Coral Cove Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 4), who had existing pressure ulcer injuries ([PU] localized damage to the skin and/or underlying tissue usually over a bony prominence) was turned and repositioned at least every two hours. This deficient practice resulted in Resident 1 being left in the same position on her left side for over seven hours and Resident 4 being left on his back for over seven hours. This deficient practice had the potential for new PUs to develop, a delay in healing current PUs, and risk for pain and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were fall pads (a cushioned floor mat designed to absorb impact and minimize injuries in the event of an accidental fall) placed on each side of the bed for one of two sampled residents (Resident 1), per Resident 1's Care Plan. This resulted in Resident 1 having no protection during a fall and had the potential for Resident 1 to sustain injuries from falling from herbed onto the floor.

Inspectors wroteBased on observation, and interview, the facility staff failed to ensure an indwelling urinary catheter (a hallow tube inserted into the bladder to drain or collect urine) bag and the connecting tubing for one of three sampled residents (Resident 1) was not on the floor. This resulted in Resident 1 being exposed to bacteria and placed her at risk for developing a catheter- associated urinary tract infection ([UTI] an infection in the bladder/urinary tract).

Inspectors wroteBased on interview, and record review, the facility failed to ensure: 1. A ventilator assisted individual ([[NAME]] a person who relies on a medical device to completely or partially assist with their breathing) received appropriate airway management by ensuring the ventilator (a medical machine that helps or fully takes over the breathing process for a patient) was turned on after one of five sampled residents (Resident 1) was transported to her room following a shower. 2. A Respiratory Therapist ([RT] a specialized health professional who diagnoses, treats, and manages patients with breathing and cardiopulmonary disorders) was available to monitor and manage Resident 1's airway. As a result, Resident 1 was connected to a portable ventilator (Vent 2) on [DATE] at 8:53 a.m., and Vent 1 was powered down (turned off) at 8:55 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately initiate Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to one of five sampled residents (Resident 1), when Respiratory Therapist (RT) 1, who was CPR certified (successfully completed a training course and received a credential that qualifies a person to perform CPR), found Resident 1 unresponsive (a person is unconscious and fails to react to any external stimulation), without pulses and no oxygen saturation level ([O2 sat] a measurement of how much oxygen the blood is carrying as a percentage normal range from 92% to 100%) on [DATE] at 11:08 a.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to answer the call lights (device that allows residents to request assistance from nursing staff) for two out of three sampled residents (Resident 5 and 6) in a timely manner. These failures had the potential to result in delays of care and services, and negatively impact resident outcomes.

Inspectors wroteBased on observation, interview, and record reviews the facility failed to ensure the Physical Therapy Assistant (PTA - staff who implement guided therapy), Occupational Therapist Registered (OTR - licensed professional who helps develop life skills through therapy), and the Certified Occupational Therapy Assistant (COTA - professional who help implement therapy) were wearing isolation gowns (personal protective equipment [PPE] - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when providing Physical Therapy services (healthcare treatments designed to help you move, reduce pain, recover from injuries, and manage chronic conditions) for one of one sample resident (Resident 2). The failure had the potential to result in the spread of dangerous germs that can cause severe infection.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the alleged physical abuse between Resident 1 and Resident 2 to the State Survey Agency (California Department of Public Health -CDPH) within two hours of the occurrence for two of three sample residents (Resident 1 and Resident 2) The failure had potential to result in a delay of an onsite inspection by the CDPH to ensure alleged physical abuse was investigated and lead to a delay in prevention of potential ongoing physical abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff (Cook 1, [NAME] 2, Dietary Aid 1 [DA1] and, Dietary Aid 2 [DA 2]) wore appropriate hair and beard nets in the kitchen while preparing or handling food for 73 out of 104 residents in the facility who received meals prepared in the kitchen. This deficient practice had the potential to increase the risk of foodborne illness and affect 73 of 104 residents who received meals prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Infection Control policy and procedure (P&P) titled Enhanced Barrier Precautions ([EBP] infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) when Licensed Vocational Nurse 1 (LVN 1) performed a dressing change, disconnected a feeding tube (a medical device used to deliver nutrients, fluids, and medications directly into the gastrointestinal tract) without wearing a gown or performing hand hygiene for one of one resident, (Resident 6), who was on EBP precautions. This deficient practice had the potential to place all residents at risk of infection and increase the risk of spreading microorganisms (bacteria, viruses or fungi) to residents and staff.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse to the state agency (Department of Public health) for two of three sampled residents (Resident 1 and Resident 2) who were engaged in verbally aggressive behavior. This deficient practice resulted in a delay in an onsite inspection by the State Agency and had the potential to place other residents at risk for unaddressed abuse and unsafe interactions.

Inspectors wroteBased on interview and record review, the facility failed to investigate an incident of verbal abuse for two of three sampled residents (Resident 1 and Resident 2). This deficient practice resulted had the potential to place residents at risk for ongoing abuse.

Inspectors wroteBased on interview and record review, the facility failed to re-admit one of one resident (Resident 1) back to the facility after Resident 1 was evaluated and cleared by the Long-Term Acute Care ([LTAC] a hospital that provides specialized, extended care for critically ill patients) facility to return on 10/7/2025. This deficient practice resulted in Resident 1 being denied returning to the facility that has been their home for two years and had the potential for psychosocial harm.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure two out of five sampled residents (Resident 62 ,Resident 101 and Resident 80) received care and services to promote wound healing and to prevent new pressure injuries (PI: localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) from occurring by: 1. Failing to initiate a wound treatment for Resident 62 when a change of condition (COC) was identified as a Stage III pressure injury (injury that extends through the skin into deeper tissue and fat)on 6/26/2025. 2. Failing to follow and implement the plan of care for repositioning every two (2) hours for Resident 62, Resident 101 and Resident 80. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement infection control policies when the facility failed to:a. Keep the laundry's designated clean area clean without staff's personal items and food.b. Implement the water management plan (comprehensive plan aimed to prevent waterborne illnesses by controlling germs in the water) by not checking control measures (things the facility will do in the building water system to limit growth and spread of Legionella [bacteria that can cause Legionnaire's Disease - serious type of infection in the lungs]).c. Implement the water management plan by not testing one of one resident (Resident 9) who had pneumonia (an infection/inflammation in the lungs) for Legionella. [...]

Inspectors wroteBased on interview and record review the facility failed to implement two of three residents' care plan (Resident 8 and 62) when: a. The facility failed to ensure the Registered Dietician ([RD] food and nutrition expert) evaluated Resident 8. b. The facility failed to ensure Resident 62 and Resident 101 was repositioned every two hours. These deficient practices had the potential to result in poor quality of care and a delay in care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its residents with or without limited range of motion (ROM - movement of the joints) received appropriate treatment and services to increase, prevent, or maintain the ROM mobility for four of seven residents (Resident 7 , Resident 8, Resident 90, and Resident 54) with physician's orders for Restorative Nursing Assistant (RNA) exercises. These deficient practices placed residents with orders for RNA exercises at risk for decline in physical function and at risk for contractures.

Inspectors wroteBased on interview and record review the facility failed to maintain acceptable nutritional parameters for one of three sampled residents (Resident 77) when:1. The facility failed to notify the physician on 7/29/2025 after Resident 77 had a significant weight loss (weight loss greater than 10 percent [%] in 6 months).2. The facility failed to ensure the Registered Dietician ([RD] a health professional who has special training in diet and nutrition) recommendations made on 7/29/2025 were implemented in a timely manner and not implemented on 8/4/2025, six days after the significant weight loss was identified. Resident 77's order for Ensure Enlive (nutritional supplement) three times a day was not ordered, and Resident 77 did not receive the supplement until 8/5/2025. Resident 77's order for Megestrol Acetate Suspension (appetite stimulant) was placed and carried out on 8/6/2025. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not provide respiratory care and services consistent with professional standards of practice to three of three residents (Resident 8, 63, and 82) when the facility failed to:a. Ensure Resident 8's oral hygiene and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs) care was administered as ordered.b. Ensure Resident 63 received 2 liters of supplemental oxygen (element essential for life) as physician ordered.c. Ensure Resident 82's humidifier (medical device used to humidify supplemental oxygen) was labeled with a date to ensure it was changed timely. These deficient practices had the potential to result in a delay in care, infection and unsafe administration of oxygen in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure food is properly stored with label and open date. 2. Ensure expired food is discarded. 3. Monitor the temperature of the hydration freezer. These failures had the potential to expose all residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another) which could lead to nausea, vomiting or diarrhea.

Inspectors wroteBased on interview and record review the facility failed to:a) Ensure to offer the Corona virus disease ([COVID-19] contagious infectious disease) vaccination (medications used to prevent diseases usually given by injection or by mouth) to one of five sampled residents (Resident 95).b) Ensure to provide documented evidence of all employees, including consultants and physicians, COVID-19 vaccination status and the provision of education on benefits and potential side effects and offering of the 2024 to 2025 COVID-19 vaccine. This failure had the potential to result in staff and residents contracting COVID-19 which can cause serious illness, hospitalization, and death.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of Resident 62s Electroencephalogram ([EEG] - is a test that measures the electrical activity in the brain, called brain waves, using small metal disks called electrodes that are attached to the scalp) test was incomplete. This deficient practice had the potential for Resident 62 to have a delayed diagnosis and treatment of neurological conditions placing Resident 62 at risk for worsening symptoms.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Notice of Proposed Transfer and Discharge Form (written notification to the resident or responsible party that included the reason for the transfer or discharge, where the resident will be transferred or discharged to, how to contact the State Long Term Care Ombudsman, and how to appeal the transfer or discharge if necessary) was provided timely to the resident's responsible party (RP) 1 for one of two residents (Resident 90). This deficient practice had the potential to result in the RP 1's ability to contact the State Long Term Care Ombudsman (public advocate) on how to appeal the transfer if needed.

Inspectors wroteBased on interview and record review, the facility failed to accurately document Restorative Nurse Assistant (RNA- a Certified Nurse Assistant (CNA) who received special training to provide range of motion (ROM) and daily activities under the guidance of nurses and therapists) services on the Minimum data set (MDS - a resident assessment tool), for one of three sampled residents (Resident 54). This failure had the potential to result in Resident 54 to have a delay of care.

Inspectors wroteBased on interview and record review the facility failed update the care plan titled, Nutrition after significant weight loss (weight loss greater than 10% in 6 months) was identified on 7/29/2025 for one of three sampled residents (Resident 77). These deficient practices resulted in a delay in care and services to improve weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 7) received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by: Failing to follow up with a referral consultation for rheumatology (medical specialty focused on the diagnosis and treatment of disorders affecting connective tissues like bones, muscles, joints, and tendons [tissue connecting muscle to bone]) and neurology (medical specialty focused on diagnosis and treatment of disorders of the brain, spinal cord, and nerves), and a follow-up appointment in six weeks on 10/1/2024 for results. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of three sampled dependent resident's (Resident 90) toenails were not dirty and thick. This deficient practice had the potential to result in infection, a decreased quality of life and negatively impact the residents' self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 14 sampled residents (Resident 98 and Resident 101) who are fed by a gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) were following appropriate standard of practice by:a. Failing to ensure the tube feeding was disconnected from Resident 98 when the feeding was turned off.b. Failing to follow the care plan and hold the tube feeding while Resident 101 was lying flat. This deficient practice had the potential to cause dislodgement for Resident 98 and result in aspiration (inhalation of foreign materials) which can lead to pneumonia (a lung infection) for Resident 101.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who received dialysis (process of removing waste products and excess fluid from the body) received treatment as ordered for one out of one sampled resident (Resident 10). This deficient practice had the potential to delay provision of dialysis treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Licensed Vocational Nurse (LVN 3) remained competent in medication administration for one of one residents (Resident 119) by not re-evaluating LVN 3's competency skills when Resident 119 expressed concerns of receiving more pills than her usual medication pass. This failure had the potential to lead to medication errors for Resident 119 and all residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered on time for one of four sampled residents (Resident 7). This failure had the potential to result in Resident 7's pain not being managed or experiencing adverse medication side effects.

Inspectors wroteBased on interview and record review the facility failed to ensure accurate medical records for two of three residents (Resident 30 and 90) when the facility:A. Failed to ensure Certified Nurse Assistant (CNA) 5 accurately documented in Resident 30's chart. B. Failed to ensure Restorative Nurse Assistant (RNA) 2 accurately documented in Resident 90's chart. C. Failed to ensure RNA 2 documented the amount of time spent with the Resident 90, Resident 90's tolerance to service rendered, and signature initial of RNA providing the services in each occurrence. These deficient practices resulted in an inaccurate depiction of services and care rendered and lack of documentation in the medical record.

Inspectors wroteBased on interview and record review, the Infection Prevention Nurse (IPN) incorrectly identified residents to receive antibiotics (medication to treat infection) that did not meet Mc Geer's criteria (standardized tools with definitions for infections to aid if antibiotic use was appropriate) for two of three residents (Resident 11 and 47). This deficient practice resulted in the improper implementation of the antibiotic stewardship program (coordinated program that promotes the appropriate use of antibiotics by clinicians).

Inspectors wroteBased on interview and record review the facility failed to offer a pneumococcal vaccination (protects against pneumococcal disease, a serious infection that can cause pneumonia) for one of five sampled residents (Resident 95). This failure had the potential to result in Resident 95 contracting the pneumococcal disease.

Inspectors wroteBased on interview and record review, the facility failed to readmit one of three sampled residents (Resident 3) after Resident 3 was transferred to a General Acute Care Hospital (GACH) to evaluate a distended (swollen or enlarged) abdomen with pain on 6/7/2025. This failure resulted in Resident 3 experiencing a prolonged stay at the GACH and frustration from not being able to return the facility which he considered to be his home.

Inspectors wroteBased on interview and record review, the facility failed to review and revise a care plan for one of three sampled residents when Resident 2 was readmitted to the General Acute Care Hospital (GACH) on 6/23/2025 after being transferred to the GACH for aggressive behavior on 6/10/2025. This failure resulted in Resident 2 throwing a book at Resident 1 on 6/27/2025.

Inspectors wroteBased on interview and record review, the facility failed to ensure two Certified Nursing Assistants (CNAs 1 and 2) were provided training and orientation to work in the Subacute Unit (a specialized unit in a Skilled Nursing Facility [SNF] which offers more intensive care than standard long-term care but less than acute hospital care). The deficient practice had the potential for the lack of appropriate care to residents in the Subacute Unit.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled Certified Nursing Assistants (CNA 1) had an active license and/or certificate. The deficient practice resulted in CNA 1 working as a CNA without an active license and/or certificate.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled Certified Nursing Assistants (CNA 1) certification was active and not expired. This deficient practice resulted in the CNA 1 working 10 shifts (from [DATE] to [DATE]) with an expired certification.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring of targeted behaviors for the use of psychotropic medications was documented and psychiatry (medical specialty that diagnose, prevent, and teat mental health conditions) was notified when one of four sample residents (Resident 3) refused to take their medications. This deficient practice had the potential to result in delayed provision of necessary care and services. During a review of Resident 3 ' s admission record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) [bipolar type]), violent behavior, and delusional (mental health condition in which a person cannot distinguish what is real and imagined). [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a functioning call light and place the call light in a reachable position for two of six sampled residents (Resident 10 and 13). This deficient practice had a potential for a delay in meeting the resident's needs for assistance and can lead to frustration, falls and accidents. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure their front door was alarmed to prevent a resident who was under conservatorship (a legal status in which a judge appoints a person [conservator] to manage the financial and personal affairs of a minor incapacitated person), who wandered (random or repetitive locomotion maybe goal directed, or non-goal directed) around the hallways in the facility, and was assessed incorrectly during her elopement evaluation, did not elope (act of leaving a facility unsupervised and without prior authorization) from the facility for one of three sampled residents (Resident 1). This deficient practice resulted in a care plan not being created for Resident 1 based on an incorrect elopement evaluation (12/24/2024) and no interventions in place to address Resident 1's elopement risk. [...]

Inspectors wroteBased on interview and record review, the facility failed to uphold residents ' rights. The facility failed to : a. Address and ensure the concerns of the resident council (group of residents who meet to discuss and advocate for improvements in care and quality of life at the facility) which were stated during the meetings held on 1/7/2025 and 2/10/2025 regarding delayed call lights response time occurring during the 11pm-7am shift. b. Ensure the Director of Staff Development (DSD) provided appropriate oversight to staff during the 11pm-7am shift as indicated in the facility job description Director of Staff Development. This deficient practice resulted in residents rights , including dignity not being upheld and placed residents at risk for a delay in care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents rights were maintained for one of three sampled residents (Resident 1), when the facility failed to notify Resident 1 ' s physician regarding a change of condition. On 12/3/2024, the Minimum Data Set (MDS) nurse witnessed Resident 1 holding Resident 2 hands away from him (Resident 1) and was informed by Resident 1 that Resident 1 was attempting to protect himself from being hit by Resident 2. This deficient practice resulted in Resident 1 ' s physician being unaware of the altercation between Resident 1 and Resident 2, causing a delay in needed assessments and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to report a physical altercation between two of three sampled residents (Resident 1 and Resident 2), to the California Department of Public Health (CDPH), within two hours of the incident. On 12/3/2024, the Minimum Data Set (MDS a resident assessment tool) nurse witnessed Resident 1 holding Resident 2 hands away from him (Resident 1) and was informed by Resident 1 that Resident 1 was attempting to protect himself from being hit by Resident 2. The facility reported the incident on 2/6/2025 (65 days after the incident occurred). This deficient practice resulted in CDPH being unaware of the abuse incident and injury to Resident 1 and had the potential for a delay in CDPH ' s investigation and other abuse allegations to go unreported.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident centered comprehensive care plan was developed for one of three sampled residents (Resident 1) when on 12/3/2024, the Minimum Data Set (MDS) nurse witnessed Resident 1 holding Resident 2 hands and was informed by Resident 1 that Resident 1 was attempting to protect himself from being hit by Resident 2. These deficient practices resulted in a delay and care and services for Resident 1 placing Resident 1 at risk for decline in mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information including actual number of staff and staff working was posted and placed and readily available to residents and visitors. This failure resulted in residents and visitors not being able to access accurate daily numbers of clinical staff taking care of residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with dignity and respect when Resident 1 was not provided incontinence care due to insufficient staffing when Certified Nursing Assistant (CNA 1) was assigned to care for 82 residents. This failure resulted in Resident 1 calling the police (911) when she was not changed on 12/24/2025 from the 11 p.m. to 7 a.m. shift. This failure also had the potential for the other 81 residents in the facility to not receive care and/or a delay of care due to CNA 1 ' s inability to care for 82 residents by herself.

Inspectors wroteBased on interview and record review, the facility failed to ensure the water management plan (a program that identifies and addresses hazardous conditions in a water system) was implemented. The facility failed to ensure: 1. The water management plan team (a group of individuals responsible for overseeing and implementing the facility's water management plan) met regularly to discuss issues related to water management in the facility. 2. Control measures (actions taken in the facility's water systems to limit growth and spread of Legionella [bacteria that causes disease such as pneumonia] which could include adding disinfectant, cleaning, and heating) were acceptable and being monitored, logs and documentation were accessible for review and discussed amongst during meetings. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to designate a fulltime infection preventionist nurse ([IPN] a healthcare professional who works to prevent the spread of infections in healthcare facilities) to perform IPN responsibilities and duties as indicated by the facility's job description titled Infection Preventionist (IP). This deficient practice resulted in a lack of oversight to ensure the facility's water management plan team (group of individuals responsible for overseeing and implementing the facility's water management plan [a program that identifies and addresses hazardous conditions in the facility's water system]) met regularly to discuss any issues related to water management in the facility to ensure changes that may lead to legionella growth were not occurring. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who had an unwitnessed fall on 1/11/2025 with injuries, was provided appropriate care by the nursing staff. The facility failed to: 1. Ensure Resident 1 ' s physician was notified following Resident 1 ' s unwitnessed fall to obtain instructions for care and monitoring. 2. Ensure Resident 1 ' s Responsible Party (RP 1) was notified following Resident 1 ' s unwitnessed fall and subsequent injuries. 3. Ensure Resident 1 was assessed, monitored with documentation of Resident 1 ' s incident, and continued health status following his unwitnessed fall in order to update the physician of the resident status. 4. Ensure Resident 1 ' s incident and care were endorsed to the oncoming shift (7 a.m. - 3 p.m.) following his unwitnessed fall and injuries on 1/11/2025 during the 11 p.m. - 7 a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an injury of unknown origin for one of seven sampled residents (Resident 1) was reported to the California Department of Public Health (CDPH) when Resident 1 sustained multiple skin tears on his body. This deficient practice resulted in the inability of the CDPH to investigate Resident 1's injuries in a timely manner and had the potential for facts related Resident 1's injuries to be forgotten by staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of seven sampled residents (Resident 4), who had a history of falling was provided a one on one sitter (a person who provides constant observation and assistance to a resident at risk for harm), per the physician's order. This deficient practice resulted in Resident 4 not being closely supervised at all times placing Resident 4 at risk for continued falls and subsequent injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 4 sampled residents (Resident 2) ' s bed was kept clean and bed with piled up blankets. This deficient practice resulted in Resident 2 not having enough bed space to move and be comfortable while in bed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Long Beach Department of Health and Human Services (LBDHHS) guidelines were followed during a facility outbreak of Carbapenemase-producing organisms ([CPO] gut bacteria that has become resistant to many antibiotics known as carbanemens), by not posting the correct isolation precaution signs on 8 out of 12 rooms on the facility's sub-acute unit ([SAU] a place that provides short-term intensive care for patients who need more care than what's available at home or in a assisted living facility, but less than what's needed in a hospital). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the residents ' right to be free from verbal and physical abuse by Certified Nursing Assistant (CNA 1) for one of three sampled residents (Resident 1). The facility failed to: a. Ensure CNA 1 did not yell at Resident 1 and threw the urinal and bottle of water towards Resident 1. b. Ensure CNA 1 waited for Resident 1 to finish using the bathroom and not enter the bathroom when Resident 1 pleaded for CNA 1 to wait before entering. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) no later than two hours for one of one sampled resident (Resident 1) when Resident 2 pulled Resident 1 ' s beanie (small close fitting hat) off her head and had her hair pulled. This failure had the potential to result in unidentified abuse in the facility and the failure to protect residents from abuse. Findings During a review of Resident 1 ' s Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including multiple sclerosis (nerve damage disrupting communication between the brain and body), heart failure (heart muscle is unable to pump enough blood to meet the body ' s needs for blood and oxygen), and muscle weakness. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure by failing to submit a five-day investigative report for one of one sampled resident's (Resident 1). This deficient practice resulted in an incomplete investigation and incomplete conclusion of the alleged abuse in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a care plan with a goal to minimize falls and to decrease significant injuries as a result of any the falls by placing a bed at the lowest position with floor mats on both sides of the bed, for one of three sampled residents (Resident 1) was followed. Resident 1 was found kneeling on the floor by the left side of her bed, holding onto the bed's siderail with the bed in a high position and no floor mats on the floor beside Resident 1's bed. The facility failed to: Ensure Resident 1 had her bed in the lowest position with floor mat on the left side of Resident 1's bed, based on Resident 1's Care Plan dated 3/20/2022. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 4) was not restrained, by pushing the right side of her bed against a wall, with pillows on the left side of her bed tucked underneath her sheets, thus preventing Resident 4 from getting up from bed or moving in bed. This deficient practice resulted in Resident 4's inability to get out of bed and restricted her movements in bed. This deficient practice had the potential to result in the further decline in her mobility and function and an undignified existence.

Inspectors wroteBased on interviews and record review, the facility failed to ensure there was a facility policy developed and implemented to verify whether the prescribers of residents ' antipsychotic (medications that treat symptoms that happen with schizophrenia and other conditions that involve psychosis) medications had obtained informed consents prior to administration, for two (2) of 3 sampled residents (Residents 1 and 3). These deficient practices had the potentials of unnecessary medications and residents ' rights issue.

Inspectors wroteBased on interviews and record review, the facility failed to ensure there a diagnosis for the use of an antipsychotic medication was consistent in one (1) of 4 sampled residents (Resident 1). These deficient practices had the potentials of unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to re-admit one of three sampled residents (Resident 1), when Resident 1 due to low oxygen (an element of air breathed in by humans to sustain life) levels of 84 percent ([% part in every hundred] the amount of oxygen [O2] in person ' s blood: reference range is 95% to 100% without the use of supplemental oxygen]) on 9/20/2024. This deficient practice resulted in Resident 1 remaining at the GACH after Resident 1 was deemed appropriate for transfer back to the facility on [DATE] but was denied readmission by the facility. Resident 1 had not been readmitted to the facility as of 10/17/2024, placing the resident at risk for confusion, disorientation and psychosocial harm related to dislocation from a place that was considered Resident 1's home.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 2) were not inappropriately touched; Resident 1 on her buttocks twice by a male resident (Resident 3), when Resident 3 and Resident 2 were left unattended on the facility's patio on 10/1/2024, and when Resident 3 was not closely monitored following his inappropriate sexual behavior with Resident 2 on the previous day (10/1/2024), leading to Resident 3 touching Resident 2 on her left thigh and left breast on 10/2/2024. This deficient practice resulted in Resident 1 and Resident 2 feeling unprotected, uncomfortable and/or disrespected when they were touched inappropriately by Resident 3. This deficient practice and had the potential for inappropriate sexual contact to continue with other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 3) was closely monitored and supervised, following an allegation by a female resident (Resident 1) that she was inappropriately touched by Resident 3 on 10/1/2024. This deficient practice resulted in Resident 3 inappropriately touching another female resident (Resident 2) on 10/2/2024 at 10 a.m. This deficient practice had the potential for Resident 3 to continue his behavior of inappropriately touching other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3), who was transferred to a General Acute Care Hospital's (GACH) emergency room (ER) after two episodes of inappropriately touching two female residents, was readmitted to the facility after the GACH's ER evaluation was completed, and Resident 3 was deemed appropriate for transfer back to the facility. This deficient practice resulted in Resident 3's unnecessary and extended stay in the GACH's ER (as of 10-21-2024 Resident 3 was still at the GACH, 17 days) and had the potential for Resident 3's continued displacement from his residence at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three residents ' (Resident 2) orthopedic (aim at the treatment of the musculoskeletal system) consult for right shoulder pain after hospitalization in 1/2024 and for left hip dislocation on 6/2024 was completed in a timely manner. The outpatient orthopedic consult was completed on 9/25/2024. The failure resulted in a delay of care which can result in negative health outcomes. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of three residents ' (Resident 4) Oxycodone (strong pain medication) was available to administer to Resident 4 when he was in pain. The failure had the potential to result in unrelieved pain which can result in negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to administering psychotropic (a drug that affects a person ' s mental state) medication on two occasions for one of three sampled residents (Resident 6) who was on quetiapine (a medication used to treat schizophrenia [a serious mental health condition that affects how people think, feel and behave] and bipolar disorder [a mental illness that causes extreme mood swings, which can make it hard to do daily tasks]). This deficient practice had the potential for Resident 6 to be uninformed about the adverse (unwanted or dangerous medication side effects) effects of quetiapine he may experience when receiving the medication .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, the resident who had intact ( not impaired) right eyesight did not lose eyesight and became blind, for one of four sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses acted upon and carried out the optometrist ' s (specialized health care profession that involves examining the eyes and related structures for defects or abnormalities) [OPT 1]) recommendations made on 3/22/2024 for Resident 1 to see a retina (the light sensitive lining of the eye) specialist (medical doctor who specialized in disease of the retina) and a glaucoma specialist (medical doctor who specialized in glaucoma [eye disease that can cause vision {state of being able to see} loss and blindness]). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to developed a comprehensive plan of care for one of four sampled residents (Resident 1) for the potential of impaired vision in the right eye and the actual vision loss in the left eye due to diagnosis of glaucoma (eye disease that can cause vision loss and blindness) and advanced diabetic retinopathy (complications of diabetes that affects patient ' s eye that can lead to blindness) upon admission. This deficient practice resulted in delay of services for Resident 1 including the need for eye specialist referrals or monitoring for a decline in eyesight. Resident 1 had a decreased vision in the right eye leading to right eye vision loss.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one out of four sampled residents (Resident 1) ' s right eye intact vision was not deteriorated, and the resident did not lose right eye vision and became blind. The facility failed to: 1. Ensure licensed nurses acted upon the optometrist ' s (OPT 1) recommendations made on 3/22/2024 and carried out for Resident 1 to see a retina specialist (medical doctor who specialized in disease of the retina) and a glaucoma specialist (medical doctor who specialized in glaucoma [ eye disease that can cause vision loss and blindness]). Resident 1 was not seen by retina specialist (MD 2) until 8/1/2024 (132 days later) and was seen by the glaucoma specialist (MD 3) on 8/27/2024 (158 days later). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent prior to the administration of psychotropic (medications that affect the mind, emotions, and behavior) medications for one out of three sample residents (Resident 16). This failure had the potential to place Resident 16 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an adaptive call light system was provided to a resident that was a quadriplegic (paralyzed on all limbs) and was completely dependent on staff to perform activities of daily living (ADLs, daily self-care activities such as grooming, dressing, toileting, and personal hygiene) for one out of out six sampled residents (Resident 101). This deficient practice had the potential for Resident 101 to be unable to make his needs known and placed Resident 101 at risk for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of one sampled resident (Resident 318) with the opportunity to choose a primary care physician (PCP) of his choice. This deficient practice violated Resident 318's right to choose a care provider of his choice and had the potential to affect Resident 318's quality of life, sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure for restraints for one out of one sampled resident's (Resident 52) by failing to: 1. Ensure the order for a right-hand mitten restraint (purposely limiting or obstructing the freedom of a person's bodily movement) specified a duration (time frame) of use for Resident 52, as specified in the facility's policy. 2. Ensure documentation was performed for the assessment of Resident 52's circulation, sensation, movement, and skin integrity for the duration of Resident 52's use of a right-hand mitten restraint. These deficient practices had the potential to cause unnecessary use of a mitten restraint, skin breakdown and impaired circulation (movement of blood throughout the body) for Resident 52.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the nutritional care plan, perform ongoing assessments, and revise the interventions for one of one sampled resident (Resident 317) after returning to the facility from the general acute care hospital (GACH) due to failure to thrive (features of weight loss, exhaustion, weakness, and decreased physical activity) and decreased oral intake. This deficient practice placed Resident 317 at risk for altered nutritional status and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Medication was not left at the bedside for one out of 5 sampled residents (Resident 24). This deficient practice had the potential to result in medication errors and having another resident possibly take the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet and maintain the nutritional needs of one of three sampled residents (Resident 317) by: 1. Failing to follow the nutritional care plan and interventions. 2. Failing to consistently record Resident 317's oral intake for every meal. 3. Failing to follow the recommendations of the registered dietician (RD, a health professional who specializes in nutrition and diet) to add nutritional shakes three times a day during med pass. This deficient practice placed Resident 317 at risk for altered nutritional status and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a physician order for oxygen administration for one out of 5 sampled residents (Resident 48). This deficient practice had the potential to cause breathing complications as a result of being under oxygenated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the adequate storage and disposal of controlled (a drug that is secured under lock and key and has the potential to be misused), and non-controlled medications when the facility failed to ensure the following: 1. Ensure Hydrocodone and Acetaminophen (a controlled medication, used to treat severe pain) 5-325 milligram ([MG]-a unit of measurement) was properly disposed and wasted, and not kept in the medication bubble pack (a special packaging for resident medications) sealed with paper tape located in Medication Cart 2 . 2. Ensure a liquid bottle of Docusate Sodium (stool softener) was disposed in the proper medication disposal bin receptacle in Medication room [ROOM NUMBER]. 3. Ensure the door to Medication room [ROOM NUMBER] was locked and secured. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up on the missing/lost dentures for one out of six sampled residents (Resident 6). This deficient practice had the potential for Resident 6 to exhibit weight loss due to limited food choices and choking.

Inspectors wroteBased on observation and interview, the facility failed to ensure: 1. One of four of the facility's trash dumpsters was not overfilled with an open lid. This deficient practice had the potential to result in pest and vermin infestation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective infection prevention practices were implemented for a resident with suspected scabies (a contagious skin condition caused by the human itch mite) for one out of three sampled residents (Resident 8) when the facility failed to: 1. Obtain an order and perform a scabies skin scraping (a diagnostic procedure for scabies that involves scraping a suspected lesion with a scalpel blade or glass slide to collect a sample that can be examined under a microscope for mites or eggs) for Resident 8 in a timely manner and before treatment for scabies was administered. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 3, 4, 5, and 6 accurately documented Vimpat, a medication for seizure (a sudden, uncontrolled burst of electrical activity in the brain which can cause changes in behavior, movements, feelings, and level of consciousness) disorder, for one of four sampled residents (Resident 1) on the Medication Administration Record (MAR) and/or the Individual Narcotic Record (a form used to document and track the administration of controlled substances [a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction and may cause significant risk to patient safety]). [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assurance Performance Improvement ([QAPI] facility team who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to implement the facility ' s plan to monitor and address staff noncompliance (failure to comply with something) with medication administration. This deficient practice resulted licensed nurses continued noncompliance with medication administration and documentation and had the potential to result in poor resident outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 3, administered Vimpat, a medication for seizure (a sudden, uncontrolled burst of electrical activity in the brain which can cause changes in behavior, movements, feelings, and level of consciousness) disorder, in a timely manner as ordered by the physician for one of four sampled residents (Resident 1). This deficient practice placed Resident 1 at increased risk for adverse effects including drowsiness (excessive sleepiness), stupor (state of near consciousness) and/or insensibility (lack of physical sensibility) due to the medication doses taken too close together.

Inspectors wroteBased on interview and record review the facility failed to report to the state agency (Department of Public Health: DPH) an unwitnessed fall with injury on 4/13/2024 in a timely manner for Resident 1. This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' fall circumstances were investigated and can lead to a delay in prevention of further falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure an unwitnessed fall with injury was thoroughly investigated within 5 working days for one of one sampled resident (Resident 1) as indicated in the facility's policy and procedure. This deficient practice had the potential to place other resident at high risk for falls that could sustain injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident received supervision and assistance to prevent an unwitnessed fall with injury for one of three sampled residents (Resident 1). This failure resulted in Resident 1 fell on the floor and was transferred to general acute care hospital (GACH) on 4/13/2024.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an Interdisciplinary Team ([IDT] team of health care professionals that work together toward and prioritize the resident's needs) meeting was conducted for one of four sampled residents (Resident 2) when Resident 2's tracheostomy (a surgical procedure to create an opening through the neck into the windpipe that provides an air passage to help you breathe when the usual route for breathing is obstructed or impaired) was accidentally dislodged, it was decided Resident 2 no longer required the tracheotomy and Resident 2 was subsequently transferred from the facility's Sub-Acute unit (level of care requiring more intensive licensed skilled nursing services than is typically provided to the majority of residents) to the facility's skilled nursing unit (a unit where lower level of care is required). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one sampled resident (Resident 2) who had a tracheostomy (a surgical procedure to create an opening through the neck into the windpipe that provides an air passage to help you breathe when the usual route for breathing is obstructed or impaired) that became dislodged on 1/22/2024 and again on 3/23/2024, was investigated by the facility to determine why dislodgement was occurring and to prevent it ' s recurrence. This deficient practice resulted in the Resident 2's tracheostomy dislodging more than once and had the potential to interfere with the ability of Resident 2 and other residents with tracheostomies to breathe and possible death.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was informed of a resident's change in condition (COC) for one of six sampled residents (Resident 1). The facility failed to: 1. Notify Resident 1's physician of Resident 1's continuously high blood sugar (b/s) level for four consecutive days. 2. Notify Resident 1's physician of Resident 1's COC on [DATE], including confusion, lethargy (a state of being drowsy and dull, listless, and unenergetic, indifferent, and lazy, sluggish, and inactive), inability to speak with an oxygen saturation rate of 70% ([O2 Sat] the oxygen concentration level in blood. The reference range is 95-100%) on room air. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive centered care plan was developed for one of three sampled residents (Resident 1). The facility failed to develop a care plan to address Resident 1 ' s impaired vision. These deficient practices caused Resident 1 to feel frustrated and had the potential to cause a delay in care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise one of three sampled resident's (Resident 2) comprehensive, resident centered care plan to include the need for direct line of sight (unobstructive view) monitoring for Resident 2. These deficient practices placed Resident 2 at increased risk for harm due to accidents and or resident to resident altercations.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure four of seven sampled resident's (Resident 4, 5, 6 and 7) bathroom did not smell like feces and did not have pasty feces on the toilet seat and on the floor. This failure made Resident 5 feel uncomfortable and had the potential for Resident 4, 5, 6, and 7 to be at risk in acquiring infection that can negatively affect his over-all health condition.

Inspectors wroteBased on interview, and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of seven sampled residents (Resident 4) by failing to consistently document Resident 4's activities of daily living (ADLs). This deficient practice had the potential to negatively impact the delivery of care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four of seven sampled residents (Resident 4, 5, 6 and 7) were free from exposure to human waste in their living environment when feces was noted on Resident 4's clothing and bed linen, on the toilet seat and on the floor of the shared the bathroom for Resident 4, 5, 6, and 7, and on the floor of Resident 4,6, and 7's room. This failure increased Resident 4, 5, 6, and 7's risk for infection from a potentially infected human waste.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who was aphasic (a communication disorder after a stroke) was provided a communication tool necessary for Resident 1 to communicate her needs. This deficient practice had a potential for delay of appropriate care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Responsible Party of one of seven sampled residents (Resident 1) was informed of Resident 1's chest x-ray (an imaging test to produce pictures of the organs, tissue, and bones of the body) results when Resident 1 was transferred to General Acute Care Hospital (GACH) on 1/23/2024. This failure resulted in Responsible party (RP 1) feeling concerned of Resident 1's change in condition and the failure had the potential to delay care and services that could negatively predispose Resident 1 to further health complications.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure one of seven sampled residents (Resident 4) was supervised while transferring (sitting to standing position and getting out of bed), ambulating (the ability to walk) and toilet use. This failure resulted in Resident 4's fall on 2/6/2024 and had the potential to result in complications that can negatively affect his well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the inventory list records were complete and accurate for one out of three sampled resident (Resident 1). This deficient practice had the potential to result in misappropriation of Resident 2's personal property.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of five sampled Certified Nursing Assistants (CNA 1, 2, and 3) from the registry company (an agency that offers health care related contracts for temporary staff to health care facilities) received abuse training prior to working at the facility. This deficient practice resulted in the facility being unaware of registry staff's knowledge of abuse regulations and placed residents at risk for abuse, neglect, and exploitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) call light ' s was answered timely. This failure resulted in Resident 2 felt upset, ignored, and anxious for not receiving assistance timely.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to observe infection control measures for one of three sampled residents (Resident 1). by: 1. Failing to perform hand hygiene after removing the gown from the isolation room. 2. Failing to use the disinfectant correctly by not knowing the contact time of the disinfectant in use. These deficient practices had the potential to spread infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light system was operable with visual and audible in all of the residents' rooms, bathrooms, and at the nursing stations, to alert and relay the residents' needs to the staff for 19 of 19 residents (Residents 5, 10, 11, 14, 21, 23, 26, 43, 47, 52, 53, 63, 77, 80, 81, 83, 88, 89, and 98) with a universe of 94, and had the potential to affect all the residents who resided in the facility. During a review of the facility's Resident Census and Conditions of Residents (CMS 672 form) completed by the facility, the CMS 672 indicated the facility had 60 residents occasionally or frequently were incontinent (inability to control) of bladder; 68 residents occasionally or frequently were incontinent of bowel; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control interventions in the yellow zone (unit for residents suspected Corona Virus [COVID-19] a highly contagious virus that causes severe respiratory illness that affects the lungs and airways) to prevent and control the spread of COVID-19 for six (6) of thirteen (13) residents (Residents 1, 2, 3, 4, 5, and 6) and three (3) out of four (4) staff in the facility in accordance with the facility's infection control policies and procedures (P/P) and mitigation plan ([MP] a plan to reduce the spread of the COVID-19 virus) by failing to: 1. Provide and ensure that four of four visitors (Visitor 1, 2, 3 and 4) in the yellow zone are wearing required Personal Protective Equipment (PPE, gowns, gloves, N95 -facemask that filters out a minimum of 95 percent of airborne particles and gloves). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Juice machine tubing connectors were disconnected from the machine and left on the shelving with juice dripping, two gnats were flying around the dirty shelf. One juice tubing connector was down inside the dirty floor drain. 2. Not all foods were dated upon receipt, sealed after opened, labeled to identify prepared food content, and discarded prior to use by date. 3. Personal drink stored inside the reach in freezer and personal portable speaker was hanging on the drying rack by the hand washing sink. 4. Food preparation and storage area were not maintained clean. Gap between reach in freezer and food preparation counter had visible dust and food-like debris buildup in between. [...]

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure hand mittens (a glove covering the whole left hand) were not used on 2 of 3 sampled residents (Residents 66 and 67) as a physical restraint to stop the residents from pulling out the gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) and scratching the staff during care, without first attempting least restrictive measures. a. Resident 66 had no orders, assessment, and care plans for the use of hand mittens/physical restraints. b. Resident 67 had no reassessment to continue the use of restraints and no monitoring was found for the use of the hand mittens for the months of 5/2021 and 6/2021. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete and encoded (entering information into the facility minimum data set [MD'S, a federally mandated comprehensive assessment tool used for care planning] software in the computer) residents assessment for eight of 22 sampled residents (Residents 3, 4, 5, 7, 10, 13, 16, and 20). These deficient practices had the potential to prevent the facility from monitoring each resident's decline or progress to be assessed correctly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater as evidenced by the identification of 3 out of 28 medication opportunities for error, to yield a cumulative error rate of 10.71% for one of three sampled residents (Residents 61), during the medication administration facility task by: 1). Not administering the correct dose of oyster shell calcium with vitamin D 2). Not clarifying the dosage before administering Diclofenac Sodium 1% gel (arthritis pain reliever) These deficient practices had the potential to result in harm to Residents 61

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staffs were routinely trained, monitored and evaluated for competency related to their duties when: 1. Diet Aide 1 (DA 1) and Diet aide 2 (DA 2) stored personal belonging inside the kitchen and unfamiliar with department requirement regarding personal belonging storage. (cross reference F812) 2. DA 2 did not know the difference between regular dessert and controlled carbohydrate (CCHO) diet dessert for 7/6/21 lunch service and served regular desserts to the CCHO diet residents. (cross reference F803) 3. [NAME] 2 did not know how to calibrate manual thermometer and there was no documented training in-service or documented competency skills evaluation for cooks and diet aides. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dessert portion served to controlled carbohydrate diet (CCHO - diet for blood sugar control) were prepared according to the spreadsheet (food portioning and serving guide) instruction on 7/6/2021 lunch service. This failure could result in increased blood sugar levels for 16 out of 94 residents who were on a CCHO diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to make a good faith effort to permanently repair the broken call light system previously identified as an immediate jeopardy deficiency; using the Quality Assurance and Performance Improvement ([QAPI] the coordinated application of two mutually-reinforcing aspects of a quality management system, taking a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality, while involving residents and families, and all nursing home caregivers in practical, and creative problem solving) by reviewing services, outcomes, and systems throughout the facility for assuring that call lights within the facility worked, in relation to those standards, to decrease the risks associated with residents' not being able to summon help. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P/P) and ensure there was a consistent process for screening and determining eligibility for residents to receive influenza ([flu], a respiratory virus that infects the nose, throat, and lungs; spread when people with flu cough, sneeze or talk, sending droplets with the virus into the air and potentially into the mouths or noses of people who are nearby) and pneumonia (a bacterial, viral, or fungal infection of the lungs that causes the air sacs, or alveoli, of the lungs to fill up with fluid or pus) vaccines, ensure the provision of education related to influenza and pneumococcal vaccines, and ensure administration of pneumococcal and/or influenza vaccines for 4 of 5 residents (Residents 61, 70, 67, 37). [...]

Inspectors wroteBased on interviews and record review, the facility failed to implement its policy and procedures (P/P) when discharging one of three sampled residents (Resident 57) by not ensuring the discharge of Resident 57 was completed and documented to indicate the discharge summary. This deficient practice resulted in Resident 57's health information not given to the receiving facility and not receiving all his belongings.

Inspectors wroteBased on interview and record review the facility failed to inform and provide a seven-day bed hold notification for one of one resident (Resident 37) prior to a general acute care hospital (GACH) transfer. This deficient practice had the potential to cause psychosocial harm for Resident 37 and the resident's representative due to not knowing Resident 37 could return to the facility upon discharge from the GACH and violated resident's right to be readmitted into the facility.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure one of three sampled residents (Resident 66) with hand mitten (a glove covering the whole left hand) were assessed, use of less restrictive measures, and obtained a physician order before applying hand mitten as a physical restraint (any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) to stop the resident from pulling out the gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach). These deficient practices resulted in an unnecessarily restricting Resident 66 and prevent him from using his right hand.

Inspectors wroteBased on interviews and record review, the facility failed to document a discharge summary, including an understanding of discharged medications and a post-discharge plan of care in one of three residents (Resident 57) medical record. This deficient practice had the potential to result in Resident 57 and his Responsible Party to not understand the specifications of the medications after being discharge from the facility and for Resident 57 to not receive the medications as prescribed.

Inspectors wroteBased on interview and record review, the facility failed to notify one of one resident (Resident 61) physician about laboratory test results promptly, as per facility policy. Resident 61 had a laboratory test for valproic acid level (form of valproate, a medication used to treat residents with seizure disorders) done on 6/4/2021 and the results indicated a level of 26 (normal range 50-100). This deficient practice resulted in Resident 61's physician not being notify of the abnormal laboratory results until five (5) days later on 6/9/2021, and had the potential to delay care and treatment, which could have caused Resident 61 to have a seizure.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident (Resident 61) received assistance with communication and hearing abilities to maintain Resident 61's functional interaction with direct care staff and visitors. Resident 61's hearing aids were lost in 1/2021, however, the facility did not follow-up on the order for replacement hearing aid until 7/7/2021 (7 months after). This deficient practice resulted in Resident 61 unable to communicate her needs with care staff and had the potential to decline in communication, cause emotional distress, and to affect the activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to reposition and redistribute pressure away from bony areas for one of eight sampled residents (Resident 53). Resident 53, who was at risk for developing pressure ulcers (damage to skin or underlying tissue that usually occurs over a bony area as a result of long term pressure) due to risk factors which included Impaired/decreased mobility, decreased functional ability, and history of a previously healed Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone. Slough [dead tissue] may be visible). This deficient practice had the potential to cause Resident 53 to develop adverse skin conditions and pressure ulcers.

Inspectors wroteb. During a review of Resident 88's admission record, the admission record indicated Resident 88 was admitted to the facility on [DATE]. Resident 88's diagnoses included Parkinson's disease (progressive disease of nervous system marked by tremors, muscle stiffness and slow imprecise movement), respiratory failure (condition in which blood does not have enough oxygen or too much carbon dioxide) muscle weakness, and hypertension (high blood pressure). During a review of Resident 88's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 5/7/2021, the MDS indicated Resident 88 had severe cognitive (thought) impairment and is rarely/never understood. The MDS also indicated Resident 88 had trouble breathing when lying flat. [...]

Inspectors wroteBased on observations, interviews and records review, the facility failed to ensure one out of 13 residents (Resident 23) received salad texture prepared according to the mechanical soft diet (food textures modified for people who have difficulty chewing and swallowing) spreadsheet. This failure had the potential to result in decreased intake related to difficulty chewing and increased choking risk for Resident 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fortified cereal was provided as ordered by the physician to one of 13 sampled residents (Resident 14). This failure had the potential to result in decreased caloric intakes and lead to undesirable weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure trash stored in the dumpster area was maintained in a sanitary manner when one out of four garbage dumpsters were overfilled. This failure had the potential to attract disease causing pests to harbor in the dumpster area.