Costa Del Sol Healthcare

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper wound management and care planning for one of three sampled residents (Resident 1). These deficient practices placed Resident 1 at risk for delayed wound healing, dehiscence (the premature separation or reopening of the edges of a surgical wound), and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the following for one of three sampled residents (Resident 1):1. A follow up wound care appointment was scheduled after Resident 1's initial post procedure visit on 4/30/2026.2. Physician orders for daily wound monitoring, assessment, and treatment were obtained and clarified.3. Wound care was performed only with a valid physician order.4. Physician wound care orders were accurately transcribed and implemented. These deficient practices resulted in delayed wound treatment and placed Resident 1 at risk for wound dehiscence (the premature separation or reopening of the edges of a surgical wound) and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not stored at the bedside for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unauthorized medication use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of six sampled residents (Residents 1, 2, 5, and 6), had indwelling catheters (catheter drains urine from bladder into a bag outside the body) free of sediments (mineral deposits and bacterial biofilm, leading to potential complications such as blockage and urinary tract infections) and cloudiness (when particles or substances in the urine made it appear milky, hazy, or opaque) in the urine. This failure placed the residents at risk for delayed assessments, physician notification and implementation of necessary interventions. This failure had the potential that Residents 1, 2, 5, and 6 had developed urinary tract infection (UTI).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide 1 of 4 residents (Resident 1) with meals that accommodated the resident's food preference. This failure had the potential to result in decreased meal intake and could lead to weight loss and malnutrition for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to reconcile (process of reviewing resident medications to identify the most accurate list of all medications and resolve any discrepancies) the medication list for 1 of 3 sampled residents (Resident 1) upon re-admission or transfer back to the facility from the General Acute Care Hospital (GACH) on 11/18/2025. This deficient practice resulted in Resident 1 receiving incorrect doses of Ibuprofen (medication used to reduce pain and inflammation) and Norco ([Hydrocodone and Acetaminophen], medication used to treat moderate to severe pain). The failures also had the potential for unrelieved pain and worsening of symptoms or condition for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure quality-control test (a procedure used to ensure the accuracy and reliability of glucose testing results) were done for the glucometers (a device to measure glucose in the blood) in Medication Carts A and B, as indicated in the facility's policy and procedure (P&P) titled, Blood Glucose Monitoring and Quality Control. This failure had the potential to result in inaccurate blood sugar readings placing the residents at risk not to receive appropriate treatment and care, resulting in medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label a multi-dose insulin pen (a portable device with a pen-like body, an insulin cartridge, and a needle used to inject insulin [medicine for diabetes-abnormal blood sugar] into the body, which can be disposable or reusable) with open and expiration dates, when first used, for one of three Resident's (Resident 1). This failure had the potential to result in Resident 1 receiving expired medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of three residents (Resident 1), was re-admitted to the facility within the seven (7)- day bedhold (a policy where a facility reserves a bed for a resident who has been temporarily transferred to a hospital or for therapeutic leave, ensuring the resident can return to the same facility when they are ready) period. This deficient practice resulted in Resident 1 not readmitted to the facility as of 7/15/2025.

Inspectors wroteThe facility failed to notify the physician when one of three sampled residents (Resident 1) missed a session of dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). This deficient practice had the potential for Resident 1 to experience a delay in treatment or services due to possible unidentified complications associated with the physician not being aware of a missed session of dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a care plan or have resident-centered interventions for three of six sampled residents (Residents 50, 8, and 16) when: 1. Resident 50's preference for an interpreter when communicating with doctors and healthcare staff was not included in his communication care plan. 2. Resident 8 did not have a care plan for the use of oxygen. 3. Resident 16 did not have a care plan for the use of oxygen. These deficient practices resulted in staff being unaware of Resident 50's preference for a Cambodian-speaking interpreter. These deficient practices had the potential for Resident 8 and 16 oxygen administration and potentially caused a delay and negatively affected the delivery of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary respiratory care and services consistent with the resident's plan of care for three of 26 sampled residents (Resident 8, 16, 39). For Resident 8, who had a diagnosis of chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), there was no assessment of the oxygen saturation (measurement of the amount of oxygen in the blood). For Residents 8, 16 and 39, the prescribed liters of oxygen were not administered to the residents per the physician's order. These deficient practices had the potential to cause a negative respiratory outcome and placed residents at risk of injury due to fire hazard.

Inspectors wroteBased on observation, interview, and record review, the licensed nursing staff failed to ensure the physician's orders to hold medications were followed, medications were administered timely, and medications administered were accurately documented for four of six sampled residents (Resident 5, 93, 84, and 89) when: 1. Resident 89's order to hold medications on scheduled dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) days was clarified with Nurse Practitioner (NP) 2. 2. Resident 93's newly prescribed dose of fluconazole (a medication used to treat fungal infections) was administered timely from 5/4/2025 to 5/6/2025. 3. Resident 93's Antibiotic (medication used to treat infection) Medication Count Sheet was accurate and complete to account for all 10 doses of Resident 93's ordered doses of fluconazole. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 83 and Resident 87) were free from significant medication errors (one which causes the resident discomfort or jeopardizes his or her health and safety) by failing to: 1. Ensure licensed nurses held medications for Resident 83 and Resident 87 on scheduled hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) days per the physician orders. The deficient practice had the potential to result in a hypotensive crisis (low blood pressure) leading to harm or hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent for psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) was obtained in accordance with the facility's policy and procedures for one of five sampled residents (Resident 6). This deficient practice placed Resident 6 at risk for experiencing unexpected and/or unwanted adverse effects or complications of the medications, including increased cognitive impairment (problems with a person's ability to think, learn, remember, use judgment, and make decisions), over sedation (excessive drowsiness, loss of response to verbal command, inappropriate movement, hearing abnormalities, visual disturbances, sweating, or nausea), and tardive dyskinesia (a chronic movement disorder that causes involuntary, repetitive movements in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the needs and preference of two of 22 sampled residents (Resident 66 and Resident 50) were accommodated by failing to: 1. Ensure Resident 66's call light was kept within his reach. 2. Ensure Facility staff used a language interpreter when communicating with Resident 50. This deficient practice removed Resident 66's ability to exercise his right to request assistance from staff and removed Resident 50's ability to understand the care being provided to him.

Inspectors wroteBased on interview and record review, Licensed Vocational Nurse (LVN) 3 failed to notify the physician when one of 22 sampled residents (Resident 74) experienced seizures (sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) on 2/13/2025, 2/16/2025, 2/20/2025, 2/28/2025, 3/1/2025, and 3/14/2025. This deficient practice prevented Resident 74's physician from being able to make adjustments to Resident 74's plan of care to prevent recurring seizure activity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the following were indicated for two of five sampled residents (Resident 6 and Resident 73): 1. Non-pharmacological interventions were attempted, and behavioral indications were present and documented prior to administering psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for Resident 6. 2. Specific behavioral indications were documented and monitored from 3/1/2025 to 5/7/2025 for Resident 73 before the administration of clonazepam (a medication used to treat anxiety disorder [a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities]) three times a day. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Sets (MDS, a resident assessment tool) for two of 22 sampled residents (Resident 38 and 74) accurately reflected the care and services they received. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding the above residents' health status and unique healthcare needs. This deficient practice also created the potential for Residents 38 and 74 to not receive the interventions needed to monitor the effectiveness of the care received.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 74) had orders to monitor for seizures (sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) following his first seizure on 2/12/2025. This deficient practice placed Resident 74 at risk of experiencing injuries related to unwitnessed and/or undocumented seizures (e.g., falls, choking, low oxygen levels).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Policy and Procedure (P&P) for Intravenous line ([IV] a thin, flexible tube placed inside a vein, usually in the arm or hand, to deliver fluids, medications, or nutrients directly into the bloodstream) care for one Of eight sampled residents (Resident 87) by failing to: 1. Ensure Resident 87's left arm IV and IV dressing was changed per the physician's order. 2. Ensure Resident 87's right arm IV was assessed. These deficient practices increased Resident 87's risk of developing an infection (the invasion and growth of germs in the body), and caused pain and discomfort to Resident 87.

Inspectors wroteBased on interview and record review, the facility failed to provide the State Survey Agency (Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Public Health), a written report of the findings of the investigation of an allegation of abuse within five (5) working days of the occurrence of an incident of physical abuse for two of four sampled residents (Residents 1 and 2). This deficient practice had the potential to result in a delay in the State Survey Agency's investigation, unidentified abuse in the facility, and placed Residents 1 and 2 at risk for elder abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents ' (Resident 1) muscle relaxant medication was readily available for use when needed and the injection medication for physician ' s administration to manage resident ' s pain was available. This failure placed the resident at risk for discomfort and severe pain, which can affect in maintaining the resident ' s highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2) were prepared for a safe discharge from the facility when the following occurred: 1. On [DATE], facility staff discharged Resident 1, who required extensive assistance with activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility, without arrangements for home health services (a wide range of health care services that you can get in your home for an illness or injury), as ordered by the physician. 2. On [DATE], facility staff discharged Resident 2, who had physician orders for continuous oxygen therapy (a treatment that provides you with extra oxygen to breathe in), without ensuring Resident 2 had the required equipment and instructions for continuous oxygen therapy. [...]

Inspectors wroteBased on interview and record review, the facility failed to report unusual occurrence from one of four sampled residents (Resident 1) to the state agency California Department of Public Health (CDPH), when Resident 1 was noticed with a large bruise on her left side of the breast and left rib cage on 9/5/2024. This deficient practice resulted in a delay of an onsite inspection by CDPH to investigate Resident 1 ' s injury in a timely manner, a delay in prevention of further injuries and possible abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of eight sampled residents (Resident 2, Resident 5 and Resident 6) call lights were placed within residents' reach. This deficient practice could result in residents ' needs not met and residents ' highest practicable physical, mental, and psychosocial wellbeing will not be maintained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Resident 3 and Resident 4) who were on gastrostomy tube ([GT] a tube surgically inserted into the abdomen to administer medications and nutrition) feedings, received tube feedings (nutrition administered via GT) timely according to the physician ' s orders. This deficient practice had the potential to result in Resident 3 and Resident 4 ' s nutritional needs not met leading to weight loss and malnutrition (lack of proper nutrition).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective infection control measures were practiced, by failing to ensure: 1. Cleaned and uncleaned oxygen concentrators (a medical device that takes air from the environment and filters it into purified oxygen) were not stored in the same storage room (Storage 1). 2. The oxygen concentrators were labeled to distinguish the cleaned oxygen concentrators from the uncleaned oxygen concentrators. These deficient practices had the potential to result in cross contamination and increase the risk of infection to residents receiving supplemental oxygen.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Correctly use a Valve-bag-mask ([Ambu-bag] hand-held device commonly used to provide positive pressure ventilation [exchange of air between the lungs and the outside air] to residents who are not breathing or breathing inadequately) when one of one sampled resident (Resident 1) was in respiratory distress. 2. Ensure staff checked the Emergency Cart daily (cart with supplies used during emergencies) and ensure non-rebreather masks (device used to assist in the delivery of oxygen [O2] therapy) were stocked as per facility ' s policies and procedure (P&P). These deficient practices had the potential to result in residents not receiving emergency treatment and care needed in accordance with professional standards of practice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to: 1. Provide range of motion ([ROM] full movement potential of a joint [where two bones meet]) exercises, apply splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), and perform ambulation (the act of walking) to 43 residents requiring a Restorative Nursing Assistant (RNA, nursing aide program that helps residents to maintain their function and joint mobility) program, including five of seven sampled residents (Resident 8, 27, 49, 61, and 63) with limited mobility (ability to move). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess functional limitation (limited ability to move a joint that interferes with daily functioning) in range of motion ([ROM] full movement potential of a joint [where two bones meet]) for five of seven sampled residents (Resident 8, 27, 49, 61, and 63) with limited mobility (ability to move) and ROM limitations. This deficient practice had the potential to affect the provision of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of seven sampled residents (Resident 8, 27, 49, 61, and 65) with limited mobility (ability to move) and range of motion ([ROM] full movement potential of a joint [where two bones meet]) received services to maintain mobility and ROM by failing to: a. Apply Resident 8's left elbow extension splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) five times per week during 5/2024 in accordance with the physician orders and care plan. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and hazard free environment was maintained for one of three sampled residents (Resident 75) when a pool of enteral nutrition (form of nutrition that is delivered as a liquid) was observed on the floor in Resident 75's room. This deficient practice had the potential to cause avoidable harm to Resident 75 related to slips, falls, and possible subsequent injury associated with a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory services for three of four sampled residents (Resident 13, 57, and 69) by failing to: a. Ensure Resident 13 was provided a nebulizer machine (a device used to administer medication in the form of a mist inhaled into the lungs), incentive spirometer (device that measures the volume of the air inhaled into the lungs during inspiration), oxygen cylinder (medical device to provide supplemental oxygen to resident), nasal cannula (a device used to deliver supplemental oxygen placed directly on the resident's nostrils), respiratory treatment via nebulizer every four hours, and incentive spirometer treatment twice per day. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. Nutritional supplements labeled store Frozen with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded within the appropriate time frame. Four boxes containing 50 individual cartons of strawberry flavored nutrition supplements were stored in the walk-in refrigerator with no thaw date. This deficient practice had the potential to result in food borne illness in 24 residents who were on nutrition supplements at the facility. 2. One plastic bag of breaded cylinder-shaped food item was stored in the walk-in freezer with no label and date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide accurate documentation for two of seven sampled residents (Resident 8 and 63) with limited mobility (ability to move) and range of motion ([ROM] full movement potential of a joint [where two bones meet]). a. Resident 8's clinical record for Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) tasks did not indicate both knee splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) were applied from 11/2023 to 2/2024. b. Resident 63's clinical record for RNA tasks did not include passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to both legs from 12/16/2023 to 2/13/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain infection control measures when: 1. Staff did not ensure enhanced barrier precautions (EBPs, an infection control intervention used to reduce transmission of multidrug-resistant organisms [MDROs, organisms resistant to at least one or more classes of antimicrobial agents]) were implemented for one of 18 sampled residents (Resident 27). This deficient practice increased the risk for spread of MDROs to vulnerable facility residents, and the potential incidence of preventable infection. 2. Clean one of one vinyl (type of plastic material) gait belt (assistive device used for lifting, transferring, and walking patients who have limited mobility issues) and front-wheeled walker (FWW, an assistive device with two front wheels used for stability when walking) after ambulation (the act of walking) with Resident 69. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure staff provided assistance to one of two sampled residents (Resident 61), to accommodate the resident's preference for getting out of bed at least once a day to sit in his wheelchair. This deficient practice had the potential to cause avoidable psychosocial distress and frustration for Resident 61 from an inability to participate in his preferred activity.

Inspectors wroteBased on interview and record review, the facility did not ensure the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals with a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) screening was accurate, and determination for necessity of potential necessary services was completed for one of two sampled residents (Resident 10). This deficient practice had the potential for Resident 10 to not receive required services and care for her diagnosed mental disorders.

Inspectors wroteBased on observation, interview, and record review, the licensed nursing staff failed to follow professional standards of practice and implement the physician's written order for the administration of routine medications to one of three sampled residents (Resident 13). This deficient practice had the potential to place Resident 13 at risk to have complications of high blood pressure, avoidable harm, heart attack (heart muscle begins to die because not getting enough blood flow), respiratory distress, and chronic obstructive pulmonary disease (COPD, a lung disease causing restricted airflow and breathing problem) exacerbation (worsening of symptoms).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fingernail care was provided, and grooming and personal hygiene was maintained for two of eight sampled residents (Resident 52 and 77), who were unable to carry out activities of daily living (ADLs, self-care activities performed daily). This deficient practice had the potential for a negative impact on Resident 52's and Resident 77's quality of life and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fingernail care was provided, and grooming and personal hygiene was maintained for two of eight sampled residents (Resident 52 and 77), who were unable to carry out activities of daily living (ADLs, self-care activities performed daily). This deficient practice had the potential for a negative impact on Resident 52's and Resident 77's quality of life and self-esteem.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to administer enteral nutrition (the delivery of nutrients through a gastrostomy tube [a flexible plastic tube placed into the stomach wall]) as ordered for one of two sampled residents (Resident 27). This deficient practice had the potential to cause avoidable complications, such as malnutrition and/or delays in health promotion and maintenance for Resident 27.

Inspectors wroteBased on observation, interview, and record review, the licensed nurses failed to follow the facility policy and procedure (P&P) for initiation and maintenance of intravenous therapy ([IV] a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) for one of two residents (Resident 243) by: 1. Failing to label and date a peripheral intravenous catheter ([PIV] a short catheter inserted through a peripheral vein for the administration of solution or medication) site. 2. Failing to change the PIV site and dressing when the site appeared compromised. 3. Failing to remove the PIV after IV treatment was complete. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide timely pain management to two of two sampled residents (Resident 47 and 61). This deficient practice had the potential to cause avoidable discomfort and distress related to uncontrolled pain for Resident 47 and Resident 61.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner when: One of three garbage dumpsters lid was open and overfilled with cardboard boxes. The ground around the trash dumpsters was not clean and had plastic utensils, gloves, and paper around and under the dumpsters. This deficient practice had the potential for harborage and feeding of pests.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy when discussing binding arbitration agreements (a form of alternative dispute resolution in which both parties agree to have their case heard by a neutral party instead of a judge and jury) with three of three sampled residents and/or their responsible parties (Resident 73, 80, and 241). This deficient practice increased the risk that Resident 73, Resident 80, and Resident 241 and/or their responsible parties unknowingly forfeited their right to resolve any disputes with the facility in court, alongside a judge and/or jury.

Inspectors wroteBased on interview and record review, the facility failed to document information related to the resident ' s mental status or orientation when there was a significant change of condition in one of three residents (Resident 1). This deficient practice resulted in Resident 1 not having sufficient documentation regarding her mental status and orientation during a change in condition and before transferring to a higher level of care. This deficient practice had the potential to cause harm to Resident 1 due to poor communication of resident ' s health status which could cause inaccurate and delayed treatment to the resident.

Inspectors wroteBased on interview and record review, the licensed nurse failed to do the following for one of three sampled residents (Resident 1): 1. Follow facility established process when attempting to communicate with Resident 1 ' s medical doctor (MD). 2. Initiate an situation, background, assessment, and recommendation (SBAR- form of communication between staff) form during a sudden acute change in Resident 1 ' s health. These deficient practices had the potential for Resident 1 to have suffered life threatening complications and requiring a longer stay at a general acute care hospital (GACH).

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to implement corrective actions to the systemic problems identified: a. Ensure the medication administration error rate was below five (5) percent; b. Ensure consistent implementation of the facility's antibiotic stewardship program (effort to measure and improve how antibiotics [medications that fight infections-- germs invade body and makes the body sick]were prescribed by clinicians and used by residents in the facility) c. Ensure the competency of kitchen staff when following a pureed diet [food that doe not need to be chewed] recipe and serving the correct amount of food to residents as specified in the menus; d. Ensure competency of nursing staff when providing residents with an indwelling catheter (flexible tube inserted to bladder to drain urine) care; and e. [...]

Inspectors wroteBased on observation, interview, and record review, the staff failed to ensure resident call lights were within reach for three of three sampled residents (Residents 27, 35 and 43), and failed to ensure one of 20 random selected residents (Resident 37) was provided with a communication board. This deficient practice had the potential for Residents 27, 35, and 43's needs to not be met timely, and Resident 37 not receiving a functional communication system to facilitate communication with staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an uncluttered physical environment, and a safe, clean, comfortable and home-like environment for four of four sampled residents (Resident 3, 30, 38 and 42). This deficient practice created an unsafe environment for Resident 38 whose wheelchair was bumped by Resident 3 at the entrance door of the patio while being wheeled by Resident 30, and Resident 42 was using disposable bed pads as a floor mat. These failures had the potential for other residents, staff, and visitors to have an accident and get hurt.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Obtain an order to titrate the use of oxygen ([O2] the life supporting component of air), and date and label the oxygen nasal cannula tubing as ordered for Resident 49. 2. Obtain an order for the use of oxygen and perform a thorough assessment of Resident 261's lung sounds. These deficient practices had the potential for health complications associated with lack of guidance from the physician, delay in assessment, treatment plan and poor continuity of care and follow-up on the resident's status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three staff (Certified Nurse Assistants [CNA 2], CNA 3, and CNA 4) had the necessary knowledge and skills to care for residents with an indwelling catheter (a urethral catheter designed to be held in place to drain urine from the bladder). The deficient practice had the potential to result in infection and hospitalization for the residents

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five (5) percent, due to improper medication administration for three (3) of four (4) randomly selected residents (Resident 56, 29, and 11) during the medication administration. The outcome was six (6) medication errors out of thirty (30) opportunities, which resulted in a medication administration error rate of 20 percent and exceeded the five (5) percent threshold.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove and replace expired medical supplies and tube feeding formula in one of two Storage Rooms. This deficient practice had the potential to result in the use of ineffective or spoiled equipment and formula for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff (Cook 1 and [NAME] 2) had appropriate skills set to carry out the duties of a cook. This deficient practice resulted in 69 residents, who were receiving regular, pureed, or mechanical diets, receiving an incorrect portion size for pureed carrots, mechanical soft chicken, and potato salad, and 13 residents who were on a pureed diet received pureed carrots and pureed bread made with water instead of broth and milk. Findings During an observation on 3/22/22 at 12:15 p.m. of the tray line, [NAME] 1 was observed using the following scoop colors: 1. [NAME] scoop for potato salad for Pureed, Regular and Mechanical Soft diets. 2. [NAME] scoop for BBQ chicken, and a gray ladle (4 oz) for carrots for Mechanical Soft and Regular diets. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. Follow its menu as written for residents on regular, pureed, and mechanical soft diets. 69 residents who were receiving regular, pureed, or mechanical diets received an incorrect portion size for puree carrots, mechanical soft chicken and potato salad. This deficient practice had the potential to affect the residents' weight resulting in weight loss when the menu was not followed for residents on regular, pureed, and mechanical soft diet. b. Follow the pureed recipe for making pureed carrots and pureed bread. 13 residents who were receiving a pureed diet received pureed carrots and pureed bread made with water instead of broth and milk. These deficient practices had the potential to affect the nutritive value of the pureed carrots and bread served to the residents. Findings a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety when: 1. Several food items were not dated and labeled after being placed in the reach-in freezer and walk-in refrigerator. 2. Vegetables were stored in open bags in the walk-in refrigerator. 3. The ice machine was not cleaned properly and there was pink residue inside the ice machine. This failure had the potential to result in germ exposure to residents and placed residents at risk for developing foodborne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) which can lead to other serious medical complications and hospitalization for 69 out of the 76 residents who received food from the kitchen. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a facility-wide assessment was implemented when the facility failed to: a. Ensure the competency of kitchen staff when preparing meals for the pureed diet (food that does not need to be chewed) recipe and serving the correct amount of food to residents as specified in the menus. b. Ensure competency of nursing staff when providing residents with an indwelling catheter (flexible tube inserted to bladder to drain urine) care and when administering medications safely. c. Ensure sufficient nursing staff in the day-to-day operations. This deficiency had the potential to result in poor resident health outcomes and diminished quality of care for facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control and prevention program to prevent the development and transmission of communicable diseases by not ensuring the use of personal protective equipment ([PPE] protective clothing, garments or equipment designed to protect the wearer or the resident from infections) prior to entering a yellow zone room (designated area for residents exposed to COVID-19). This deficient practice placed the residents, staff, and the community at higher risk for cross contamination, and increased spread of COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath) in the facility and the community.

Inspectors wroteBased on interview and record review, the facility did not ensure two of two residents (Resident 55 and Resident 51) were prescribed antibiotics appropriately by failing to develop a clear policy and implementing an antibiotic stewardship program. This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification. Findings During a concurrent interview with the Infection Preventionist Nurse (IP) and record review of Resident 55's electronic health record (EHR) on 3/23/22 at 2:08 p.m., the IP stated that there was no completed McGeer's criteria (criteria used to determine appropriate use of antibiotics) in Resident 55's chart. During a concurrent interview with the IP and record review on 3/23/22 at 2:08 p.m. of Resident 51's EHR, the IP stated that there was no completed McGeer's criteria in Resident 51's chart. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Develop and implement residents' rights policies and procedures, in accordance to state laws and regulations, related to psychotherapeutic (used to treat psychosis, which refers to a group of mental disorders such as depression, schizophrenia, and manic-depressive disorders, that affect mood and behavior) informed consent for one of 20 residents (Resident 34). 2. Have a policy and procedure (P/P) in place for psychotherapeutic medication informed consent usage. This deficient practice potentially affected the resident or responsible party to make informed health care decisions based on the resident's medical condition, changes in medical condition, benefits and reasonable risks of medications or treatment, and reasonable available alternatives.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information was provided to the residents and/or responsible parties for one of 20 residents (Resident 37). This deficient practice violated Resident 37's and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan after one of two sampled residents sustained a fall (Resident 20). This failure had the potential to result in repeated falls, harm, and serious injury to Resident 20 due to a delay in developing cause-specific interventions to prevent further falls. Findings A review of Resident 20's facesheet indicated Resident 20 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included unspecified fall and unsteadiness on feet. A review of Resident 20's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 1/18/2022, indicated Resident 20 was cognitively intact and independent in activities of daily living in the areas of transfers, dressing, eating, toilet use, personal hygiene, and bathing, and was continent (able to control) of bowel and bladder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that meet professional standards of quality for three of three sampled residents (Residents 11, 52, and 18) by failing to ensure: a. Licensed Vocational Nurse 3 (LVN 3) did not administer Resident 11's medications via gravity through the resident's gastrostomy tube ([G-Tube] tube surgically inserted into the stomach for nutrition, hydration, and medication). This failure had the potential to cause clogging or damage to the G-Tube. b. The licensed nurse received an order to transfer Resident 52 to the hospital and provided adequate documentation upon the resident's transfer. This failure had the potential to cause miscommunication regarding Resident 52's change of condition. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess Resident 261's health status and initiate a change of condition (COC). This deficient practice had the potential to result in Residents 261 not receiving needed treatment and/or services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility was free from clutter and accidental hazards and provided adequate supervision to prevent accidents for four of four sampled residents (Resident 3, 30, 38 and Resident 42). This deficient practice had the potential to result in serious harm and injury to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nurse Assistants (CNA) 2 performed indwelling catheter (a urethral catheter designed to be held in place to drain urine from the bladder) care that meets professional standards of quality. CNA 2 did not maintain clean technique (reduce the risk of introducing potentially pathogenic micro-organisms into susceptible sites) and caused pain and discomfort while providing indwelling catheter care to one of three Residents (Resident 59). This deficient practice had a potential to result in Resident 59 being at higher risk for developing a urinary tract infection (is an infection in any part of the urinary system) as well as other complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a licensed nurse did not administer medications via gravity (holding up a syringe to allow nutrition formula, water, or medications to flow by gravity) through a gastronostomy tube ([G-tube] a flexible tube placed into the surgical opening in the stomach that allows for nutrition, fluids, and medications) for one of three sampled residents (Resident 11). This failure had the potential to cause clogging and/or damaging Resident 11's G-tube.

Inspectors wroteBased on interview and record review, the facility failed to administer the influenza (flu) vaccine (substance to protect against influenza viruses [germ that infects people and attacks the respiratory system--nose, throat, lungs]) to one of five sampled residents (Resident 20). This deficient practice placed Resident 20 at higher risk for acquiring and transmitting the flu to other residents in the facility.