Cottage Crest Post Acute

Inspectors wroteBased on interview, and record review, the facility failed to ensure a care plan for one of three sampled residents (Resident 4) was created when Resident 4 refused a skin assessment during admission to the facility (7/3/2026). This deficient practice resulted in no initial assessment of Resident 4's skin until 7/8/2026 (five days after she was admitted to the facility on [DATE]) and had the potential for interventions necessary for the implementation of Resident 4's care to not be addressed and a baseline assessment of Resident 4's skin to be delayed.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a follow up attempt was made to assess the skin for one of three sampled residents (Resident 4), when Resident 4 initially refused to have her skin assessed (7/3/2026). They failed to provide an oral and written endorsement to a licensed nurse on the oncoming shift regarding Resident 4's refusal to have her skin assessed, and they failed to assess Resident 4's skin/wounds on 7/4/2026, 7/5/2026, and 7/7/2026. These deficient practices resulted Resident 1's skin not being assessed for five days after Resident 1 was admitted to the facility (7/3/2026) and had the potential for a delay in recognition of wound deterioration and an inaccurate evaluation of necessary treatment to prevent progression and/or healing of Resident 4's wounds.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan failed to address for three of 15 sample residents (Resident 64, 66, and 1) by failing to:a. Initiate a care plan for a Peripheral Intravenous line (PIV, short, flexible, small tube inserted into a vein to deliver medications or fluids directly into the bloodstream) monitoring for Resident 64.b. Initiate a fall care plan for Resident 66.c. Implement Resident 1's care interventions to monitor signs and symptoms of hyperglycemic (high blood sugar) and hypoglycemic (low blood sugar) episodes. These failures had the potential to negatively affect the delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure:1. The door was closed for Resident 66 who was on Novel Respiratory Precautions (isolation)2. Facility staff did not wear the same gown from room to room.3. Staff performed hand hygiene prior to giving medications to Resident 47 and Resident 11. 4a./4b. A Peripheral Intravenous line (PIV, short, flexible, small tube inserted into a vein to deliver medications or fluids directly into the bloodstream) for Resident 64 and Resident 67 was discontinued and removed when no longer indicated. These failures had the potential to increase the risk of infection and cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) among residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation an advance directive ([AD] 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) was discussed and written information provided to the resident and/or responsible party ([RP] the person handling a resident's finances and care decisions) in their primary language for one of 15 sampled residents (Resident 4). This deficient practice violated the Resident 4 and the RP right to be fully informed of the option to formulate their AD and had the potential to cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician that a resident was experiencing new abdominal pain for one of three sampled residents (Resident 64). This deficient practice had the potential to result in Resident 64 delay of treatment and further harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure a communication system was in place to translate for one of 15 sample residents (Resident 4) in their primary language. This deficient practice had the potential for Resident 4 not being provided with the appropriate care and treatment needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to objectively measure the range of motion (ROM, full movement potential of a joint) for one of five sampled residents (Resident 23) in the left hand in the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 2/17/2026. This deficient practice had the potential for Residents 23 to experience further decline in ROM resulting in contracture (loss of motion of a joint associated with stiffness and joint deformity) development and have a decline in physical functioning, mobility (ability to move), and activities of daily living (ADL, basic activities such as eating, dressing, toileting).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff provided feeding assistance for one of seven residents (Resident 10) who required one to one (1:1) feeding assistance during meals and was at risk for aspiration as recommended by the speech therapist. This failure had the potential to result in Resident 10's inadequate nutritional intake, weight loss, dehydration, choking and aspiration.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Assess and monitor the urinary catheter (tube inserted into the bladder to drain urine) for one of seven sampled residents (Resident 64). b. Ensure one of seven sampled residents (Resident 7) had a physician order with indication for the urinary catheter. These deficient practices had the potential to result in a urinary tract infection (UTI, an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 11) received the correct amount of gastrostomy tube (GT - an opening to the stomach from the abdominal wall made surgically for the introduction of food) feeding formula. This deficient practice had the potential to result in weight loss or gain, dehydration and fluid overload.

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of 10 sampled residents (Resident 64, 1, and 3)'s medication regimens were monitored for side effects and signs/symptoms as ordered by failing to:a. Monitor for side effects of opioid medication for Resident 64.b. Monitor signs and symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) for Resident 1.c. Monitor signs and symptoms of anticoagulant therapy for Resident 3. These deficient practices had the potential to result in adverse drug reactions, unrecognized complications, and ineffective medication management for the affected residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fortified diets (diet to increase calories) were identified and communicated during lunch tray line meal service for ten residents who were on fortified diet as recommended by the dietitian and ordered by the physician. This failure had the potential to result in residents not receiving required nutritional fortification (adding extra vitamins and minerals to food), leading to inadequate nutritional intake, and unintended weight loss.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Responsible Party (RP) for one of four sampled residents (Resident 1), who did not have the capacity to make decisions, was advised of Resident 1's dental needs and a consent was obtained from Resident 1's RP prior to Resident 1's tooth extraction. This deficient practice resulted in the extraction of Resident 1's tooth without the knowledge or consent of Resident 1's RP. This deficient practice had the potential for Resident 1 to be subjected to an unnecessary procedure and/or to suffer complications such as discomfort/pain, bleeding, and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) care plan was revised after Resident 2 fell on [DATE]. This deficient practice had the potential for the nursing staff to be unaware of Resident 2's current fall-risk precautions and interventions, which could delay or negatively impact the delivery of her care and potentially lead to further falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 1) was provided with his preferred activities. This failure resulted in Resident 1 feeling sad and frustrated and had the potential to further affect Resident 1's emotional well-being, which may impact his quality of life and mental health.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) 1 accurately documented vital signs (essential measurements taken by the healthcare team providers to check the body's most basic and life sustaining functions) for one of three sampled residents (Resident 2) when Resident 2 had a change of condition on 12/25/2026 and was transferred to a General Acute Care Hospital via 911 for further evaluation. This deficient practice had the potential for Resident 2's change of condition to be unrecognized, undetermined, or inadequately identified. This deficient practice also had the potential to negatively impact Resident 2's health status, interrupt the continuity of care, and impair timely and accurate communication among facility team members and with emergency personnel.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for four out of seventeen sampled residents (Resident 10, Resident 23, Resident 44, and Resident 45) related to: 1. Resident 45's usage of Apixaban (a blood thinner medication). 2. develop and implement care plans of bowel and bladder retraining and bowel incontinent for Resident 10. 3. develop and implement care plans of bowel and bladder retraining and bowel incontinent for Resident 44. 4. develop and implement care plans of hypoglycemia [a condition in which a person's blood sugar (glucose) level is lower than normal] for Resident 23. These deficient practices could result in the Resident's needs not being met, negatively impacting their well-being, and leading to suboptimal patient outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents (Resident 10, Resident 44, and Resident 3) who were incontinent (unable to voluntarily control retention of urine or feces in the body) of bowel and bladder, were provided a retraining and/or toileting program to regain the resident's normal bowel and bladder function as much as possible by failing to: A. ensure Resident 10's bowel and bladder assessment was done and follow through quarterly, and Resident 10 received bowel and bladder retraining as the assessment indicated. B. Ensure Resident 44's bowel and bladder assessment was conducted upon admission, and that Resident 44 participated in the bowel and bladder retraining program. C. Ensure Resident 3 was offered a bowel and bladder training to restore as much bladder function as possible. [...]

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility did not store food in a sanitary manner, which is necessary to prevent the growth of microorganisms. These microorganisms can cause foodborne illnesses, such as those resulting from contaminated food with pathogenic bacteria, viruses, parasites, or toxins. This issue affected 47 out of the 50 residents at the facility due to the following deficiencies: A. Ensuring food items were dated, labeled, and discarded properly. B. Ensuring [NAME] (CK) 2 performed hand hygiene (washing Hands) and changed gloves between tasks during trayline (Resident's trays are assembled and check for accuracy before food is delivered to them). This failure had the potential to impact residents, resulting in exposure to pathogens and placing them at risk for foodborne illnesses. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to report the outbreak (urgent emergencies accompanied by rapid efforts to save lives and prevent further cases) of corona virus- 19 (COVID-19, a highly contagious infection, caused by a virus that can easily spread from person to person) to the State Agency (CDPH, California Department of Public Health) starting on 5/14/2025 for six out of six sampled Residents (Resident 12, Resident 30, Resident 37, Resident 40, Resident 44, and Resident 45). These deficient practices had the potential for continued spread of the COVID-19 infection to all the facility's residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure (P/P) for Antibiotic Stewardship (the effort to measure and improve how antibiotics (a medication used to kill bacteria and to treat infections) are prescribed by clinicians and used by patients) for two of five sampled residents (Resident 43 and Resident 154) who were prescribed antibiotics without meeting criteria. This deficient practice had the potential for Resident 43 and Resident 154 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on the interview and record review, the facility did not obtain informed consent for one of the five residents (Resident 45) who was diagnosed with depression-a mood disorder characterized by persistent sadness and loss of interest that can affect daily life-and was being treated with the medication Celexa (a medication that treats depression) . This deficient practice had the potential for Resident 45 to not be informed of the risks and benefits of Celexa.

Inspectors wroteBased on interviews and record reviews, the facility did not ensure that residents received appropriate treatment and care for hypoglycemic episodes in accordance with professional standards of practice. Specifically, for one of three sampled residents (Resident 23), the facility failed to ensure the resident consumed a meal after receiving insulin and did not monitor blood glucose levels or provide necessary treatment during the hypoglycemic episode. This failure led to Resident 23's preventable hospitalization for further evaluation and treatment.

Inspectors wroteBased on the interview and record review, the facility did not monitor anticoagulant (blood thinning medication) usage for one out of six sampled residents (Resident 45). This deficient practice had the potential for complications related to anticoagulant use including bleeding to go unnoticed for Resident 45.

Inspectors wroteBased on observation, interview, and record review, it was noted that one tube of Triamcinolone Acetonide External Cream 0.5% (used to treat rashes) belonging to Resident 26 was not labeled or dated in medication cart 1. This deficient practice had the potential for the medication to be used after it was expired.

Inspectors wroteBased on observation , interview and record review the facility failed to ensure 33of 33 Residents room requirements of 80 square feet (sq.ft - a unit of area measurement ) per residents in multi-bed resident rooms were implemented. This deficient practice had the potential to result in inadequate provision of safe nursing care, and privacy for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled resident (Resident 2) touch pad call light (enables residents with limited movement to call for help) and telephone were within Resident 2 ' s reach. This failure had Resident 2 to feel frustrated, useless and had the potential for her needs not met which could result to delay of care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report an unusual occurrence of an acute (sudden and severe onset) right femoral neck fracture (a particular type of hip fracture that occurs at hip region below the ball-and-socket joint ) and right temporal (side of the head behind the eye between the forehead and the ear) hematoma (a closed wound where blood collects and fills a space inside your body because it can't flow or drain out) of unknown cause to the State Survey Agency (California Department of Public Health-CDPH) within 24 hours of the occurrence for one of three sample residents (Resident 1). This failure had the potential to result in a delay of an onsite inspection by CDPH to ensure injuries from unknown origins were investigated timely and lead to a delay in prevention of potential ongoing unknown injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was not verbally abused (using words to name call, bully, demean, frighten, intimidate, or control another person) by certified nursing assistant (CNA 1). This deficient practice caused Resident 1 to feel offended and cry hysterically (to cry in an uncontrolled state of anger, excitement, or panic) when CNA 1 re-entered Resident 1's room.

Inspectors wroteBased on observation and interview, the facility failed to create a person-centered care plan for diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) for one of three sampled residents (Resident 2). This deficient practice had the potential for Resident 2 to have episodes of hypoglycemia (occurs when your blood sugar level drops too low for your body to function normally) and/ or hyperglycemia (elevated blood sugar) related to her diagnosis of diabetes.

Inspectors wroteBased on interview and record review the facility failed to monitor the blood sugar levels for one of three sampled residents (Resident 2) who had type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and was receiving insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). This deficient practice had the potential to cause hypoglycemia (occurs when your blood sugar level drops too low for your body to function normally).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Twenty medication errors out of total 41 opportunities contributed to an overall medication error rate of 48.78 % affecting five of five residents observed for medication administration (Residents 19, 26, 209, 210, and 211.) The medication errors noted were as follows: 1. Omitted administration of Metoprolol Tartrate (a medication used to treat high blood pressure) 75 milligrams ([mg] a unit of measure for weight) to Resident 26. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide adequate Restorative Nursing Assistant ([RNA] -a certified nursing assistant (CNA) with specialized training in rehabilitation skills who assists the restorative team with supervised and delegated restorative programs) staff to provide range of motion ([ROM]- the amount of movement that a particular joint or series of joints can achieve in a specific direction), splint (a rigid support for restricting movement of an injured part) application, and ambulation to 28 of 54 residents on RNA program. This failure had the potential to result in 28 residents being at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Licensed Vocational Nurses (LVN) 1, LVN 2 and LVN 5 were trained to administer medications via gastrostomy tube (g-tube - a surgically placed tube used to administer mediations or food directly into the stomach) with the appropriate technique and/or in accordance with physician's orders for three out of three sampled residents for g-tube administration (Resident 19, Resident 6 and Resident 47.) This failure had the potential to result in g-tube complications and infection for Resident 19, Resident 6 and Resident 47.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure availability of metoprolol tartrate (a medication used to treat high blood pressure), apixaban (a medication used to prevent and reduce the risk of blood clot), furosemide (a medication for heart failure and high blood pressure), amoxicillin (a medication used to treat infection), lidocaine (a medication used to treat localized pain) cream, and tussin DM ([Generic name - guaifenesin and dextromethorphan] a medication used to provide cough relief) in accordance with physician orders or professional standards of practice for five of nine sampled residents (Residents 6, 26, 209, 210 and 211.) 2. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by: 1. Failing to dispose expired food from the fridge. 2. Failed to store food in the appropriate section. 3. Failed to do proper hygiene when entering the kitchen. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization. During a concurrent observation of the refrigerator and interview on 6/4/2024 at 8:26a.m. with Dietary Aide 1 (DA 1). DA 1 stated the cilantro in the bag that was dated 5/9/2024 is supposed to be good for one week and was supposed to be thrown away. [...]

Inspectors wroteBased on observation and interview, the facility failed to dispose of garbage and refuse properly by not completely covering two (2) of 2 dumpsters (a large trash container designed to be emptied into a truck) and two smaller carts for an unknown length of time. This deficient practice had a potential to attract flies, insects, cats, and other animals to the dumpster area placing 54 of 59 facility residents getting food from the kitchen cross-contamination (a transfer of harmful bacteria from one place to another). During a concurrent observation and interview on 6/4/2024 at 12:32p.m. with Dietary Manager (DM), it was observed there were two big garbage dumpsters full and overflowing and the lids were unable to be closed for both of the bins. Additionally, there were two extra carts in the front of the big dumpsters with disposable places with no lid. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify unresolved quality deficiencies, some of which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process as evidenced by the severity and number of deficiencies cited involving sufficient staffing, significant medication error, providing medications as physician ordered, and maintaining medication in stock. This failure had potential to result in 54 of 54 residents residing in the facility not receiving services and care they need.

Inspectors wroteBased on interview and record review the facility failed to ensure two of 18 sampled resident (Resident 7 and Resident 44 ) were offered an advance directive (a legal document that specifies what actions should be taken for your health if you are no longer able to make decisions for yourself) and provided information regarding the advance directive. This failure had the potential to violate the residents' 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 interview and record review the facility failed to a. Ensure one of 18 sampled residents (Resident 7)'s assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to the section in the MDS called Swallowing/Nutrition Status was accurately documented to reflect Resident 7's nutritional approaches. b. To conduct an accurate fall assessment for one of three sampled residents (Resident 36). This failure had the potential to result in a negative effect on Resident 7 and Resident 36's plan of care and delivery of necessary services, care and treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, residents did not develop an adverse effect (an undesired effect of a medication or other type of treatment) due to receiving antipsychotic medications used to treat mental health conditions like schizophrenia (a serious mental disorder in which people interpret reality abnormally), bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), Seroquel, Risperdal and Ativan and for two of 18 sampled residents (Resident 18 and Resident 25). The facility failed to: 1. Ensure Resident 25, who had a physician's order to discontinue administration of Seroquel 25 milligrams ([mg]- a unit of measure of weight) dated 5/14/2024, was not administered Seroquel for an additional 20 days, a total of 20 extra doses from 5/14/2024 to 6/4/2024. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control measures by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 performed hand hygiene during and after caring for Resident 31. 2. Ensure CNA 2 wore proper Personal Protective Equipment ([PPE]- equipment used to prevent or minimize exposure to hazards) during the care of Resident 6 who was on enhanced precaution (a level of infection control that requires interventions such as wearing gloves and a gown) and exposed Resident 211 who was not on any precaution for possible cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of 18 sampled residents (Resident 7)'s documentation of a significant change of condition (COC-documentation of a resident's sudden change from baseline) was done when Resident 7 was transferred to the hospital. This failure had the potential to result in resident 7 not receiving the appropriate care and necessary treatment.

Inspectors wroteBased on interview and record review, the facility failed to follow through and accurately assess with the Preadmission Screening and Resident Review (PASARR- a comprehensive evaluation that ensures people who have been diagnosed with serious mental illness, intellectual, and/or developmental disabilities are able to live in the most independent settings while receiving the recommended care and interventions to improve their quality of life) level I and level II evaluation for four of four sampled residents (Resident 22, Resident 6, and Resident 1) to determine the facility's ability to provide the special need of the residents. This deficient practice placed Resident 22, Resident 6, and Resident 1 at risk of not receiving the necessary care and services they need.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for two of three sampled residents (Resident 25 and Resident 36) by: 1. Failing to address multiple falls and a fall with injury by initiating an at risk for fall care plan, the use of psychotropic medication (medication capable of affecting the mind, emotions, and behavior) in the care plan for Resident 25 who was on Ativan (generic name Lorazepam is used to treat anxiety) Rexulti (generic name Brexpiprazole is an antipsychotic (medication used to treat a collection of symptoms that affect your ability to tell what's real and what isn't) medication to treat major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and dementia (a group of symptoms that affects memory and thinking)-related agitation. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure and implement their policy and procedure on fall prevention for one of three sampled residents (Resident 52) by: 1. Failing to develop person-centered interventions/approaches addressing Resident 25's high risk for falls. 2. Failing to revise the fall risk care plan for multiple falls, doing a post fall assessment, and doing proper neurological checks (assessing mental status and level of consciousness). 3. Failing to identify potential risk factors of psychotropic medications (any medications that affect behavior, mood, thoughts, or perception) Resident 25 was taking. This deficient practice resulted in Resident 25 having six falls between 4/11/2024 to 5/24/2024 with a bump and bruising on the right eyebrow. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of 18 sampled residents (Resident 47) received the pneumonia (an infection that inflames the air sacs in one or both lungs) vaccine (a substance introduced into the system to help the body fight against infections). This failure resulted in enhancing the potential for Resident 47 developing pneumonia and getting hospitalized on [DATE] and again on 5/6/2024. During a review of Resident 47's admission Record, the admission record indicated Resident 47 was originally admitted to the facility on [DATE] with diagnoses of but not limited to contractures (permanent shortening of muscle fibers, leading to muscle and joint stiffness), tachycardia (an abnormal heart rate over 100 beats a minute), dysphagia (difficulty in swallowing), and anoxic brain damage (damage to the brain due to a lack of oxygen supply). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 33 of 33 resident rooms met the requirements of 80 square feet ([sq. ft.] a unit of area measurement) per residents in multi-bed resident rooms. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to contact and notify the hospice agency (health care service that focuses on the care, comfort, and quality of life of a person with serious illness who is approaching the end of life) that one of five sampled residents (Resident 1) had missed dialysis treatments (mechanical process of removing waste products and toxins, and excess fluid from the body) on [DATE], [DATE], [DATE] and [DATE] due to issues with transportation from the facility to the dialysis center. This deficient practice resulted in Resident 1 being sent out via 911 (emergency medical transport) to a general acute care hospital (GACH) for emergency dialysis on [DATE]. Resident 1 ultimately expired (died) at 9:32 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received dialysis (process of mechanically removing waste products/ toxins and excess fluid from the body) according to the physician ' s orders and plan of care for dialysis management by failing to: 1. Ensure Resident 1 did not miss three scheduled dialysis treatments ([DATE], [DATE], and [DATE]) and one make-up dialysis treatment ([DATE]). 2. Notify the hospice (health care service that focuses on the care, comfort, and quality of life of a person with serious illness who is approaching the end of life) agency overseeing Resident 1 ' s care while in the facility when Resident 1 missed his first dialysis treatment in the facility ([DATE]). [...]

Inspectors wroteBased on interview and record review the facility failed to provide sufficient staffing to accommodate residents' needs for two out of four sampled residents (Resident 1, Resident 2). This deficient practice had the potential for call lights not to be answered promptly, showers not being given, and a decrease in Resident ' s quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of three sampled residents (Resident 1), who had history of wandering (traveling aimlessly from place to place) was provided with a one to one (1:1) sitter at all times. This deficient practice had the potential for Resident 1 to elope (leave the facility without staff knowledge, may present an imminent threat to the patient's health or safety), exposing her to dangerous elements outside such as harsh weather, accident, and dehydration and starvation.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of three sampled residents (Resident 1), who had a history of wandering (a person that roams around and becomes lost or confused about their location) was supervised and monitored. 2. Ensure Resident 1 had an air tag (small tracking device used to track the location) in place as stated in Resident 1 ' s care plan. 3. Ensure facility implement interventions for Resident 1's risk of elopement and wandering behavior. These failures resulted in Resident 1 leaving the facility unsupervised on 11/2/2023, entering another Resident 2 ' s room uninvited on 10/26/2023, holding Resident 2 on the shoulder making Resident 2 nervous and screaming inside her room and multiple incidents where Resident 1 was found inside another resident ' s room.

Inspectors wroteBased on interview and record review, the facility failed to, for one out of three sampled resident's (Resident 1): a. Develop resident centered interventions for the care plan for noncompliance. b. Implement the comprehensive care plan for pain by not to monitoring and recording the Resident 1's pain characteristic, quality, location, onset, duration, aggravating factors, and relieving factors. This deficient practice had the potential to negatively affect Resident 1's pain management and care.

Inspectors wroteBased on interview and record review the facility failed to conduct an interdisciplinary team (IDT-health care providers who have knowledge of the residents needs and are involved in the resident's care) care conference discussing one of three sampled resident's (Resident 2) rehabilitation (set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment) plans after physical therapy ([PT] care that aims to ease pain and help residents function, move, and live better) was discontinued on 8/8/2023. This failure resulted in Resident 2 feeling frustrated and not involved in their plan of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to evaluate and supervise one of four residents (Resident 4) when drug paraphernalia (equipment to use drugs) was found in Resident 4's room. The facility failed to: 1. Ensure Resident 4 was prevented from procuring (an effort of getting something) and using illicit (addictive and illegal) drugs while at the facility by monitoring and supervision of Resident 4. 2. Ensure staff assessed, monitored, and educated Resident 4 about adverse interaction and adverse effects of amphetamine (central nervous system stimulant that causes hypertension, increased heart rate with increased feelings of energy) and other illicit drugs. 3. Ensure Resident 4's primary care physician (PCP) was informed of Resident 4's possible use of illicit drugs the day of the incident, 9/18/2023. 4. [...]