facility failed to obtain weekly weights for one of three sampled residents (Resident 2) as indicated in the facility's Policy and Procedure (P&P) titled, Weight Change Protocol, undated. This failure had the potential for Resident 2 to experience unexplained/unnoticed weight loss.

Inspectors wroteBased on interview and record review the facility failed to obtain and maintain copies of advance directives (AD, a legal document explaining a resident's health care wishes when residents cannot speak for themselves) for four of six sampled residents (Residents 3, 6, 43, and 44). This failure had the potential to result in conflict regarding Residents' 3, 6, 43, and 44 health care choices.

Inspectors wroteBased on interview and record review the facility failed to ensure adequate indications for psychotropic medication (medication used to treat mental health disorders [conditions that affect thinking, feeling, mood, and behavior]) use and failed to ensure specific psychotropic medication behavior monitoring (tracking expressions or indications of distress) was completed for two of five sampled residents (Residents 7 and 64). These failures had the potential to result in unmet medical, physical, mental, and psychosocial needs (the emotional and social requirements that individuals must have to feel safe, supported, and capable of functioning well in their environment) to Residents 7 and 64 and had the potential to result in Residents 7 and 64 receiving unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to:(A) follow-up with the MD for the pharmacist drug regimen review recommendation to have the MD assess for Diclofenac gel (a non-greasy, topical medicine used to relieve joint pain caused by arthritis) and Tizanidine's (a medication used to treat muscle spasms, tightness, and cramping caused by spinal cord injuries or diseases like multiple sclerosis) effectiveness and evaluation if dose reduction or adjustment is warranted for one of one sample resident, (Resident 5)(B) indicate the physician's rationale for not following the pharmacist's recommendation in the resident's medication regime review (MMR) for one of one sampled resident (Resident 2). These deficient practices placed the resident at risk for receiving unnecessary medications that can lead to adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate and complete documentation in the medical records for two of two residents (Residents 5 and 64) by:Failing to include Resident 5's diagnosis for diabetes on Resident 5's admission Record (AR). Indicating a diagnosis of bipolar disorder (BPD, an illness in which the patient goes back and forth between opposite extremes such as high and low levels of mood) for Resident 64 on the AR and the Minimum Data Set (MDS - a federally mandated resident assessment tool) without verification from Resident 64's medical record or confirmation with Resident 64's Medical Doctor (MD). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform one of one sampled resident's (Resident 64) physician (Medical Doctor [MD] 1) of Resident 64's change of condition (CoC, an alteration in a resident's physical health that differs from their previous baseline) when Resident 64 was observed with redness on Resident 64's left eye on 1/27/2026. This failure had the potential for Resident 64 not to receive adequate treatment for a potential infection in Resident 64's left eye.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan (CP) for one of one sampled resident (Resident 57), who was on hospice care (care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort and quality of life, rather than a cure). This deficient practice had the potential to result in unmet individualized needs for Resident 57 and the potential to affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to revise the Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments) related to gastrostomy tube (G-tube, a small flexible tube placed through the skin of the abdomen directly into the stomach) and nutrition for one of one sampled resident (Resident 6) after Resident 6's g-tube was removed. This failure had the potential for Resident 6 not to receive necessary care or services related to the removal of the g-tube.

Inspectors wroteBased on interview and record review, the facility failed to justify a diagnosis of bipolar disorder (BPD, an illness in which the patient goes back and forth between opposite extremes such as high and low levels of mood) for one of one sampled Resident (Resident 64) based on a comprehensive assessment Resident 64 as indicated in the facility's policy and procedure (P&P) titled, Antipsychotic [a class of psychiatric medications primarily used to manage psychosis symptoms] Medication Use. This failure had the potential for Resident 64 to receive unnecessary treatment and/or services and the potential to result in a physical decline to Resident 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's low air loss (LAL - composed of multiple inflatable air tubes that alternately inflate and deflate, mimicking the movement of a patient shifting in bed or being rotated by a caregiver, never leaving the patient in one position for any extended length of time) mattress was set to the correct setting for one of one sample resident (Resident 5). This deficient practice placed Resident 5 at risk for discomfort and the potential for developing pressure ulcers. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to administer a zinc ointment (a medication that helps protect and heal the skin) per the physician's order for a pressure ulcer (PU - injury to the skin and underlying tissue caused by constant long term pressure) to the sacral area (the bottom of the back right above the tail bone) for one of three sample residents (Resident 3). This failure has the potential to effect the healing of Resident 3's pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident did not store medications in their room for one of three residents (Resident 3). This failure had the potential to place Resident 3 at risk for unsafe self-administration of medication, which could result in skin irritation, systemic absorption (the process by which medication is absorbed into the bloodstream) and contamination.

Inspectors wroteF627INTENT These regulations and guidance address inappropriate discharges and:Ensure a facility does not transfer or discharge a resident in an unsafe manner, such as a locationthat does not meet the resident's needs, does not provide needed support and resources, or does notmeet the resident's preferences and, therefore, should nothave occurred. F627Based on observation, interview and record review, the facility failed to ensure Resident 1's discharge location met Resident 1's needs for family support and resources. This deficient practices led to an inappropriate discharge.

Inspectors wroteBased on interview and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Abuse Prevention Policy for one of three sampled residents (Resident 1) when the facility did not report a staff to resident abuse allegation (a claim that abuse has occurred) to the State Agency (SA-the state health inspection team that ensures healthcare providers are following federal laws) within two hours. This failure had the potential to result in Resident 1 experiencing abuse and to affect Resident 1's psychosocial (the emotional and social requirements that individuals must have to feel safe, supported, and capable of functioning well in their environment) wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled N95 Fit Testing, (N95 respirator, a device designed to protect the wearer from hazardous particles in the air such as fumes gases and viruses) by failing to ensure one of four sample staff [Certified Nurse Assistant 4 (CNA 4)] was fit tested for an N95 respirator mask upon hire. This failure had the potential to result in the spread of Coronavirus 2019 (COVID-2019, a severe respiratory illness caused by a virus and spread from person to person) and other airborne diseases to the residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation to meet residents needs for two of two sampled residents (Residents 21 and 25) by failing to ensure that the call light was within reach for both residents. These deficient practices resulted in delayed provision of services and had the potential to negatively impact the psychosocial well-being of Residents 21 and 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three of three sampled residents (Residents 15, 23, and 38) by failing to: A. Ensure Resident 15 had padded side rails to prevent injury from potential seizures, per physician's orders. B. Ensure and monitor that hospice staff were signing in and out during visits for Resident 23. C. Ensure Resident 38 physician's orders to obtain a STAT (right now, immediate) chest x-ray (images of inside the body) were followed. These deficient practices resulted in the failure to the delivery of necessary care and services for Residents 12, 23 and 24. Findings A. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure personal beverages for employees were not stored in one of two kitchen refrigerators (Refrigerator 1). This deficient practice had the potential for cross contamination and placed the residents at risk for foodborne illness (illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain its infection prevention and control program for 5 of 5 sampled residents (Residents 11, 23, 34, 241 and 242) by failing to ensure: A. The urinals were stored in shared restrooms for Residents 23, 34, 241 and 242 were properly labeled. B. Licensed Vocational Nurse (LVN) 2 disinfected (to thoroughly clean something by using a special chemical solution that kills germs like bacteria and viruses on a surface) the pill counting tray before and after use for Resident 11. C. Ensure the facility had sufficient hand hygiene supply and resources in the laundry area. D. Housekeeping Supervisor (HS) performed hand hygiene after touching the dumpster. [...]

Inspectors wroteCROSS REFERENCE - F656 and F676 Based on interview and record review, the facility failed to develop a comprehensive communication assessment for Resident 2 who primarily spoke Arabic, as indicated in the facility's policy and procedure. This deficient practice had the potential to result in Resident 2 being unable to communicate the residents needs and wants and not receive individualized care to meet the resident's medical, nursing, and mental and psychosocial needs that would have been identified in the language assessment.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop or implement an individualized person-centered care plan for one of one sampled resident (Resident 2) who only spoke and understood Arabic (language of the Arabs) as indicated in the facility's policy. This failure had the potential to result in unmet individual needs and not receiving the necessary care and services for Resident 2 to achieve an optimal level of function and had the potential to affect the resident's physical well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 2) was provided a communication tool or resources to effectively communicate his needs. Resident 2 who spoke Arabic (language of the Arabs), was not provided a communication tool. These deficient practices had the potential to result in the resident's care needs not being effectively conveyed to the staff which could lead to a decline in the resident's quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 191) who received hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) had been provided with an emergency kit at the resident's bedside. This deficient practice had the potential to delay treatment to Resident 191 when needed during an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide, restore, or improve normal bladder function for one of two sampled residents (Resident 92) whose urinary indwelling foley catheter (a tube that removes urine from the bladder to a collection bag) was observed with the presence of sediments (cells, debris and other solid matter in urine). This deficient practice had the potential to result in catheter related complications such as urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, bladder, or urethra).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 191) who received hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) had been provided with an emergency kit at the resident's bedside. This deficient practice had the potential to delay treatment to Resident 191 when needed during an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 20's fluoxetine (medication used to treat depression) had clinical justification as to why gradual dose reduction (GDR) was contraindicated and adequately define the indication for fluoxetine. This deficient practice had the potential to overmedicate Resident 20 with unnecessary medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs/medications used in the facility were labeled properly and/or discarded in accordance with professional standards of practice for one of two sampled medication carts (Med Cart 2). This deficient practice had the potential for residents to be administered (the act of giving a treatment, such as a drug, to a patient) with ineffective medications and potentially compromise the health, safety, and well-being of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure unauthorized person/s did not enter the facility undetected when: 1. The facility back door remained unlocked to the outside of the facility after dark. 2. Licensed Vocational Nurses (LVNs) 1, 2, 3, and 4 did not know how to lock the facility doors. These failures had the potential to compromise the safety of 37 of 37 residents in the facility and placed the residents at risk for accident hazards and harm.

Inspectors wroteBased on interview and record review the facility failed to implement its policy and procedure (P&P) titled, Isolation (separation of residents with an infection from residents without an infection) - Categories of Transmission-Based Precautions, when two of two residents (Residents 5 and 6) diagnosed with clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) infection did not have their own package of incontinent wipes (disposable washcloths or wipes used to cleanse the skin and manage urine and/or stool) inside the isolation room during the night shift (11 pm to 7 am) on 9/30/24. This failure had the potential to spread infection to residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to readmit one of two sampled residents (Resident 1) to the first available bed at the Skilled Nursing Facility (SNF) as indicated in the facility policy. This deficient practice resulted in the violation of Resident 1's rights to resume residency at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing was labeled for one of one sampled resident (Resident 2) who was receiving respiratory therapy by a nasal cannula (N/C, a tube used to deliver oxygen to help with breathing). This deficient practice had the potential to result in Resident 2's oxygen tubing not being changed and could have resulted in infection to Resident 2.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure proper pain management interventions were in place for one of one sampled resident (Resident 3). Resident 3 had penile fungal dermatitis (inflammation of the skin) and the facility put on an adult brief (diaper) on Resident 3 despite Resident 3 having diagnoses of unuria (lack of urine) and oliguria (low urine output) and being continent (ability to control bowel movement) of bowel. This failure resulted in Resident 3 to experience pain and had the potential to result in psychosocial and physical declines to Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct an N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit testing (the use of a protocol to evaluate the fit of a respirator on an individual) for two of four sampled staff (Licensed Vocational Nurse 1 [LVN 1] and Certified Nurse Assistant 1 [CNA 1]) upon hire during a Coronavirus (COVID-19, a mild to severe respiratory illness that spread from person to person) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) in accordance with the Department of Public Health's (DPH) guidelines and the facility's policy and procedure titled, Fit testing Policy for N95. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure ten of ten sampled residents (Residents 20, 182, 183, 184, 185, 6, 12,15, 22, and 82) were provided information regarding the right to formulate an advance directive (AD, legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes). This failure had the potential to result in Residents 20, 182, 183, 184, 185, 6, 12,15, 22, and 82 to receive unwanted care and treatment or unnecessary life-sustaining treatment.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan (CP) for three of three sampled residents (Residents 12, 15, and 10). a-b. For Residents 12 and 15, the facility did not include interventions (left blank) in the care plans (CP), titled, Imbalance Nutrition. c. For Resident 10, who was prescribed medication for her depression, the facility did not create a care plan for depression. This failure had the potential to result in no individualized care and a physical decline to Resident 12 and Resident 15.

Inspectors wroteBased on observation, interview, and record review, the facility's interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) failed to reassess fall prevention interventions for one of one sampled resident (Resident 8), according to the facility's policies and procedures (P&P). This failure had the potential to result in injury and a physical decline to Resident 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%, unit of measurement). During a medication administration observation, two of 32 medications were not administered in accordance with pharmacy instructions resulting in a medication error rate of 6.25%. 1. For Resident 4, Licensed Vocational Nurse 1 (LVN 1) crushed potassium chloride extended release (K+ER, medication used to treat low levels of potassium [mineral that the body needs] in the blood) and almost administered the medication to Resident 4. The pharmacy instructions indicated to not crush the medication prior to administration. 2. For Resident 4, LVN 1 removed the contents out of a medication capsule, Amitiza (medication to treat chronic [long standing] constipation) and almost administered the medication to Resident 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety requirements were followed when, a. two frozen pies located in the freezer and 23 refrigerated blocks of margarine located in the refrigerator were undated in one of one food storage room (Food Storage room [ROOM NUMBER]) according to the facility's policy and procedure (P&P). b. Pureed eggs that were held on one of one steam table (Steam Table 1) had a temperature of 120 degrees Fahrenheit (F, a unit of measurement) and the pureed hash browns that were held on Steam Table 1 had a temperature of 122 degrees F. The facility failed to ensure the temperatures were greater than 140 F. These failures had the potential to result in food-borne illnesses (illness cause by food contaminated with infectious organisms) and a physical decline to all residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed in one of one laundry room (Laundry room [ROOM NUMBER]) by not ensuring proper temperatures were used when processing resident soiled laundry as indicated in the facility's policy and procedure (P&P), titled Departmental (Environmental Services) - Laundry and Linen. This failure had the potential to result in the spread of infections throughout the facility and negatively impact the health of all residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship program (promotes the appropriate use of antibiotics) for one of four sampled residents (Resident 183). Resident 183 was administered Vancomycin (type of antibiotic) for eight consecutive days and the antibiotic administration did not meet the McGreer's criteria (infection surveillance checklist to determine appropriate antibiotic use). This failure resulted in unnecessary administration of Vancomycin to Resident 183 and had the potential to result in Resident 183 to develop resistance to the antibiotic.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 183) had a baseline care plan (CP provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan) developed and implemented within forty-eight hours of admission. This failure could result in the impediment of continuity of care and lack of communication among staff which could lead to decrease resident safety and safeguard against adverse events that could most likely occur right after admission for Resident 183.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 184) was provided an environment that promoted Resident 184's well-being by failing to provide Resident 184 with a properly working television (TV) remote control. This failure resulted in a tension between Resident 184 and her roommate and preventing Resident 184 from watching TV that helped distract her from her pain.

Inspectors wroteBased on interview and record review, the facility failed to follow a physician's order that indicated Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services for one of two sampled residents (Resident 15). This failure had the potential to result in contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and tightness of the joints) and a physical decline to Resident 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide wound care services and treatment in accordance with the facility's policy and procedures for one of two sampled residents with pressure ulcers (Resident 183) by failing to ensure Resident 183's low air loss mattress (LAL, special type of mattress used for both the prevention and treatment of pressure ulcer, a localized damage to the skin and underlying soft tissue usually over a bony prominence from prolonged pressure on the skin) was set correctly. This failure could impede in preventing the development of new pressure ulcers or result in reoccurrence of the pressure ulcers for Resident 183.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care & services for one of two sampled residents (Resident 15). Resident 15 did not receive Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services due to Resident 15 being on Coronavirus-19 (COVID-19, highly contagious virus that can affect lungs and airways and spreads form person to person) isolation (staying away/kept away from others). This failure had the potential to result contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and tightness of the joints) and a physical decline to Resident 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure an indwelling catheter (urinary catheter, a tubing inserted through the urethra and into the bladder to drain urine) tube to the leg for one of three sampled resident (Resident 232) in accordance with the facilities policy and procedure (P&P). This failure had the potential to result in a urinary tract infection (UTI, an infection of any part of the urinary system, kidneys, bladder, or urethra) to Resident 232.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Registered Dietitian (RD) evaluated and monitored weight loss for two of two sampled residents (Resident 12 and Resident 15). In addition, the facility failed to ensure Interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care for residents) meetings were held to address weight loss for one of two sampled residents (Resident 12). These failures had the potential to result in further weight loss and physical declines to Residents 12 and Resident 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 232 and 183) were provided with appropriate care and services for oxygen treatment when: a. Resident 232 received 5 L (L, unit of measurement) of oxygen instead of 2-3 L of oxygen by a nasal cannula (a tube used to deliver oxygen to help with breathing) and as indicated by the physician's order. b. Resident 183's oxygen humidifier (a medical device used to humidify supplemental oxygen to prevent the resident's airway from becoming dry) and nasal cannula tubing were not labeled with the date they were changed. These failures had the potential to result in Resident 232 to receive too much oxygen and Resident 183 to develope a respiratory infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the number of hours worked by licensed nursing and Certified Nursing Assistant (CNA) staff directly responsible for resident care within two hours of the start of each shift, in one of two Nursing Stations (Nursing Station 1), as indicated in the facility's policy and procedure (P&P), titled, Posting Direct Care Daily Staffing Number. This failure resulted in inaccurate nursing hours posted by the facility and had the potential to result in residents and family members obtaining misleading information posted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents remined free from significant medication errors for one of two sampled residents (Resident 4). This failure had the potential to result in an increased risk for adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) to Resident 4 and had the potential to result in a negative impact to Resident 4's health and physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with a nourishing, palatable, well-balanced diet when, one of one Kitchen Staff (the Kitchen Staff) served residents, who were on pureed diets (foods with a soft, pudding-like consistency), 3 ¼ ounce (oz., unit of measurement) of purred eggs and pureed hashbrowns versus a serving of 4 oz. This failure had the potential to result in unmet nutritional needs for residents that required pureed diets.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a one-to-one sitter (1:1 sitter, a staff member designated to provide constant observation) was assigned to one of five sampled residents (Resident 3) as ordered by the physician due to Resident 3 being at high risk for falls on dates 10/14/2023 to 10/15/2023 (2 days). This failure had the potential to increase Resident 3's risks for injury and/or death.

Inspectors wroteBased on interviews and record review, the facility failed to ensure sufficient qualified nursing staff were assigned and providing nursing care to two of five sampled residents (Residents 3 & 4) in accordance with the facility's policies and procedures and the Facility Assessment by failing to: A. Ensure call lights were answered and addressed in a timely manner with Resident 4's needs. B. Ensure a one-to-one sitter (1:1 sitter, a staff member designated to provide constant observation) was assigned to Resident 3 as ordered by the physician on dates 10/14/2023 to 10/15/2023. These failures had the potential to result in a decline in the Resident 3 & 4's physical and psychosocial well-being due to poor quality of care and staff burnout.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the needs of one of five sampled residents (Resident 4) was accommodated by answering Resident 4's call light and addressing the reason for her call. This failure had the potential to negatively affect Resident 4's physical and psychosocial well-being due to the delay of provision of services.