Clearwater Healthcare Center

Inspectors wroteBased on interview, and record review, the facility failed to ensure medications were administered according to physician orders for one of one sampled resident (Resident 1) when:1. Resident 1's blood pressure medications were administered without following the set parameters for multiple days during June of 2026; and,2. Resident 1's vaginal cream was administered incorrectly for 3 days. These failures had the potential to negatively affect the health and well-being of Resident 1 including hypotension (low blood pressure) and vaginal bleeding.

Inspectors wroteBased on interview, and record review, the facility failed to ensure medical records were complete and accurate in accordance with professional standards for one of three sampled residents (Resident 1) when:Resident 1's low air mattress (LAL, a specialized powered air mattress used primarily in healthcare designed to prevent and treat pressure injuries to skin) checks were not documented every shift daily in the medical record per physician's orders; and,Resident 1's turning and repositioning was not documented every two hours in the medical record. These failures resulted in inaccurate documentation in Resident 1's medical record and had the potential for decreased well-being for Resident 1.

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of four sampled residents (Resident 1) when Resident 2 struck Resident 1 on his head with a metal cane (walking stick used for stability) on 4/6/26. This deficient practice resulted in Resident 1 sustaining a head laceration(cut) that required hospital transfer for the treatment and wound closure with staples (a metal fastener used by doctors to close deep cut or surgical incision).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of one of three sampled residents (Resident 3), when Resident 3 was repeatedly yelling for help and activated the call light (a device used to request assistance), and staff did not respond in a timely manner. This failure placed Resident 3 at risk for unmet care needs, accidents or injury, and had the potential to negatively affect Resident 3's psychosocial well-being (overall emotional and social health).

Inspectors wroteBased on interview and record review, the facility failed to permit Resident 1 to return to the facility following a hospitalization and in accordance with a facility established policy when:1. Resident 1 was transferred to the hospital on 4/7/26 for a suprapubic catheter (a medical device inserted through an incision in the lower stomach that helps drain urine from your bladder) change and the facility did not allow Resident 1 to return to the facility on 4/8/26 when the hospital informed the facility Resident 1 was ready to be sent back; and2. Resident 1's medical record did not include documentation from the physician which indicated the needs that could not be met by the facility and the attempts the facility made to meet those needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Notice of Discharge (NOD - an official, written document stating a nursing home intends to discharge a resident from the facility) for Resident 1 when the facility refused to readmit Resident 1 on 4/9/26, following Resident 1's transfer from the facility to the hospital on 4/7/26, resulting in a facility-initiated discharge without a completed NOD provided to Resident 1 and to the Ombudsman (advocate to protect resident rights). This failure resulted in Resident 1 being discharged without a clear and coordinated discharge plan, including continuity of care, placed Resident 1 at risk for an unsafe transition of care, and prevented timely Ombudsman advocacy and oversight to protect resident rights.

Inspectors wroteBased on record review, and interview, the facility failed to develop and implement a comprehensive, person-centered care plan to address the identified tracheostomy stoma care needs for 1 of 2 sampled residents (Resident 1) reviewed for respiratory care. Resident 1 was admitted with a tracheostomy stoma; however, the facility did not develop a care plan that included measurable goals and interventions for monitoring, assessment, and care of the tracheostomy stoma site. The omission existed from admission through the resident's transfer to the hospital, placing the resident at risk for unmet respiratory and nursing care needs, delayed identification of complications, and inconsistent care delivery among staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide post-fall monitoring and interventions to prevent falls and identify changes in condition for one of three sampled residents (resident 5) when Resident 5 had anunwitnessed fall and was transferred to the emergency room (ER) due to hypotension (low blood pressure) and bradycardia (slow heart rate) on 12/10/25 and on 12/17/25. This failure had the potential to delay the identification and treatment of head injuries, hypotension, bradycardia, and other changes in condition, placing Resident 5 at risk for additional falls, injury, and emergency medical intervention. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices for one of three sampled residents (Resident 4) when soiled linens from Resident 4's roommate (Resident 3), who was on Enhanced Barrier Precautions (EBP - use of personal protective equipment or PPE, such as gowns, gloves, and masks, during care of residents who may be at higher risk of spreading germs and infection) were placed on the bathroom sink in the bathroom used by Resident 4, creating a potential source of contamination. This failure had the potential to expose Resident 4 to germs that can cause infection and increase the risk of infection transmission within the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete a safe and coordinated discharge for Resident 1 when Resident 1 was transferred to an Independent Living Facility (ILF) that could not accommodate his need to use a wheelchair. This failure caused Resident 1 psychosocial distress and had the potential to result in physical injury or harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate transfer and discharge information was communicated to the receiving provider for Resident 1. This failure caused Resident 1 to be transferred to a facility that could not meet his needs and had the potential to negatively impact the safety and well- being of Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) at risk of wandering/elopement received adequate supervision to prevent an elopement (when a resident leaves the facility without supervision) from occurring, when:1. Resident 1 did not have a care plan (a personalized, living document developed by healthcare professionals, patients, and families to manage health conditions, define care needs, and establish goals for daily living, treatment, and support) developed to address his known drug use; and,2. Resident 1 left the facility unsupervised with staff unaware of his location on 1/25/26. These failures had the potential to cause psychosocial harm and/or potential injury to Resident 1.

Inspectors wroteBased on interview, and record review, the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of two sampled residents (Resident 1) when the substance use history section of Resident 1's admission nursing assessment was inaccurately documented. This deficient practice had the potential to result in confusion in the care and services for Resident 1 and placed Resident 1 at risk of not receiving appropriate care due to inaccurate and incomplete documentation.

Inspectors wroteBased on interview, and record review, the facility failed to safely discharge on e of one sampled resident (Resident 1) home with home health agency services (HHA, medical services provided at home) when Resident 1 was discharged home on [DATE], and the home health agency notified the facility they could not start home health services on 12/18/25. This failure had resulted in Resident 1's lack of home health services that caused a delay in the continuity of care following her discharge from the facility and had the potential risk for falls, injuries, and of readmission.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate and timely social services support for one of three sampled residents (Resident 1) when, the facility was made aware of Resident 1's wish to leave the facility approximately one month post admission due to not being able to use his motorized wheelchair in the facility, however, referrals were not sent to other facilities to find alternative placement until approximately three months later, nor was follow up conducted by facility staff following the referrals being sent to check on the status. This failure had the potential to negatively affect Resident 1's mental health and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the rights of one of three sampled residents (Resident 2) to be free from physical abuse when, Resident 2, who was on continuous one-to-one (1:1 - a high-level intervention where a staff member provides continuous, direct observation of a single patient to prevent harm to themselves or others) observation, was punched in the chest by Resident 3, while Resident 2 wandered into Resident's 3's room unattended on 7/26/25. This failure had the potential to result in physical and psychosocial distress (state of emotional and psychological discomfort that can impact a person's well-being) to Resident 2.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one out of three sampled residents (Resident 1) was assisted with transportation arrangements to attend a post-surgery appointment on 9/4/2025. This failure resulted in Resident 1 missing a scheduled physician's appointment and caused a delay in care and treatment.

Inspectors wroteBased on interview, and record review, the facility failed to ensure medications were administered according to physician orders for one of three residents (Resident 2) when Resident 2 missed a dosage of three medications on 8/20/25. This failure had the potential to negatively affect the health and well-being of Resident 2, and the efficacy of the medications being administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that accommodation of needs was met when call lights (system/device used by residents to call staff for assistance) were not answered in a timely manner for 2 of the 4 sampled residents (Resident 1, and Resident 3). This failure had the potential for residents' needs to be neglected and to negatively affect their psychosocial well-being for a census of 119.

Inspectors wroteBased on interview and record review, the facility failed to ensure transportation was provided for two out of four sampled residents (Resident 1 and Resident 4), when Resident 1 missed a scheduled physician's appointment on 6/26/2025 at 11 AM and Resident 4 arrived late to a scheduled appointment on 6/20/25 and was not able to be seen. This failure resulted in Resident 1 and Resident 4 missing a scheduled physician's appointment.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 who resided at the facility and was transferred to General Acute Care Hospital (GACH) was readmitted to the facility after Resident 1 was cleared by the GACH to return to the facility on 6/15/2025. This deficient practice resulted in Resident 1 remaining at the GACH after Resident 1 was deemed appropriate for discharge back to the facility but was denied readmission by the facility. Resident 1 did not return to the facility resulting in Resident 1's temporary loss of residence and had negative psychosocial outcome, as evidenced by vocalizations of emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 who resided at the facility and was transferred to a General Acute Care Hospital (GACH) was provided a notice of transfer or discharge and a notice of a bed hold during transfer to a GACH when: 1. The facility did not provide a written notice of bed hold (holding or reserving a resident ' s bed while the resident is absent from the facility for therapeutic leave or hospitalization) to Resident 1 at the time of transfer to acute care hospital; 2. Resident 1 was not notified of the discharge in writing and in a manner he/she understood; and, 3. The facility did not notify or send Resident 1's Notice of Transfer or Discharge form to the Ombudsman's office (a government appointed person who actively supports the rights of residents). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a discharge notice (also known as a 30-day notice) for one of three sampled residents (Resident 2) when, Resident 2, Resident 2's representative (FM; family member), and the Office of the Long-Term Ombudsman (OMB, a person who assists residents with resolving conflicts or concerns at the facility) did not receive written notification of Resident 2's impending discharge within 30 days or as soon as practicable when an impending discharge date had been determined by the facility. This failure violated Resident 2's right to be informed in writing of a pending discharge and how to appeal the decision of a facility-initiated discharge. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the repositioning (turning) intervention to prevent pressure ulcer/injury (PU - areas of damaged skin typically caused by staying in one position for too long), for 4 of 5 sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) who were assessed at risk for PU development. This failure had the potential for pressure ulcers to develop for Resident 1, Resident 2, Resident 3, and Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement individualized and effective interventions to protect one of four sampled residents, Resident 6, with known yelling behavior, from verbal threats of violence by her roommate (Resident 5), on 4/18/25. This failure resulted in Resident 6 screaming fearfully with a frightened look on her face, causing potential psychosocial distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it maintained effective pest control services for a census of 115 where 107 residents received facility prepared meals when a live baby cockroach was crawling on a clean colander on the shelf next to the stove in the kitchen. This failure had the potential to spread a variety of diseases and bacteria throughout the facility to its residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide safe food storage and preparation as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 107 residents who received facility prepared meals when: 1. Unlabeled open boxes of frozen chicken patties, frozen whole kernel corn, frozen green peas, and frozen green leaf spinach were stored in the walk-in freezer, 2. An expired container of spice was stored in the dry storage room in the kitchen, 3. A thick brownish gummy substance was on the bottom and sides of a large pot used for cooking resident food on the stove, 4. A flat pan with thick brownish gummy substance on the inside edges was on the shelf next to the stove with clean pots and pans, 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 115, when: 1. Two unvaccinated (who did not receive an influenza(flu) vaccine) staff members, the assistant director of staff development (ADSD) and the receptionist (R1) did not wear a mask on 3/25/25 inside the facility; 2. Resident 307's door was left open while on airborne precaution; 3. A staff member was observed not providing hand hygiene (cleansing of hands with soap and water or an alcohol-based hand sanitizer) to residents before lunch during tray pass on 3/26/25, and the same staff member was observed not washing hands/using hand hygiene during lunch tray pass on 3/26/25. These failures in infection prevention and control measures had the potential to spread the infection to staff and other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 14 residents (Resident 15 and Resident 57) with urinary catheters (flexible tube used to empty the bladder) were treated with dignity and their privacy was protected, when Resident 15 and resident 57's urinary catheter bag (a drainage bag attached to a catheter (tube) that is inside the bladder to collect urine) was exposed and was not placed in a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag so it is not visible). This failure had the potential to cause psychosocial harm to Resident 15 and Resident 57.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one out of twenty-eight (28) sampled residents (Resident 102) received follow-up appointment care when, Resident 102 was not informed about his post-surgery appointment in advance. This failure resulted in Resident 102 missing his follow-up doctor's appointment which had the potential to result in readmission to the hospital when post follow-up care from a provider was not completed.

Inspectors wroteBased on interview, record review and the facility policy review, the facility failed to ensure that Notice of Medicare Non-Coverage (NOMNC - a form required by the Centers for Medicare & Medicaid Services that providers must deliver to patients receiving certain Medicare services such as skilled nursing or rehabilitation services before those services are terminated, informing them of the end of coverage and their appeal rights) was received by the representative of one out of three sampled residents (Resident 26). As a result, Resident 26 and her representative did not have knowledge neither choice to appeal changes in cost of Skilled Nursing Services.

Inspectors wroteBased on interview, and record review, the facility failed to complete the Pre-admission Screening and Resident Review (PASRR - a required assessment for individuals with mental illness, intellectual or developmental disabilities, or related conditions, so that a determination of need, appropriate setting, and a set of recommendations for services to be included in the individual's plan of care is provided) Level II evaluation for one of twenty-eight sampled residents (Resident 90) when, Resident 90's PASRR Level II evaluation was not completed after having a positive result with the Level I screening. This failure had the potential for Resident 90 to not receive the necessary services to meet their mental and psychosocial (the link between social factors and individual thought and behavior) needs.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary services to maintain personal hygiene for 2 of 28 sampled residents (Resident 357 and Resident 11) when, showers were not provided to Resident 357 and Resident 11 at least two times a week as scheduled. This failure had the potential for poor hygiene, infection, and emotional distress for Resident 357 and Resident 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective pain management was provided for one of twenty-eight sampled residents (Resident 463), when Resident 463 complained of pain and was not assessed or given pain medication for approximately 2 hours. This failure resulted in Resident 463 waiting for an extended period of time for pain medication and had the potential to experience emotional distress from inadequate pain relief.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to the physician orders for one of twenty-eight sampled residents (Resident 43) when, Resident 43's medications were not administered in a timely manner and some medications were missed on 3/24/25. This failure had the potential to result in causing Resident 43 to experience preventable medication-related adverse events (undesirable medical occurrence experienced by a resident) of a serious nature related to high blood pressure (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high), breathing difficulties, and pain.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure safe medication storage practices in two out of five medication carts (a mobile cart stored medication and supplies for immediate use) when: 1. There was opened medication stored in the medication carts that were not labeled with an opened-on date (a date the medication was first opened); 2. An over-the-counter medication (OTC-medication that does not require a prescription) was stored in the medication cart that should have been refrigerated; 3. A Hazardous medication (medications that are known to cause harm if handled incorrectly) was not in the appropriate protective plastic bag (a specially engineered plastic bag/container designed to safely contain and transport hazardous medications, ensuring they are handled in accordance with regulations and best practice); and 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu's prescribed portion sizes for mashed sweet potatoes (yams), and vegetables during lunch service on 3/26/25, and the roast beef entrée was served with blackened edges during lunch service on 3/26/25 for a total of 107 residents who received facility prepared meals. These failures had the potential to result in an unprescribed increase or decrease in meal intake based on resident diet ordered, and a potential for the residents' preferences not being met.

Inspectors wroteBased on interview, and record review, the facility failed to ensure safe medication use and practices when one of the three sampled residents (Resident 1) received duplicate blood thinner medications concurrently (drugs with potential to cause significant internal bleeding) for 3.5 days after admission to the facility, and failed to seek clarification before continuing with the blood thinning therapy after identified the error on [DATE]. These failures resulted in Resident 1 having a critically high Prothrombin Time/International Normalized Ratio (PT/INR: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of care were met for 3 out 3 sampled residents, (Resident 1, Resident 2, and Resident 3) when: 1. Resident 1, Resident 2, and Resident 3 ' s scheduled medications were not administered in a timely manner, 2. Resident 1 did not receive timely interventions for constipation, and 3. The photo on Resident 1 ' s clinical documents, used for identification, was of another resident. These failures had the potential for: 1. Reduced therapeutic benefits of the medications prescribed to Resident 1, Resident 2, and Resident 3; 2. Discomfort from constipation for Resident 1; and, 3. Inaccurate identification of Resident 1, with a risk for incorrect treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure privacy and confidentiality were maintained for one of four sampled Residents ( Resident 4) when Resident 4's medication was sent home with Resident 1. This failure resulted in unauthorized access of Resident 4's health and personal information.

Inspectors wroteBased on interview and record review the facility failed to ensure a safe and effective transition of care after discharge from the facility for Resident 3, when Resident 3 was unable to care for herself, therapy did not prepare her to maneuver the steps in her home and was transferred home alone. This failure created undue stress for Resident 3 and her family and resulted in Resident 3 ' s readmission to a hospital.

Inspectors wroteBased on interview and record review, the facility failed to protect two of three sampled residents' (Resident 1 and Resident 3) right to be free from sexual abuse by another resident, when Resident 2, who had a history of inappropriate behaviors, touched Resident 1 ' s thigh and Resident 3 ' s abdomen and groin without consent. This failure had the potential to negatively affect Resident 1 and Resident 3's psychosocial well- being.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care and services were provided for two of four sampled residents (Resident 1 and Resident 2), when 1a. Resident 1 did not get a shower on 2/20/24, due to a sling (part of a mechanical lift used to transfer residents between surfaces) not being available, 1b. Resident 1 received bed baths (sponge baths) instead of showers on 1/2/24, 1/19/24, 1/26/24, 1/30/24, 2/9/24, and 2/27/24, and there was no documentation which indicated Resident 1 had refused the 6 showers, and, 2a. Resident 2 received bed baths instead of showers on 1/31/24, 2/4/24, 2/21/24, and 3/2/24, and there was no documentation which indicated Resident 2 had refused the 4 showers, and, 2b. There was no record of a shower or bed bath being given to Resident 2 on 1/10/24, 1/13/24, 2/7/24, 2/10/24, and 2/28/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sufficient number of slings (part of a mechanical lift used to transfer a resident between surfaces) were available for 45 of 45 residents who used a mechanical lift for transfers, when the facility did not have enough slings for all 45 residents and did not have a system to evaluate the amount of slings needed for residents. As a result, Resident 1 did not receive a shower on 2/20/24 due to a lack of slings and placed other residents who required mechanical lift transfers at risk of not receiving quality care and needed services.

Inspectors wroteBased on interview and record review, the facility failed to follow up on a grievance (cause for complaint) for one of four sampled residents (Resident 3) when Resident 3's grievance of two missing slings (part of a mechanical lift used to transfer residents between surfaces) was not followed up on appropriately or timely. This failure resulted in Resident 3's grievance to go unresolved.

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 (Resident 3) when: 1. Resident 3's care plan for an allegation of bending another resident's right pointer finger on 1/1/24 was not developed; and, 2. Resident 3's care plan for inappropriate behavior had no interventions in place. These failures decreased the potential for the facility to provide person-centered care and ensure safety for residents.

Inspectors wroteBased on interview, and record review, the facility failed to only employ licensed professional staff when one out of three sampled Licensed Nurses (LN) 4 was hired as a full time Licensed Vocational Nurse (LVN- nurse that is trained in basic nursing skills, such as taking vital signs, administering medications, and assisting with basic patient care) from 6/30/23 to 11/5/23 without an active California vocational nurse license. This failure had the potential to negatively impact the care and safety of the facility's residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe environment for one of six sampled residents (Resident 1) when Resident 1 reported a male resident (Resident 2), with a known history of wandering and aggressive behavior, came into her room on 10/26/23 and attempted to remove her bedding. This failure resulted in Resident 1 leaving the facility against medical advice due to a fear of being molested.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow facility policy and standards of practice for medication administration for five of five residents, (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) when four of four licensed nurses (LN), LN 2, LN 3, LN 4, and LN 5, failed to sign off medications at the time of administration. This failure had the potential to result in medication errors for all residents receiving medications in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses (LN) documented accurately when over an eight day period, over three shifts, licensed nurses documented, in three areas on the Medication Administration Record (MAR) and two areas on the Treatment Administration Record (TAR), urinary catheter (a tube inserted into the bladder to allow drainage of urine) care had been performed for Resident 1, who did not have a catheter at any time during the eight days. This failure resulted in inaccurate documentation in Resident 1's medical record for eight consecutive days, with LNs signing off assessments and care they did not perform, and had the potential for resident assessments not to be done.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain its infection control program when licensed nurse (LN) 1 did not consistently perform hand hygiene during wound care for two of ten residents (Resident 1 and Resident 2) receiving wound care in the facility. This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria, germs, from one person, object, or place to another) resulting in infection, affecting the health and wellbeing of residents receiving wound care services at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prescribed treatment medications and treatment supplies were secured, when a treatment cart located at Nursing Station 2 was found to be unlocked in the center hall. This failure had the potential to result in access to prescription ointments and treatments, which could result in illness and/or injury from unauthorized use by residents or visitors.

Inspectors wroteBased on observation, interview, and the facility policy review, the facility failed to properly store, label, and prepare food in accordance with the professional standards for food service safety for 106 of 108 residents who received food from the facility kitchen, when: 1. One jug of pineapple juice in the refrigerator, two bags of hot dog buns with 6 buns in each bag, and one open bag of cereal in dry storage were available for use after the labeled use by date, 2. One bag of 12 burger buns, one open box of cereal, and 10 open 8 ounce boxes of spices were not labeled with an open and use by date, and 3. Chicken was not submerged in the water during thawing process. These failures placed residents at risk of food borne infections (illness caused by consuming contaminated foods or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an accommodation of needs for one of 32 sampled residents (Resident 44) when Resident 44's request that the facility wash personal laundry with an alternative soap, due to a skin reaction, was not accommodated. This failure resulted in Resident 44 not receiving laundry services from the facility for personal clothing items.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services which meet professional standards of quality for one of three residents (Resident 78), when Resident 78's PICC line (a long, thin tube inserted into a large vein in the upper arm to administer medications) dressing was not changed weekly. This failure had the potential to cause infection.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and services for one of 34 sampled residents (Resident 61) to increase range of motion (ROM) and/or prevent further decline in ROM, when Resident 61 was not assisted to get out of bed and into the wheelchair to recieve restorative nurse aide (RNA) services (to provide restorative and rehabilitation care for residents to maintain or regain physical, mental and emotional well-being). This failure had the potential to decrease Resident 61's ROM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice and person-centered care were maintained for one of 32 sampled residents (Resident 201) when adequate pain management was not provided. This failure had the potential to negatively impact Resident 201's physical and emotional well-being and resulted in ineffective pain management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure; 1. A physician's order was followed for two of 32 sampled residents when a used nicotine patch was not removed prior to the application of a new patch for Resident 203 and oxygen was administered at a higher flow rate than prescribed for Resident 50. 2. A controlled medication (medications/drugs that are tightly controlled by the government because they may be abused or cause addiction) was not reconciled by licensed nurses after the initial receipt of acceptance for one of 108 residents (Resident 5). These failures had the potential to cause adverse health events for Resident 203 including an irregular heart beat, trouble sleeping, and increased blood pressure, lung damage caused by oxygen poisoning for Resident 50, and had the potential to result in drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe storage of controlled substances (medications/drugs that are tightly controlled by the government because they may be abused or cause addiction) for a census of 108 when the key to open a locked refrigerator which contained a controlled substance, was accessible to unauthorized staff. These failures had the potential to result in drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain complete medical records for one of three residents (Resident 78), when Resident 78's clinical record had no physician order and documentation of PICC line ( a long, thin tube inserted into a large vein in upper arm to administer medications) dressing change. As a result, Resident 78's clinical record did not accurately reflect whether or when his PICC line dressing was changed. Resident 78's PICC line dressing change procedure was missed which placed him at risk of catheter related infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow infection control practices when: 1. An isolation precaution (to create barriers between people and germs) sign was not located on or near the doorway of Resident 38's and Resident 86's room to indicate the personal protective equipment (PPE; protective clothing, goggles, facemask, or other garments used to prevent the spread of germs) staff should put on prior to entering their room; 2. Facility staff did not remove her isolation gown (barrier used to prevent the spread of infection) properly and prior to leaving room [ROOM NUMBER] that was designated as an isolation room. These failures had the potential to transmit and spread Carbapenem-resistant Acinetobacter baumannii (CRAB - a type of bacteria which can cause human infections of the blood, urinary tract, lungs, wounds, and other body sites. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain kitchen equipment in a clean and safe manner, when a convection oven (an oven that heats food by the circulation of hot air) had baked-on food and grease. This failure had the potential to cause a fire.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate did not exceed 5% for three of 41 sampled residents (Residents 14, 94 and 352) when: 1. For Resident 14, a licensed nurse administered undiluted oral KCl 10% (potassium chloride, a bitter tasting medication indicated for low blood potassium), not in accordance with manufacturer specifications; and a multivitamin with minerals supplement, not plain multiple vitamin, in accordance with the Physician's Orders, with the potential for gastric upset. 2. For Resident 352, a licensed nurse administered 250 mg (milligrams, a unit of measure) of oral Vancomycin HCl (antibiotic medication indicated for infection) liquid, instead of 125 mg as ordered by the physician, with the potential for adverse medication effects. 3. [...]

Inspectors wroteBased on observation, interview, clinical record and facility document review, the facility did not implement their medication storage and labeling policies and procedures for a facility census of 106 when: 1. One of two medication refrigerators (Refrigerator #2) in the Station 1 medication room containing 74 doses of influenza vaccine and an emergency supply of Humulin R® (short acting insulin indicated for lowering blood sugar in diabetes) was observed to be below the manufacturer-recommended and facility policy storage threshold temperature of 36 degrees Fahrenheit when the thermometer indicated 22 degrees Fahrenheit; and the facility did not implement their policy of twice daily temperature monitoring in refrigerators storing vaccines. This failure had the potential for freezing the medications within and rendering them sub-potent or ineffective. 2. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to discard food in the kitchen refrigerator by the use by date for a facility census of 106. This failure had the potential to cause food borne illness to the residents of the facility.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to implement its infection control program for 49 residents (residents whose meal trays were in dining carts 3, 4, and 5) out of a census of 106 when: 1. Certified Nurse Assistant (CNA) 3 did not perform hand hygiene after repositioning a resident in a wheelchair, before opening dining cart 3 with multiple residents' tray in it, and before handling the coffee pot used to serve residents in rooms 201 to 214; 2. CNA 4 did not perform hand hygiene after touching the privacy curtains in room [ROOM NUMBER], before opening dining cart 4 which had lunch trays for residents in rooms 1 to 11, and in rooms 215 to 222 in it, and before serving Resident 13's tray; 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide information to one of 41 sampled residents (Resident 23) about the purpose of an advanced health care directive (AHCD-a form that allows an individual to name who would make health care decisions for them if they were unable to make that decision) and how to complete one. This failure placed Resident 23 at potential risk for not having a decision maker of choice in the event of a change in mental status, and that specific wishes would not be known and followed. Resident 23 was admitted to the facility with diagnoses including Parkinson's disease (a progressive nervous system disorder) and cerebral infarction (lack of blood flow to brain tissue). [...]

Inspectors wroteBased on observation, interview, clinical record and facility document review, a licensed nurse did not document one of 41 sampled resident's (Resident 83's) fingerstick blood sugar in the electronic MAR (medication administration record) after the assessment was completed in accordance with facility policy. This failure placed Resident 83 at potential risk for administration of an inaccurate dosage of insulin.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide hygiene care for one of 41 sampled residents (Resident 50) when Resident 50 did not have his hands washed and teeth brushed regularly. This failure placed Resident 50 at potential risk of oral health problems and infection. Resident 50 was admitted to the facility with diagnoses including a stroke (blood supply to part of the brain is interrupted) with left sided weakness. A review of Resident 50's Minimum Data Set (MDS-an assessment and care screening tool) dated 2/4/19, indicated that Resident 50 required extensive assistance with activities of daily living (ADLs) in the area of personal hygiene. The MDS specified that personal hygiene included brushing teeth and washing hands. A review of the MDS dated [DATE] further revealed that Resident 50 did not reject care, including ADL assistance. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide sufficient fluids to maintain proper hydration for one out of 3 (Resident 353) sampled residents, when water pitchers at the bedside were not filled. This failure had the potential for Resident 353 to become dehydrated.

Inspectors wroteBased on observation, staff interview, and record review the facility failed to ensure the enteral tube feeding (nutrition administered through a tube inserted through the abdomen) bottle for 1 of 41 sampled residents (Resident 40) was labeled with the resident's name, date, time, and nurse's initials as specified in the physician's order. This failure had the potential for Resident 40 to receive the wrong formula and/or develop complications from being administered spoiled and/or contaminated tube feeding formula.

Inspectors wroteBased on observation, interview and record review, the facility did not implement pharmacy services policies and procedures for two of 41 sampled residents (Residents 36 and 351) when: 1. A licensed nurse did not follow manufacturer specifications to accurately measure a dose of diclofenac sodium 1% transdermal (an anti-inflammatory medication applied to the skin for joint pain) gel for Resident 351; as a result, the resident received an excessive dose of the medication. 2. Resident 36's expired supply of Advair 250-50 inhaler (medication used to open lung airways and decrease inflammation in chronic lung disease) was present in the medication cart and in use; as a result, the resident received expired medication that was potentially sub-therapeutic.

Inspectors wroteBased on interview, record review and facility document review, the CP (Consultant Pharmacist) did not identify a Medication Regimen Review (MRR) irregularities for one of 41 sampled residents (Resident 96) when Resident 96 was receiving quetiapine (antipsychotic medication indicated for psychosis-disordered thought processes) for an inadequate indication, with the potential for antipsychotic adverse effects such as sedation, falls and abnormal involuntary movements.

Inspectors wroteBased on interview, record review and facility document review, one of 41 sampled residents (Resident 96) failed to be free of unnecessary psychotropic (drug prescribed to affect the mind, emotions or behavior) medications when Resident 96 was receiving quetiapine (antipsychotic, a type of psychotropic medication indicated for psychosis) for an inadequate indication, with the potential for antipsychotic adverse effects such as sedation, falls and abnormal involuntary movements.