Claremont Heights Post Acute

Inspectors wroteBased on interview and record review, the facility failed to treat two of four sampled residents (Resident 1 and Resident 4) with respect and dignity when on 4/15/2026 Resident 1 and 4's urinals (a receptacle used to collect urine [a yellowish liquid waste product produced by the kidneys]) were half filled with urine and left on top of the resident's dressers. This deficient practice resulted in feelings of embarrassment to Resident 1 and Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed for two of four sampled residents (Resident 1 and Resident 4) whose urinals (a receptacle used to collect urine [a yellowish liquid waste product produced by the kidneys]) were observed half full of urine and were left on top of the resident's dressers. This deficient practice had the potential to result in bacterial growth inside the urinals and infections to Resident 1 and Resident 4. Cross Reference with F550Findings:a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of three sampled residents (Resident 1, 6, and 54) were treated with dignity when:a. Certified Nursing Assistant (CNA) 6 left Resident 54's lower body exposed. b. CNA 12 stood over in front of Resident 1 while assisting Resident 1 to drink during lunch. C. Speech Therapist (ST) was standing while feeding Resident 6. These deficient practices resulted in Resident 54 feeling uncomfortable, cold and naked and had the potential to cause Resident 1, 6 and 54 feeling humiliated, negatively impacting the residents' psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy and procedure (P&P) titled, Advance Directives, for two of two sampled residents (Resident 4 and Resident 35) when:1. Copies of Resident 4's and Resident 35's advance directives (AD-a legal document that provides instructions for medical care when a person can no longer decide on their own) were obtained and filed in Resident 4's and Resident 35's medical records.2. The Social Services Director (SSD) did not ensure the Durable Power of Attorney (DPOA, a legal document allowing another person to manage one's financial, legal, or medical affairs when one can no longer decide on their own) filed in Resident 35's medical records also covered medical or healthcare decisions. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments) for three of three residents (Resident 103, 13, and 67) as evidenced by:Failure to develop a CP for Resident 13's behavior of pulling and removing Resident 13's gastrostomy tube (GT - medical feeding tube inserted through the abdomen directly into the stomach to deliver nutrients, fluids, and medications.)Failure to develop a CP for Resident 67's personal preference to apply tape to the eyelids. Failure to develop a CP for Resident 103's admission to hospice care. These failures had the potential for Resident 103, 13 and 67 to not obtain their highest physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure appropriate and necessary care and services were provided for three of three sampled residents (Residents 58, 105 and 29) by failing to:A. Ensure Resident 58's physician order for Tresiba (a once-daily long-acting injectable insulin [a hormone that removes excess sugar from the blood] used to improve blood sugar control) contained administration parameters (specific instructions that must be followed when giving insulin). B. Ensure Resident 58's blood sugar levels were checked prior to administering Tresiba. These deficient practices had the potential to result in serious health complications for Resident 58. C. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods brought in from outside of the facility were stored properly for two of two sampled residents (Resident 105 and Resident 4), in accordance with the facility's policy and procedure (P&P) titled, Food Brought in by Visitors. This deficient practice placed Resident 105 and Resident 4 at risk for serious complications from food borne illnesses (any illness resulting from eating contaminated/spoiled foods).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices by failing to ensure two of two sampled residents' (Resident 105's and Resident 50's) personal care items were labeled and stored properly. This deficient practice had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and/or the development and transmission of disease (an illness or sickness) and infections for Resident 105 and Resident 50.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe and clean environment for one of one sampled resident (Resident 76) when the wall in Resident 76's room was observed with a red tinged substance. These failures resulted in Resident 76 living in an unclean environment and had the potential to result in psychosocial decline to Resident 76.

Inspectors wroteBased on interview and record review, the facility failed to provide evidence that the use of physical restraints (any manual method, physical or mechanical device, equipment, or material that restricts the resident's freedom of movement or normal access to his/her body) for one of one sampled resident (Resident 13) was a measure of last resort to protect the safety of the resident. This deficient practice had the potential for Resident 13 to be restrained unnecessarily and could negatively impact Resident 13 mentally, psychosocially and increase the risk for impaired skin integrity.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 35's) 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), was revised after Resident 35 had a significant weight loss (5% in 1 month or 10% in 6 months of total body weight). This deficient practice had the potential to result in the continued implementation of an ineffective or inadequate CP interventions to prevent Resident 35 from further unplanned weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure the nursing staff had the appropriate competencies and skills sets necessary to care for residents' needs and related services when the facility:a. Failed to provide documentation indicating nursing staff (general) had been trained in the use of physical restraints (any manual method, physical or mechanical device, equipment, or material that restricts the resident's freedom of movement or normal access to his/her body) while one of one sampled residents (Resident 13) used bilateral mitten restraints (specialized glove that covers the fingers and palm designed to limit the ability to grip or pull at medical lines and devices) and an abdominal binder (compressive, elastic garment worn to reduce access to medical devices.b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three Certified Nursing Assistant's (CNA 15's) performance review was completed at least once every 12 months. This deficient practice resulted in the facility not assessing and evaluating the necessary skills and competencies of CNA 15 and placed residents assigned to CNA 15 at risk for inadequate and unsafe care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were not left at the bedside for one of one sampled resident (Resident 73) when Resident 73's Calcium Carbonate oral chewable tablet (generic for Tums, over the counter medication containing calcium carbonate designed to relieve heartburn, sour stomach, acid indigestion and upset stomach) was found on Resident 73's bedside table on 2/24/2026. This failure had the potential for Resident 73 to choke or take more medication than prescribed.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's protocol for antibiotic stewardship for one of one sampled resident (Resident 106). Resident 106 was screened for pneumonia (an infection that causes the lungs to fill with fluid or pus) and prescribed levofloxacin (a strong broad-spectrum antibiotic used for bacterial infections like pneumonia) without meeting the necessary criteria. This deficient practice had the potential for Resident 106 to develop antibiotic resistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan's (CP) interventions to keep bilateral (both sides) floor mats next to the bed for one of two sampled residents (Resident 2). This deficient practice had the potential to result in unmet individualized needs for Resident 2 and the potential to affect the resident's physical well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Certified Nursing Assistant 1 (CNA 1), CNA 2, and Licensed Vocational Nurse 1 (LVN 1) responded in a timely manner to requests for assistance to the bathroom for one of one resident (Resident 4). This deficient practice resulted in Resident 4 having unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system was functioning to allow one of one resident (Resident 4) to call for staff assistance. This deficient practice had the potential for Resident 4 to have unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse 4 (LVN 4) immediately notified the physician and the family for one of six sampled residents (Resident 2) after Resident 2's unwitnessed fall on 11/12/2025 at 6:30 pm. This failure had the potential for Resident 2 to receive inappropriate care and had the potential to delay the assessment and treatment of Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe environment and protect one of six sampled residents (Resident 3) from physical abuse (aggressive or violent behavior with the intention to cause physical harm) and mistreatment when Certified Nursing Assistant 6 (CNA 6) roughly placed Resident 3 into a wheelchair, brushed Resident 2's hair roughly, and yelled at Resident 3 on 11/25/2025. This deficient practice had the potential to place Resident 3 at risk for physical and psychosocial harm.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1), who had diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life), had a history of fall (unintentionally coming to rest on a lower-level surface) on 6/1/25, and was assessed at a high fall risk on 6/1/25, received care needs and services to prevent a fall on 6/19/25 by failing to ensure:Licensed Vocational Nurse (LVN) 2 monitored (observed and checked) and promptly (quickly/rapidly/immediately) redirected Resident 1 (direct Resident 1 to a new or different place or purpose) when Resident 1 got up from Resident 1's wheelchair unassisted while Resident 1 was at Nurses' Station 1 on 6/19/25 [at around 10 am]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the residents' right for dignity for two of five sampled residents (Residents 3 and 4) when:A. Resident 3 was observed with a large wet stain in the inner and middle area of Resident 3's pants. B. Resident 4 was observed sitting in Resident 4's wheelchair in the facility dining room with a large wet stain on both sides and the middle area of Resident 4's shorts. These failures had the potential to result in low self-esteem and humiliation for Residents 3 and 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) received adequate supervision to prevent an elopement (when a patient leaves a healthcare facility without authorization or proper discharge). On 6/23/25, Resident 2 was found on the ground outside the facility with a bleeding laceration (type of open wound) on Resident 2's left eyebrow area. This failure resulted in Resident 2 sustaining bruising around the left eye and a laceration on Resident 2's left eyebrow which required 3 stitches. Resident 2 was transferred to General Acute Care Hospital (GACH) 1 for evaluation and for stitches to left eyebrow laceration after Resident 2 fell on 6/23/25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained two of five sampled residents' (Resident 3's and Resident 4's) dignity when: 1. Certified Nursing Assistants (CNAs) (unidentified) on the night shift (11 pm to 7 am shift) would sometimes leave Resident 4 uncovered and with Resident 4's gown up to assist another resident (unidentified). 2. An unidentified male staff and CNA 4 only asked what Resident 5 (Resident 3's roommate) needed and not Resident 3, when the unidentified male staff and CNA 4 answered the call light (a device used by a resident to signal their need for assistance from staff) in Resident 3's and Resident 5's room on 5/29/2025. This failure caused Resident 4 to feel that Resident 4 was put aside and the CNAs did not concentrate on Resident 4's care. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures (P&Ps) titled, Pressure Injury (PI- refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence) Prevention and Skin and Wound Management, for one of five sampled residents (Resident 1) when: 1. Resident 1 developed additional pressure injuries on the left buttocks/ischium (a paired bone forming the lower and back part of the hip bone) and on both heels 22 ½ hours after Resident 1 was admitted to the facility on [DATE]. 2. Resident 1's level of risk for development of pressure ulcers (PUs/PIs) was not accurately assessed upon admission on [DATE]. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses and certified nursing assistants (CNAs) knew how to properly care for one of one sampled resident (Resident 2) with a nephrostomy tube (a tube used to drain urine directly from the kidney into a bag). Consequently, this failure resulted in Resident 2's nephrostomy tube to become dislodged and for Resident 2 to receive inappropriate care. Consequently, Resident 2 was transferred to the general acute care hospital (GACH) 2 's emergency department (ED) for evaluation and reinsertion of the nephrostomy tube on 5/17/2025 and on 5/20/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Infection Prevention and Control Program for two of five sampled residents (Resident 3 and Resident 4) by failing to ensure: 1. Certified Nursing Assistant 1 (CNA 1) wore a protective gown when CNA 1 removed Resident 4's splints (devices used to immobilize a body part) while Resident 4 was in bed on 5/28/2025. Resident 4 had wounds and an indwelling urinary catheter (a flexible tube left inside the bladder and used to empty the bladder and collect urine in a drainage bag). 2. CNA 2 and CNA 3 wore a protective gown when they provided care to Resident 3 on 5/28/2025. Resident 3 had wounds and an indwelling urinary catheter. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one of five sampled resident ' s (Resident 9) physician of Resident 9 ' s refusal of blood tests. This failure had the potential for Resident 9 to experience a decline in health and well-being. (Cross Reference F656)

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of five sampled residents (Residents 9) by failing to: a. Ensure the facility included in Resident 9's care plan interventions addressing Resident 9 ' s behavior of refusing the ordered weekly blood tests. b. Ensure the facility included Resident 9's ordered blood tests in the interventions of the untitled care plan, initiated on 2/29/2025. These failures had the potential for Residents 9 not to receive interventions to address the Resident 9's specific needs and experiencing harm. (Cross Reference F580)

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents (Residents 10, 11, and 12), were assessed before, during, and after dialysis (the process of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions naturally) and/or assessment documentation was placed in the residents ' medical records according to the facility ' s policy and procedure (P&P), titled, Dialysis Management, revised 1/25/2024. These failures had the potential for Residents 10, 11, and 12 to experience complications associated with dialysis and for the facility staff to not provide lifesaving interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sample resident ' s (Resident 5) controlled medication (a drug that is tightly controlled by the government), morphine sulfate (used to treat moderate to severe pain), was accurately inventoried and reconciled to Resident 5 ' s Medication Administration Record (MAR). This failure had the potential for the diversion of Resident 5 ' s morphine sulphate.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure safe provision of pharmaceutical services for two of two sampled residents (Resident 10 and 11) by failing to: 1. Ensure Resident 10's physician ordered medication Cilostazol and Memantine HCI were not on the desk at Nurse Station (NS) 1 unsupervised. 2. Ensure Resident 11's physician ordered medication Metoprolol was not on the desk at NS 1 unsupervised. These deficient practices had the potential for diversion of medication and/or ingestion by other residents of the facility which could lead to harm.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's influenza immunization (flu vaccination, protect against infection by influenza viruses) and/or pneumococcal immunizations (pneumococcal vaccine [PCV] protects against infections caused by the bacterium Streptococcus pneumoniae) program for four of seven sampled residents (Resident 1, 2, 3, and 4) when: a. For Resident 1, who refused the flu vaccination on 10/7/2024, the facility failed to document that education was provided regarding risk vs benefits of taking an influenza vaccination. Resident 1's medical record did not contain a signed declination for the flu vaccination. b. Facility staff administered a flu vaccination to Resident 2 on 10/1/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's Covid-19 (a respiratory illness caused by a virus that easily spreads from person to person) immunization (Covid vaccination, a vaccine intended to provide immunity against Covid-19) program for three of seven sampled residents (Resident 2, 4, and 5) and all facility staff when: a. The facility failed to offer the latest covid vaccination to Resident 2. b. The facility failed to administer a covid vaccination to Resident 4 after Resident 4 signed an informed consent on 2/5/2025 to receive the covid vaccination. c. For Resident 5, who received a covid vaccination on 4/24/2024, the facility failed to document if Resident 5 was provided education regarding the benefits and potential risks associated with the covid vaccination. d. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate an individual as the infection preventionist (IP, oversees the facility Infection Prevention and Control program) on 2/24/2025 to 2/25/2025 and while the facility was having a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) outbreak (at least three COVID-19 positive cases in the facility within a seven-day period among residents and/or staff). This failure had the potential for the facility's Infection Prevention and Control program to not be implemented which could result in residents (in general), staff, and visitors contracting and spreading Covid-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the spread of infections to all 93 residents of the facility during the Coronavirus-19 (COVID-19 an illness caused by a virus that can spread from person to person) outbreak (OB-the occurrence of disease cases in excess of normal expectancy) in the facility by failing to ensure: 1. Activity Assistant (AA) 1 did not remove AA 1's N95 mask (a respiratory protective device designed to have a very close facial fit over the nose and the mouth, and filters airborne particles) while standing in the hallway in the resident care area where residents and other staff were. 2. Certified Nursing Assistant (CNA) 1 had CNA 1's N95 mask on correctly on 2/18/25 and was able to demonstrate how to properly don (put on) an N95 mask. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and orderly discharge for one of six sampled residents (Resident 2) by failing to ensure: 1. Resident 2's skin assessment was done and documented upon Resident 2's discharge from the facility on 2/3/25. 2. Resident 2's skin condition was communicated to the receiving facility. These failures resulted in an incomplete and unsafe discharge of Resident 2 and had the potential to negatively impact Resident 2's health, safety, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide needed care and services to 2 of 6 sampled residents (Residents 2 and 4) when: 1. Resident 2's clinical record did not indicate how Resident 2 scratched Resident 2's right leg and sustained a right leg wound on 1/23/25. 2. Resident 2's treatment order, dated 1/23/25, for Resident 2's right leg wound was not transcribed (to put in written or printed form) in Resident 2's clinical record until 1/24/25 and was not transcribed in Resident 2's Treatment Administration Record (TAR). There was no documented evidence wound treatment was provided to Resident 2's right leg wound according to the physician's order. 3. There was no documented evidence in Resident 4's clinical record to indicate Resident 4 had teeth extraction at the bedside on 1/23/25. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical record for 3 of 6 sampled residents (Residents 2, 3, and 4) was complete and accurate when: 1. Resident 2's clinical record did not indicate how Resident 2 scratched Resident 2's right leg and sustained a right leg wound on 1/23/25. 2. Resident 2's treatment order, dated 1/23/25, for Resident 2's right leg wound was not transcribed (put into written or printed form) in Resident 2's clinical record until 1/24/25 and was not transcribed in Resident 2's Treatment Administration Record (TAR). 3. Resident 3's clinical record did not indicate where Resident 3's tooth extraction was performed on 12/9/24. 4. There was no documented evidence in Resident 4's clinical record to indicate Resident 4 had teeth extraction at the bedside on 1/23/25. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff promoted dignity while assisting three of three sampled residents (Residents 55, 19 and 52) during meals when the facility fed Residents 55, 19 and 52 and did not maintain eye level with the residents. This deficient practice had the potential to affect Resident 55's, 19's and 52's self-worth and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, two of five sampled residents (Resident 54 and 286) were free of unnecessary drugs by failing to: 1A, 1B. Indicate specific targeted behaviors for the administration of antipsychotic medications (main class of drugs used to treat people that have mental disorders like schizophrenia [mental disorder characterized by loss of contact with the environment]) for Resident 54 and 286. 2. Ensure Resident 54's physician order for Lorazepam (medication used to treat anxiety disorders) indicated the duration for the use of the medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed for four of fourteen sampled residents (Resident 72, 4, and 58) by failing to: A. Ensure Resident 7 's restroom's toilet was kept and maintained under sanitary conditions. B1 and B2. Ensure unlabeled personal toiletry was not stored inside the shared restroom of Resident 4 and 58. These deficient practices resulted in contamination of the resident's environment and had the potential to result in cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with a harmful effect) between the residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide and/or document the provision of vaccination (a simple, safe and effective way of protecting you against harmful diseases, before you come into contact with them) to three of three sampled residents (Residents 22, 23 and 32) during the flu season (per CDC, in the United States, flu viruses typically circulate during the fall and winter between December and February). This deficient practice had the potential to put Residents 22, 23 and 32 at risk for influenza infection during the flu season.

Inspectors wroteBased on interview and record review, the facility failed to provide and/or document the provision of pertinent information regarding the immunizations (a process by which a person becomes protected against a disease [a disorder of structure or function in a human, animal, or plant]) through vaccination (a simple, safe and effective way of protecting you against harmful diseases, before you come into contact with them) for 9 of 21 residents upon admissions (Residents 43, 185, 186, 286, 335, 337, 338, 339, 340 ) regarding the benefits and potential side effects of the COVID-19 (a mild to severe respiratory illness that spread from person to person). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled discharged residents (Resident 83's), physician was informed of Resident 83 leaving the facility Against Medical Advice (AMA, when a resident chooses to leave the hospital before their doctor recommends discharge) as indicated by the facilits's policy and procedure (P&P) titled, Discharge Against Medical Advice. This deficient practice had the potential for Resident 83 not to be adequately prepared for a smooth transition back home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 67) was provided with a comfortable and homelike environment during lunch in the dining room area, when, On 1/6/2025, Resident 72, repeatedly, regurgitated and spit into a trashcan located inside the dining room area without staff intervention. Due to this action, Resident 67, who witnessed the incident, felt uncomfortable, nauseated, and lost her appetite. This deficient practice had the potential to result in a decline in Resident 67's physical and psychosocial well-being and the potential for no communal dining participation by Resident 67.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 185) 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]) as indicated in the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a form where licensed nurses can summarize a person's health conditions, specific care needs, and current treatments), for one of one sampled resident (Resident 43), that addressed Resident 43's impaired vision. This deficient practice had the potential to result in unmet individualized needs for Resident 43 and the potential to affect the resident ' s physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 285) was provided care and services to maintain good grooming and personal hygiene. This deficient practice resulted in no fingernail care to Resident 285 and had the potential to negatively impact Resident 285.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the low air loss mattress (LAL, a mattress designed to distribute body weight and prevent and treat pressure wounds) was set correctly for one of three sampled residents (Resident 76) who was at risk for developing pressure ulcer/injury (PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). This failure had the potential to result in the development of a PI to Resident 76.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 185) who was receiving enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) through a gastrostomy tube (GT, a tube inserted through the belly to bring nutrition and/or medications directly to the stomach) received appropriate care and services as indicated in the physician order. This failure had the potential to result in Resident 185 to aspirate (when something like a fluid or solid enters your airway or lungs by accident) that could lead to serious health problems and complications such as pneumonia (infection in the lungs).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 185) received proper respiratory (relating to breathing) care such as oxygen (02, a colorless, odorless, tasteless gas essential for living) therapy to meet Resident 185's needs consistent with professional standard of practice and in accordance with the physician's order. This failure had the potential to cause Resident 185's respiratory status (the movement of air in and out of the lungs and exchange of carbon dioxide [a colorless, odorless gas] and 02 at the alveolar level [alveoli, the functional units of the lung with the overall task to warrant gas exchange, i.e., 02 supply and carbon dioxide removal from the body]) to be compromised that could potentially lead to hypoxia (a medical condition that occurs when there is a lack of oxygen in the body's tissues).

Inspectors wroteBased on interview and record review, the facility failed to communicate the pharmacy recommendations for one of five sampled residents (Resident 68). When, for Resident 68, the facility did not follow pharmacy recommendations to obtain laboratory test (labs) for Complete Metabolic Panel (CMP, a blood test that measures the levels of various substances in blood), Complete Blood Count (CBC, a blood test that measures the number and types of cells in your blood), Lipid Panel (a blood test that measures the amount of lipids, or fats, in your blood), A1C (a blood test that measures the average level of blood sugar in your body over the past three months) and Thyroid-stimulating hormone (TSH, indicate whether your thyroid is producing the right amount of thyroid hormones) for Resident 68. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 10) observed during medication pass (term used to describe the process through which medication is administered [given] to patients) was free of significant medication errors by failing to ensure Resident 10's eye drop medication, TobraDex (a medication used for eye infections caused by certain bacteria, and to help relieve eye inflammation and swelling from the infection) was administered properly in accordance with professional standard of practice and the facility's policy and procedure (P&P). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by failing to ensure one of one kitchen staff (Cook [CK] 1) was wearing a beard net during the preparation of food. This deficient practice had the potential to result in foodborne illnesses (also called food poisoning caused by eating contaminated food with infectious organisms) for the residents in the facility who were able to consume the food.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accuracy of medical records for one of one sampled resident (Resident 54) by failing to ensure there was a physician's order for the use of a LAL (LAL, a mattress designed to distribute body weight and prevent and treat pressure wounds) mattress in Resident 54's medical record. This deficient practice had the potential to result in inconsistent or inaccurate treatments provided to Resident 54.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 24) had coordinated care between the facility and the hospice (provides medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness) agency, by ensuring Resident 24 had calendars to notify staff when the hospice staff visited and/or have sign in/flow sheets indicating the type of care that was provided while the hospice staff was at the facility. This deficient practice had the potential for Resident 24 not receive the appropriate and coordinated care and/or services from the facility and the hospice agency needed by Resident 24.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's Policy and Procedure for Antibiotic Stewardship Program (ASP, a set of actions that work to improve how antibiotics are used in healthcare settings. ASPs aim to ensure that antibiotics are prescribed and used appropriately, which can lead to better patient outcomes and reduced antibiotic resistance.) for one of three sampled residents (Resident 40). This deficient practice had the potential to increase Resident 40's antibiotic resistance (occurs when bacteria no longer respond to the antibiotics, the antibiotics become ineffective and infections become difficult or impossible to treat increasing the risk of disease spread, severe illness, disability, and death).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 3), were provided a clean, comfortable, and homelike environment. This failure resulted in Resident 3 to feel dirty and uncomfortable and had the potential for Resident 1 and other residents in the facility to not feel safe and comfortable. (Cross Reference F880)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four shower rooms (Shower Rooms 3, 7, and shower room next to room [ROOM NUMBER]) were clean and in good repair. This failure had the potential for the shower rooms to harbor growth of bacteria (microscopic organisms, some can make a person sick) and had the potential to cause residents to become sick with bacterial infections. (Cross Reference F584)

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received medications as ordered by Resident 1's physician. This failure resulted in Resident 1 to feel uncomfortable and had the potential for Resident 1 to experience a decline in his health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized person-centered plan of care (CP) timely that included measurable objectives, timeframes, and interventions to meet the needs of 1 of 3 sampled residents (Resident 1) as indicated in the facility's policy & procedure (P&P) titled, Comprehensive Person-Centered Care Planning, by failing to: 1. Develop an individualized/person-centered CP that included goals and interventions that addressed Resident 1's depression, Resident 1 feeling down, depressed, or hopeless and after Resident 1's Patient Health Questionnaire (PHQ, a self-administered tool that assessed mental health and used to screen for depression) evaluation, dated 9/19/2024, indicated Resident 1 had moderate depression. [...]

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse 4 (LVN 4) failed notify the primary care provider (MD 1) regarding one of three sampled resident's (Resident 3) change in condition on 3/1/2024. Certified Nursing Assistant 5 (CNA 5) reported to LVN 4 Resident 3's seizure-like (sudden, uncontrolled body movements and changes in behavior due to abnormal electrical activity in the brain) episode and unresponsiveness on 3/1/2024 at around 8 AM and seizure precautions (additional safety measures taken to prevent injury during a seizure) were not implemented for Resident 3. On 3/1/2024, in the Activity Room and at around 2 PM. Resident 3 was observed having seizure-like activity and fell from Resident 3's wheelchair. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for one of three sampled residents (Resident 2) by failing to: 1. Ensure Certified Nursing Assistant 2 (CNA 2) was aware of Resident 2's high risk for falls, prior attempts of getting up from wheelchair, and capability to propel Resident 2's wheelchair. 2. Ensure Resident 2 had the call light within reach when Resident 2 was left unsupervised (unattended, not watched) in Resident 2's room. As a result, on 2/22/2024 at 7:30 PM., Resident 2 fell when Resident 2 stood up from Resident 2's wheelchair while attempting to grab a chocolate located on a vanity (piece of furniture with a built-in basin for performing one's toilette or personal grooming) in Resident 2's room. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 7 and Resident 8) were treated with respect and dignity by failing to answer call lights (a visual cue that a patient needs assistance) in a timely manner. a. On 1/18/24, Resident 7 waited one hour to get Resident 7's soiled adult brief changed. b. On 1/18/24, Resident 8 waited one hour to get Resident 8's soiled adult brief changed. These failures resulted with Resident 7 to feel forgotten and like no one cared about Resident 7 and Resident 8 to feel very angry and upset.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and accident-free environment for one of three sample residents (Resident 2). This failure had the potential to result in a fall and injury to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement care plans for three of three sampled residents (Residents 193, 4, and 19). a. For Resident 193, a weight loss care plan (CP, document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) was not developed. b. For Resident 4, the facility did not implement daily cleansing of the Continuous Positive Airway Pressure (CPAP- a machine that uses constant air pressure through a mask to keep breathing airways open while sleeping) mask as indicated in the CPAP care plan. c. For Resident 19, there was no CP in Resident 19's medical record that addressed Resident 19 had missing teeth. These failures had the potential to result in a decline in physical well-being for Residents 193, 4 and 19.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents' (Resident 5 and Resident 23) pharmacy recommendations identified from the Medication Record Review (MRR, or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) were thoroughly acted upon as indicated in the facility's policy and procedure (P&P) titled, Drug Regimen Review. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled properly and discarded after the expiration date for two of two sampled residents (Resident 4 and 14) in accordance with the facility's policy and procedure (P&P) titled, Medication Storage in the Facility. This deficient practice had the potential to result in administration of expired medications or medications not being effective for Residents 4 and Resident 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance. The meatloaf was not served in correct portion sizes. This deficient practice placed 48 of 92 facility residents at risk for unplanned weight loss, a consequence of poor food intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in one of one kitchen (Kitchen 1) when: a. A bottle of prune juice was not labeled and dated. b. Two (2) reach-in-freezers had dirt and dust debris on the bottom shelves. c. Five (5) one (1) gallon (gal., a unit of measurement) of 2% low fat milk were expired. d. One (1) green chopping board with food residue was stored with the clean chopping boards by the preparation area. e. A container full of kitchen utensils such as three (3) whisk beater (a kitchen tool used for beating eggs and cream), spatula (a kitchen utensil that had a broad flat part with narrow holes in it attached to a long handle used for turning and lifting food when cooking), food brush, two (2) serving spoons had dirt and food residue. f. Pots and pans were not air dried. g. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for six of six sampled residents (Resident 32, Resident 58, Resident 34, Resident 37, Resident 64, and Resident 4) by: a. Failing to store an unlabeled commode (a portable toilet that looks like a chair and has a bucket-like receptacle beneath it used by someone who needs help going to the toilet) bucket properly. b. Failing to keep Resident 37's oxygen (02, a colorless, odorless, tasteless gas essential to living organisms) nasal cannula tubing (N/C, a medical device placed in the nostrils used to administer supplemental 02) off the floor. c. Failing to store Resident 34's 02 N/C properly when not in use. d. Failing to keep Certified Nursing Assistant (CNA) 6's shoes off Resident 64's bed. e. Failing to ensure two of three laundry dryer's lint traps were free of lint. f. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal the need for assistance) system was accessible to residents and functioning as indicated in the facility's policy and procedure (P&P) titled, Communication - Call System. a. For 34 of 43 resident rooms (Rooms 1, 2, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 18, 19, 20, 21, 22, 23, 26, 29, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44 and 45), the bathroom call lights did not have a cord long enough for residents to pull during an emergency if they were lying on the floor. b. For one of one sampled resident (Resident 2), Resident 2's call light (bedside) did not illuminate outside and above Resident 2's doorframe to alert staff Resident 2 needed assistance. c. For one of two sampled residents (Resident 46), Resident 46's call light was not within reach. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's call light was within reach for one of one sampled resident (Resident 52). This deficient practice had the potential for Resident 52 not to receive needed care and services in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure information regarding the resident's right to formulate an Advance Directive (AD, a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual becomes disabled) was provided to the resident's responsible party for two of two sampled residents (Residents 52 and 45). This deficient practice had the potential for Residents 52 and 45 to receive life-sustaining care and/or treatment not in accordance with the resident/responsible party's wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the use of soft mitten restraints (large glove that covers the hand used to restrict freedom of movement or access to one's body) was necessary and in accordance with the facility's policy and procedure titled, Restraints, for one of one sampled resident (Resident 12) by failing to: 1. Attempt to use the least restrictive alternative prior to the use of soft mitten restraints. 2. Notify Resident 12's physician and obtain an order for the use of soft mitten restraints. 3. Monitor Resident 12 and document the use of soft mitten restraints. These deficient practices had the potential to violate Resident 12's right to be free from unnecessary use of physical restraint and right to be treated with respect and dignity.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of staff to resident verbal abuse within two hours to the California Department of Public Health (CDPH, a government agency that promotes and protects the health of people and their communities), law enforcement, and the Ombudsman (advocates for residents of nursing homes) as indicated in the facility's policy and procedure titled, Abuse - Reporting & Investigation, for one of 20 sampled residents (Resident 21). This deficient practice violated the State mandated reporting timeframe and had the potential to subject Resident 21 to further verbal abuse that could result in harm.

Inspectors wroteBased on interview and record review, the facility failed to transmit a Minimum Data Set (MDS) within 14 days after a resident was discharged from the facility for one of one sampled resident (Resident 18). This failure had the potential to result in inaccurate assessments of the facility's quality indicators and/or care area concerns for review.

Inspectors wroteBased on interview and record review, the facility failed to revise a comprehensive care plan for hemodialysis (HD, also called dialysis, a process that removes waste from your blood when your kidneys can no longer do their job) for one of one sampled resident (Resident 4), as indicated in the facility's policy and procedure (P&P) titled, Dialysis Care. Resident 4's care plan was not updated to include interventions that addressed Resident 4's new arteriovenous shunt (AV shunt, abnormal connections made between blood vessels for the purpose of providing HD). This failure had the potential to result in Resident 4 to not receive appropriate interventions used to prevent complications or avoid harm to Resident 4.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide two of two sampled residents (Resident 37 and Resident 34) proper respiratory care in accordance with the facility's policy and procedure (P&P), titled, Oxygen Therapy. by failing to label the oxygen (02, a colorless, odorless, tasteless gas essential to living organisms) nasal cannula tubing (N/C, a medical device placed in the nostrils used to administer supplemental 02) and keep the tubing off the floor. This failure had the potential to result in unsafe delivery of 02 to Resident 37 and Resident 34 from old and compromised tubing. In addition, there was a potential for bacteria to grow in the tubing, increasing the risk for infection to Residents 37 and Resident 34.

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed (PRN) order for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) was limited to 14 days or had documented rationale in the resident's medical record and indicated the duration for the PRN order for one of five sampled residents (Resident 35). This deficient practice had the potential to result in unnecessary use of psychotropic medication for Resident 35 and could result in adverse side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as followed: a. Dishwasher 1 (DW 1) failed to follow the manufacturer's guidelines when checking the concentration of the dish machine chlorine solution. b. Dietary Aide 1 (DA 1) failed to follow the manufacturer's guidelines when checking the Quaternary Ammonium Compounds (Quats, a group of chemicals used to disinfect surfaces and equipment) sanitizer concentration. These failures had the potential to result in cross-contamination (a transfer of bacteria from one object to another), ineffective dish machine, and unsanitized food preparation areas that could lead to food borne illness (an illness caused by contaminated food and beverages) in 90 of 92 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide individual food preferences for one of one sampled residents (Resident 195). This deficient practice had the potential to cause psychosocial harm and decrease food intake resulting in weight loss for Resident 195.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for five of five sampled residents (Resident 70, 34, 72, 75 and 87) in accordance with the facility's policy and procedure (P&P) titled, Maintenance Service. This deficient practice had the potential to result in compromised safety and no home-like environment for Residents 70, 34, 72, 75 and 87.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standard infection control practices 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 procedures (P&P) by failing to a. Ensure Certified Nursing Assistant 1 (CNA 1) performed hand hygiene before and after contact with the Resident 7 and Resident 7's environment. b. [...]