Country Hills Post Acute

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide urinary catheter (a thin, flexible tube inserted into the bladder to drain and collect urine) care per facility policy for two (Resident 9 and Resident 18) of five sampled residents with urinary catheters when staff it did not:Provide meatal care (cleaning the area where a urinary catheter enters the body [the meatus] daily using mild soap and water to prevent infections) to Resident 9 for six days after readmission from the hospital. Secure Resident 18 's urinary catheter drainage bag to the frame of the bed, allowing drainage bag to rest on her bedroom floor. This failure had the potential for Resident 9 and Resident 18's urinary catheters to be at a higher risk for urinary tract infections and put their overall health at risk.

Inspectors wroteBased on observation, interview and record review the facility failed to accurately code a stage IV (4) pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the Minimum Data Set (MDS-a federally mandated resident assessment tool) after a [NAME] Ulcer (nonhealing skin sore that may form when you're dying ) was reclassified as a Stage IV pressure ulcer, for one of three sampled residents (Resident 1). These deficient practices placed Resident 1 at risk for inaccurate assessment data, inappropriate care planning and misrepresentation of the resident's health status to Centers for Medicare Services (CMS). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff adhered to proper infection control practices for one of four residents sampled residents (Resident 1) when:Resident 1's leaking/overflowing urinary catheter (a tube inserted into the bladder to aide in urine flow) was placed in a fracture pan (a device used to hold urine) and a urine-soaked towel were left on the floor. Certified Nursing Assistant (CNA) 1 did not wear Personal Protective Equipment (PPE- gown, gloves) prior to providing direct patient care. These failures had the potential for cross contamination (spread of germs and bacteria) and infection to residents, staff and visitors.

Inspectors wroteBased on interview and record review, the facility failed to respond to a resident not having a bowel movement for four days, for one of two sampled residents (1). As a result, Resident 1 was admitted to the hospital with diagnoses to include fecal impaction (hard stool that gets stuck in the body and is difficult to pass).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of five sampled residents were free from significant medication errors (an error which causes the resident discomfort or jeopardizes his or her health and safety) when: 1. Resident 1 received a fentanyl patch (a potent pain medication) which belonged to another resident (Resident 2) without a physician's order. 2. Resident 2 was not administered a fentanyl patch by nursing staff as ordered by the physician. 3. A fentanyl patch was administered to Resident 2 without verification that the previously administered fentanyl patch was removed. 4. A Licensed Nurse (LN) 3 did not properly identify (establish or indicate who someone is) Resident 3 prior to administering medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to allow one of three residents reviewed for discharges (Resident 1) to return to the facility following a hospitalization for aggressive verbal and physical behavior. This failure had the potential for Resident 1 to not receive continuity of care, violated her right to return to the facility per behold agreement, and extended Resident 1's hospital stay unnecessarily.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurately documented records when Licensed Nurse (LN) 1 documented he removed a fentanyl (a potent medication used to control pain) patch (a medication that is applied to the skin) although Resident 2 did not have a fentanyl patch to be removed at that time. This failure resulted in inaccurate documentation in Resident 2's medical record and had the potential to negatively affect her treatment and assessment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure timely reporting of an injury of unknown origin to the California Department of Public Health (CDPH), Ombudsman, and/or law enforcement (LE) in accordance with the facility's abuse reporting policy and procedures, for one of three sampled residents (Resident 1). This deficient practice placed one resident (Resident 1) at risk for uninvestigated abuse, neglect, or mistreatment and delayed protective oversight by the appropriate authorities.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure thorough investigation and appropriate corrective action of an abuse allegation when staff was not aware of the resident-to-resident altercation between Resident 1 and Resident 6, This failure had the potential for not protecting other residents from Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to make medical records available for Family Member (FM) 1 to review within 24 hours of the request, for one of two sampled residents (1). As a result, Resident 1 was not aware of the details of his medical record and the facility violated his right to access his medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine bathing hygiene to one of four residents (Resident 2), dependent on staff for Activities of Daily Living, (ADL-bathing, dressing, toileting, and re-positioning), when reviewed for Quality of Care. This failure had the potential for skin issues to develop and for Resident 2 to experience low self-esteem.

Inspectors wroteThe facility failed to administer pain medication for two of four residents (Resident 1 and Resident 2) per the Nursing Standards of Practice, reviewed for Quality of Care when: 1. Pain medication was administered to Resident 1 without assessing the level of pain before or after administration of a narcotic (a controlled that is regulated by the government due to its potential for abuse and addiction) and, 2. The correct pain medication was not administered to Resident 2 according to the pain scale (1-10: 1 being the least amount of pain and 10 being the worst pain). These failures had the potential for Resident 1 to experience addiction and for Resident 2 to not receive adequate pain relief.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure prescription medication when:1. A treatment cart (a cart with prescribed lotions and creams, used to treat wounds and skin conditions) was left unlocked for one of six treatment carts (Station 2 North); and,2. Medication was left on top of a medication cart, unsupervised for one of 11 medication carts (Station 3 North); and,3. Medication was left unsupervised at the bedside for one of four residents (Resident 1) when reviewed for safe medication storage. These failures had the potential for unauthorized people (resident, staff, and visitors) to have access to medications not prescribed to them.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident records were accurate and concise for one of four residents (Resident 1) when: 1. A quarterly pain assessment was not conducted for Resident 1, to determine if pain levels had increased or decreased over the past three months; and;2. Routine pain mediation was not charted for Resident 1 after administrated and was charted hours later. These failures provided inaccurate documentation in Resident 1's clinical records and could cause staff confusion.

Inspectors wroteountry Hills 558-E Accommodation of Needs Based on observation, interview, and record review, the facility failed to provide residents with an alert call system for 20 of 44 Residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 17, 19, 20, 21, 22, and 23) in order for staff to respond to their needs, after their electronic call system stopped working on Station 3 North, when reviewed for Accommodation of Needs. In addition, three of the 21 residents (23, 24, and 25) with manual call bells had their call bells out of reach. This failure had the potential for 26 Residents to not have their needs met in a timely manner.

Inspectors wroteBased on interview and record review the facility failed to correctly administer medications for one of six residents reviewed for competent nursing staff. (Resident 1) As a result of this deficient practice, the facility could not ensure medications were accurately and safely provided to residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure medications were correctly administered according to the physician's order for one of six residents (Resident 1) reviewed for pharmacy services. As a result of this deficient practice, the facility could not ensure pharmaceutical services were safely provided to its residents.

Inspectors wroteBased on interview and record review the facility failed to correctly administer medications for one of six residents reviewed for medication errors. (Resident 1) This failure has the potential affect Resident 1's health and wellbeing. In addition, this failure has the potential to place other residents at risk for medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff maintained sanitary food practices when: 1. Drying racks and a drying cart were not clean; and 2. The hanging sprinkler system (Ansel) heads above the stove were covered in dust; and 3. A beard net was not being worn by a dishwasher; and 4. A dishwasher aide did not wash his hands after removing trash and reentering the kitchen. These failures had the potential for cross contamination and to cause food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five out of 13 residents reviewed for dignity were provided care in a manner that promoted dignity and respect. (Resident 50, 218,148, 5 and 51) This failure had the potential for the residents' self-esteem and self-worth to be devalued.

Inspectors wrote2. According to the facility's admission Record, Resident 166 was admitted to the facility on [DATE], with diagnoses which included cirrhosis of the liver, (a type of liver damage where healthy cells are replaced by scar tissue). Resident 166's clinical record was reviewed on 3/11/25. According to the facility's Smoking Observation/Assessment form, dated 12/13/24, Resident 166 was a tobacco user and required supervision while smoking. Resident 166's clinical record was reviewed on 3/11/25. According to Resident 166's care plan, titled Potential for Injury related to smoking, revised 2/12/25, listed interventions such as, cigarettes and lighter will be stored by the smoking monitor. Resident 166's clinical record was reviewed on 3/11/25. According to the admission MDS (Minimum Data Set: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to invite and notify residents and/or their responsible parties (RP) in advance about a Resident Council meeting and care conferences for three of five residents (Resident 150, 180, and 239) reviewed. These deficient practices placed all residents at risk for not having their preferences, health needs updated. This practice did not promote a person-centered care plan. The census was 302.

Inspectors wroteBased on observation, interview, and record review, the facility failed to set low-air loss mattresses (LALM: a pressure relieving air mattress to alleviate pressure to boney areas of the body to help prevent skin breakdown and injury) according to manufacture weight recommendations and/or resident comfort for five of 36 sampled residents (Resident 240, 207, 51, 55, and 219) at risk for pressure ulcers. These deficient practices placed residents (Resident 240, 207, 51, 55, and 219) at risk for skin breakdown and injuries. Cross-Reference F867 Findings. 1. A review of Resident 240's admission Record indicated Resident 240 was admitted to the facility on [DATE] with diagnoses which included a history of left side hemiplegia (total paralysis of the arm, leg, and trunk on the left side of the body). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to date and later discard resident food, stored in three of six resident refrigerators, when reviewed for safe food handling practices. This failure had the potential for stored food to cause a food borne illness if consumed by the resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly explain the arbitration (a contract that says if there is a disagreement or legal issue between a resident and the facility, it will be settled by a private process instead of going to court) agreement to four of five reviewed residents (Residents 239, 229, 180, and 150) leaving them unaware that signing it meant waiving their rights to take legal actions. This deficient practice placed residents (Residents 239, 229, 180, and 150) at risk for signing an agreement without fully understanding their rights and options.

Inspectors wroteBased on interview and record review the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility), trends identified by surveyors during the recertification survey concerning delay of call lights, smokers, Registered Dietician (RD) recommendations, kitchen hygiene, RD kitchen audits, resident care conferences, and low air loss mattress settings. These failures had the potential for the facility to overlook trends in resident care that may have affected residents' dignity and/or health. Cross Reference:

Inspectors wroteBased on observation, interview, and record review the facility failed to provide one of 37 sampled residents (Resident 55) with a suitable call button (button used to call for assistance). This failure prevented Resident 55 (R55) from being able to use his call button and had the potential for R55 to not have his needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary living environment for one of four reviewed hospice (end of life care) residents (Resident 297) when the shared bathroom was found dirty with feces on surfaces and had a strong odor. These deficient practices placed Resident 297, other residents, staff, and visitors at risk for exposure to harmful bacteria and potential health hazard. This deficient practice also created an unsanitary living condition for residents using the bathroom.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of the bed-hold policy to residents at the time of transfer for one of 37 sampled residents (187). As a result, Resident 187 may not have been fully aware of the facility's bed-hold policy.

Inspectors wroteBased on interview, and record review, the facility failed to submit the Minimum Data Set (MDS: a federally mandated resident assessment tool) timely to the federal database after the MDS was completed and signed by the LN for one of 36 residents (Resident 196) sampled. This failure resulted in the late submission of the MDS to the federal database.

Inspectors wroteBased on observation, interview and record review, the facility failed to create a comprehensive care plan to include special instructions for one of seven sampled residents (Resident 128). As a result Resident 128 was at risk for his dialysis to be interrupted or complications to occur by not having a staff person with him during dialysis.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide routine nail care to one of one resident (Resident 190) reviewed for Activities of Daily Living (ADL, activities related to personal care) for dependent residents. As a result, Resident 190 was at risk for skin injury and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe hazard free environment for two of 34 residents (Resident 14, and Resident 15). As a result: 1. Resident 14 was placed at risk when the nursing staff placed shower blankets and/or drawsheets on Resident 14's bathroom floor for convenience, creating a slipping hazard which could have resulted in serious injury. Cross-Reference F584 2. Resident 15 was placed at risk for smoke-related injuries and burns when the facility failed to assess Resident 15's current smoking status and safety plan.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the nutritional status was monitored for one of seven residents reviewed for nutrition, with progressive weight loss since admission (Resident 260). This failure had the potential to result in Resident 260 to experience further functional decline and loss of lean body mass (the body weight that includes muscles, bones, and organs and excludes fat).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow physician's orders for post dialysis care (Res 51) and did not follow special instructions during dialysis (Res 128) for two of nine reviewed residents (Resident 51 and 128) These deficient practices placed the residents (Resident 51 and 128) at risk for complications such as infection, clotting, discomfort and compromised safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store and label Resident 204's breathing treatment medications. As a result, the facility could not ensure medications were safely stored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control standards of practice when: 1. A facility staff did not sanitize a blood pressure cuff in between use for different residents, 2. The facility did not update their Infection Prevention and Control Program (IPCP) policy and procedure (P&P) according to federal regulations. This failure had the potential to spread infection among the residents. In addition, staff had the potential to not know current standards of practice for preventing and controlling infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide two residents of 37 sampled residents (Resident 55 and Resident 268) with functional call buttons. This failure prevented residents from using their call buttons and making their needs known and having their needs met. Cross reference F558 Findings 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to keep one resident room (room [ROOM NUMBER]) free from cockroaches. This failure had the potential to affect the health of the three residents who reside in room [ROOM NUMBER].

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of staff to resident abuse for one of two residents (Resident 2) when reviewed for Resident Abuse. This failure had the potential for all resident's to be at risk of staff to resident abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess, document, and transmit Minimum Data Set (MDS-a clinical assessment tool), information to the Center for Medicare and Medicaid Services (CMS-A federal agency that oversees health insurance) regarding the preferred language for one of two residents (Resident 1), when reviewed for MDS Assessments As a result, CMS was uninformed of Resident 3 ' s language preference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department when: 1. A Dietary Aide (DA 1) dishwasher was unable to determine the correct wash, rinse and sanitizing temperatures and process. 2. A [NAME] (CK 2) did not prepare the beef roast correctly using the cool down process for cooking hot foods. These failures had the potential to expose dishes to to unsanitary practices and contaminate the food which could result in food borne illness among all residents who consume food from the kitchen. The facility census was 294.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure safe and sanitary conditions were maintained in the kitchen for food preparation tools and food storage methods, according to standards of practice and facility policy when: 1. Three (3) floor sink drains were full of dirt, food debris, trash, and black grime; and one floor sink drain was uncovered. 2. A Kitchen reach-in refrigerator with 7 full cases of 4-ounce Ready shake chocolate flavor milkshakes (75 milkshakes per case), and 3 cases with 10 Ready shakes of vanilla flavor, and the quart of lactaid milk with a broken thermometer. 3. Six measurement scoops, three dome lids, 1 metal egg slicer, and were found with brown and black grime and food debris on them after they were washed and stored as clean in drawers. 4. [...]

Inspectors wrote3. Review of Resident 548's admission Record indicated he was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS, a nursing assessment used in nursing homes) section C, Cognitive Patterns dated 3/5/24 indicated Resident 548 with a Brief Interview for Mental Status (BIMs, a test to determine cognitive levels in residents) score of 10, which indicates moderately impaired cognition. Review of MDS section GG, Functional Abilities and Goals dated 3/5/24 indicated that Resident 548 needed supervision or touch assistance for the categories of oral hygiene, toileting hygiene, shower/bath self and personal hygiene. On 3/26/24 at 10:50 A.M., during initial pooling of residents, an observation of Resident 548's room and interview with Resident 548 was conducted. Resident 548's sink was observed to have a handwritten sign that read DON'T USE. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility did not ensure the kitchen was free of flies and gnats. This failure had the potential to affect residents' health through food contamination and food borne illness. The facility census was 294.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a homelike environment for one of 35 residents (548) when the resident's bathroom sink was left nonfunctioning for at least one week. This deficient practice created an environment that was not homelike for one resident. Cross reference F880.

Inspectors wroteBased on record review the facility failed to ensure 1 of 3 residents sampled for dialysis (157) had a care plan developed for the dialysis access of an AV fistula (arteriovenous fistula is a surgical connection between an artery and a vein) to ensure the AV fistula was assessed for thrill (thrill or buzz is like a vibration caused by blood flowing through the fistula ) and bruit (Bruit is a rumbling or swooshing sound) to determine the AV fistula was functional, or to determine when the post dialysis AV fistula dressing was to be removed. As a result, and issue with the residents AV fistula would not be identified timely to receive immediate care.

Inspectors wroteBased on observation, interview, and record review, the facility did not develop patient centered care plans for 2 of 52 residents reviewed for care plans (Resident 32 and 154). These failures had the potential for the residents to not receive care and services specific to the residents' needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate nutritional parameters were maintained for a resident, Resident 60, with a severe weight loss of 18.4% in six months. This failure had the potential to result in additional unintentional weight loss and loss of lean body mass, which could lead to further nutrition decline for Resident 60.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure one of one resident (Resident 154) received Trauma Informed Care (TIC- an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health). This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past torture experience).

Inspectors wroteBased on interview and record review the facility failed to ensure they provided the minimum number of sufficient staff or PPD (PPD stand for Per Patient Day, and calculations are determined by the number of residents in a skilled nursing facility and the number of clinical staff.) the PPD minimums for Skilled nursing facilities in California were ( 3.5 DHPPD staffing requirement, of which 2.4 hours per patient day must be performed by CNAs) to be able to provide services within the facility. As a result, residents may not have gotten the care they deserve.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three licensed nurses (LN 12) was assessed for competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) to perform medication administration to residents. As a result of this deficient practice, the facility could not ensure medications were accurately and safely provided to residents. Cross reference F759.

Inspectors wroteBased on interview and record review the facility failed to ensure they posted the actual daily staffing, when they only posted the projected staffing. As a result, residetns and visitors would not know what staff were woking.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication orders for two of 35 sampled residents (Resident 60 and Resident 64) were carried out as ordered. This failure had the potential to affect Resident 60 and Resident 64's health and safety.

Inspectors wroteBased on clinical record review the facility failed to ensure that 2 of 5 residents sampled for unnecessary drugs (181, 215), had not been put on Trazodone for a non-FDA approved indication, which resulted in this medication becoming an unnecessary drug for 2 Residents, as this medication had been prescribed without an adequate (FDA approved) indication. This deficient practice resulted in this resident receiving Trazodone for a clinical indication, which had not been FDA approved, which could have caused this resident harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 12.5 percent. Four (4) medication errors were observed, a total of 32 opportunities, during the medication administration process for one of seven randomly observed residents (Resident 122). As a result, the facility could not ensure medications were correctly administered to all residents. Cross reference F726.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the Pureed diet menu was followed as printed. This failure had the potential to alter the nutritional value of the pureed meals, which could decrease the food intake and compromise the nutrition status of 30 residents on a pureed diet. The facility census was 294.

Inspectors wroteBased on observation, interviews, and record reviews the facility did not ensure essential kitchen equipment, including the dish machine thermometer gauges, a stove range handles, and three (3) mobile tray line stations were maintained to operate at their full capacity. This failure had the potential to directly affect residents and staff's safety in the facility. Facility census was 294. Findings 1. Dish machine thermometer gauges worn and cloudy. During the initial kitchen tour on 3/26/24 at 8:15 AM, a concurrent observation and interview with the Dietary Aide (DA 1) Dishwasher was conducted. The dish machine thermometer gauges were worn and cloudy inside which made the numbers blurry and difficulty to view. DA 1 stated he had trouble estimating what the correct wash temperature was because of the blurry temperature gauges. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure one of 35 residents (Resident 162) had a call light that was consistently working. As a result, Resident 162 was at risk of not getting her needs addressed timely which could potentially result in injury and falls.

Inspectors wroteBased on interview and record review, the facility failed to accurately access the hearing and vision deficits for one of seven residents (Resident 1), on admission for the Minimum Data Set (MDS-a clinical assessment tool) required for Centers for Medicare and Medicaid Services (CMS) coding and reviewed for Resident Assessment. As a result, the MDS submitted to CMS did not accurately portray Resident 1 ' s current health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices when: 1. A urinary catheter bag was in contact with the floor for one of two residents, (Resident 4). 2. An ice scoop was improperly stored and therefore exposed to germs. 3. One blood pressure cuff was used on patients without being properly disinfected, (Resident 5 and Resident 6). As a result, there was the potential of infections to be transmitted to residents.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe discharge and transition for 1 of 2 sampled residents (1). As a result, Resident 1 was hospitalized within three days of discharge from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide activities to one of six units (total of 35 Residents), in the secured unit, as posted on the unit's activity schedule. This failure had the potential to decrease residents' cognitive awareness and socialization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label, date, and seal foods in one of two refrigerators (walk-in refrigerator) and, one of one storage rooms. These failures had the potential to cause food-borne illnesses to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow safe infection control practices when: 1. Staff did not perform hand hygiene while passing meal trays to residents; 2. Smoking aprons were not disinfected after use; and 3. A urinary catheter bag was in contact with the floor. These failures had the potential for cross contamination of pathogens (microorganism that can cause disease).

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge Minimum Data Set (MDS - a comprehensive assessment and care screening tool), was developed and transmitted to the CMS system, for one of two sampled residents (Resident 2), reviewed for MDS accuracy. This failure resulted in Resident 2's discharge status not being communicated to CMS as required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for: 1. One of 37 residents (Resident 5) and one of three unsampled residents (Resident 167) reviewed for wandering (a confused person who is in search of someone, or something); and 2. One of 37 residents with weight loss (Resident 122). These failures resulted in wandering behaviors and weight loss not being recognized and addressed.

Inspectors wroteBased on interview and record review, the facility failed to provide consistent suprapubic catheter (tube used to drain urine from the bladder) care to one of two residents (Resident 65), sampled for urinary catheter care. As a result, there was a potential for infection and suprapubic catheter blockage.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff followed physician orders for the amount of feeding administered to two of two residents (47, 117) reviewed for tube feeding (provision of nutrition through a tube into the stomach). As a result, there was potential the residents did not receive the required nutrition.

Inspectors wroteBased on interview and record review, the facility failed to provide pain medication for one of one resident (Resident 246) reviewed for pain management. As a result, Resident 246's pain was not addresed or relieved.

Inspectors wroteBased on observation, interview, and record review, the facility did not assess and evaluate the need for psychotropic drugs (affects the brain and causes changes in mood, awareness, thoughts, feelings, or behavior) for one of five residents (Resident 477) reviewed for psychotropic medication. This resulted in Resident 477 having received two potentially unnecessary psychotropic medications .

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 24.32 percent. Nine medication errors were observed, a total of 37 opportunities, during the medication administration process for one of six randomly observed residents (Resident 47).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medications were administered in accordance with the physician's order for two of six randomly observed residents (Resident 47, 180) during a medication administration process when: 1. The medications were administered via the wrong route and 2. The wrong dose was administered. As a result, there was a potential the prescribed medications were ineffective.