Courtyard Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders were obtained and implemented for the assessment, monitoring, and care of a newly created ostomy (a surgically created opening on the belly that allows waste from the body to leave through an opening) for one (Resident 1) out of three sampled residents. This failure had the potential to result in inconsistent ostomy management, delayed identification of stoma ( small opening on the abdomen that the surgeon creates so stool or urine can leave the body), skin breakdown, infection, leakage, and pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored, prepared and distributed in accordance with professional standards of food service for a census of 104 Residents when:1. Two ovens were observed with blackened, burnt debris on the bottom and doors;2. Food items in Freezer #1 were opened and undated;3. Food items in the dry storage area were placed in bowls unlabeled and undated; and,4. Meal trays were observed being delivered to residents with uncovered food. These failures had the potential to cause food borne illness among a vulnerable resident population.

Inspectors wroteBased on interview and record review, the facility failed to ensure five residents (Residents 1, 3, 4, 12, and 91) out of 26 sampled residents were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors), when they received psychotropic medications while nursing staff did not implement nonpharmacological (non-drug, behavioral interventions). This failure had the potential to result in the unnecessary use of psychotropic medications and to not utilize the lowest effective dose of medication.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards were followed for four residents (Residents 1, 3, 4, and 12) out of 26 sampled residents when: 1. Resident 3 did not receive appropriate pain management services during wound care treatment;2. Resident 12's physician's order to discontinue medication was not carried out;3. Resident 4's opioid (a potent medication to treat pain) medication was not administered by nursing staff according to the physician's order; and,4. Nursing staff did not routinely check Resident 1's blood sugar (BS) prior to administration of (brand name for semaglutide)(a medication to treat type 2 diabetes). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. One of four emergency kits (E-kit, a kit/box containing medications and supplies for immediate use during a medical emergency) was replaced timely after removal of medication; and,2. One of four E-kits had the contents clearly listed on the exterior in accordance with facility policy and procedure (P&P). These failures had the potential to result in emergency medications not available when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions for a census of 103. During a concurrent inspection and interview on [DATE] at 1:14 p.m. of the Station 1 Medication Storage Room with the Director of Nursing (DON), a refrigerated E-kit was identified with a red plastic tie indicating it had been opened by nursing staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rates of less than 5 percent when four medication errors out of 37 opportunities were observed during a medication pass for two of six Residents (Residents 59 and 100) observed for a census of 104. These failures resulted in 10.81% medication error rates, and in medications not given in accordance with the prescriber's order and the potential to negatively affect residents' clinical conditions. During a medication pass observation on 7/7/26 at 8:43 a.m. with Licensed Nurse 8 (LN 8), LN 8 was observed preparing five medications for Resident 100, including levothyroxine (a medication to treat an underactive thyroid gland, to restore metabolism, energy levels, and normal body temperature) 25 micrograms (mcg, a unit of measurement), 1 tablet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper infection prevention and control measures were implemented for a census of 104 when:1. Nursing Staff did not maintain hand hygiene in accordance with accepted professional standards; 2. Resident 18's, Resident 65's and Resident 104's oxygen tubing were on the floor;3. Licensed Nurse (LN) 1 did not change gloves between two different wound sites during wound treatment for Resident 106; 4. Resident 106's PICC (Peripherally inserted central catheter- a long tube inserted into a vein in the upper arm for intravenous access for medications) line dressing was not intact; and,5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote dignity and respect for two residents (Resident 48 and Resident 104) out of 26 sampled residents, when:1. Certified Nursing Assistant (CNA) 5 remained standing while assisting and feeding Resident 48 with lunch and,2. The privacy curtain between the two residents was not closed during wound treatment for Resident 106. These failures had the potential to impact the two residents' self-esteem and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure communication needs for one resident (Resident 28) of 26 sampled residents was accommodated, when staff did not use communication board for Resident 28 per resident's care plan. Resident 28 speaks mainly Hmong and has limited ability to communicate. This failure limited the resident's ability to express discomfort during care, contributed to frustration and affected the resident's dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three residents (Resident 9, Resident 28 and Resident 102) out of 26 sampled residents, were assisted with their Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when:Resident 9 was observed with long toenails and dry thickened heels; Resident 28 was observed with long fingernails containing brown debris underneath, an oily face and hair, dried crusting inside both nostrils, long toenails, dry thickened skin surrounding the toenails and thick, dry, cracked heels; and,Resident 102 was observed with long fingernails containing brown debris underneath. These failures had the potential to result in poor personal hygiene, skin breakdown, discomfort, unpleasant odor and diminished dignity and well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident environment remained free of accident hazards for two residents (Resident 18 and Resident 91) out of 26 sampled residents when:1. A portable oxygen cylinder tank in Resident 18's room was not secured in a stand/cart; and,2. Resident 91's floormat (fall mat, a cushioned floor pad designed to help prevent injury should a person fall) was placed underneath the bed not beside the bed. These failures had the potential to result in accident and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident 3) out of 26 sampled residents received appropriate pain management services consistent with professional standards of practice and facility's policy and procedure (P&P), when Resident 3's pain was not managed during wound care treatment. This failure resulted in Resident 3 to exhibit severe pain and not attain his highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to store resident food in a sanitary manner in the resident refrigerator for a census of 104 when an 8 oz. (ounce, a unit of measurement) package of cheese, and two plastic bags with take-out food did not have residents' name and were undated. These failures had the potential to cause food borne illness in a vulnerable population. During a concurrent observation and interview on 7/7/26 at 12:47 p.m. , with the Director of Staff Development (DSD), observed in the resident refrigerator in the memory care unit with an opened package of cheese and two bags with take-out food. These items were undated and were not labeled with the residents' names. The DSD confirmed that she would not be able to tell who the food items belonged to and they should be dated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from abuse for one of five sampled residents (Resident 2) when facility staff witnessed Resident 1 hit Resident 2. This failure resulted in Resident 2 not being free from abuse and had the potential for Resident 2 to be harmed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the results of an abuse allegation investigation was reported within the required time frame for one (Resident 1) out of five sampled residents. Failure to report in a timely manner may delay state agency oversight and intervention potentially allowing on-going abuse and placing residents at risk for harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure corrective action was taken to protect residents from abuse for two of six sampled residents (Resident 1 and Resident 2) when:The facility did not report the results of all investigations to California Department of Public Health (CDPH) within 5 working days for Resident 1 and Resident 2, andThe facility did not do an assessment of Resident 2 after abuse allegations. These failures had the potential to result in ongoing abuse for Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for one of three sampled residents (Resident 1) when Resident 1 reported to nursing staff that she was injured by facility staff during patient care. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety. During a review of Resident 1's face sheet (a document containing patient information), Resident 1 was admitted to the facility in August 2025 with multiple diagnoses which included chronic kidney disease (decreased kidney function), Schizophrenia (mental health condition that affects how people think, feel and behave), and Bipolar Disorder (mental health condition that causes extreme mood swings). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store clean dishes in a sanitary manner for a census of 109 residents, when: 1. A dirty dish with half-eaten food on it was found on the shelves of clean dishes; and 2. A hot water jug stored in the clean dish area was found with dark brown residue on it. These failures decreased the facility's potential to prevent foodborne illness among vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a therapeutic diet plan to one of three sampled residents (Resident 2), when Resident 2 was served a hard to chew chicken burger at lunch. This failure had the potential to negatively impact Resident 2's nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food in a sanitary manner for a census of 108 residents, when:Clean Utensils were found with food particles and water residuals and utensil holders had multiple small black particles; andDietary Aide 3 (DA 3) did not wash hands before handling clean kitchenware. These failures had the potential to result in foodborne illness among vulnerable residents.

Inspectors wroteBased on interview and record review, the facility failed to provide proper care for one of five sampled residents (Resident 1) when:1. Resident 1's assessments (including vital signs) were inaccurate; and,2. The Medication Administration Record (MAR) indicated no evidence that Resident 1's antibiotic was given timely as ordered. These failures resulted in an adverse outcome wherein Resident 1 was admitted to acute care for hospitalization for severe sepsis (a life-threatening condition due to an infection) with septic shock (severe form of infection, life threatening condition, occurs when the body's immune system overreacts to an infection, leading to a drop in blood pressure and organ failure.)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) discharged appropriately when:1. Final discharge instructions were not reviewed with the Durable Power of Attorney (DPOA-a legal document that gives one person the authority to make medical decisions for another person),2. Resident 1 was discharged without needed supplies (tube feeding formula and a glucometer),3. Discharge orders were to discharge home with home health; however, Resident 1 was discharged to a board and care, and4. No clinical evaluation was completed for Resident 1 to determine discharge needs and/or discharge potential. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate discharge for one of three sampled residents (Resident 1), when 1. The facility did not follow physician discharge orders;2. The 30-day notice of discharge was given to Resident 1 at time of discharge; 3. The facility failed to develop post discharge care follow up for a June neurology referral; 4. There was no physician discharge summary in the medical records; and5. Minimum Data Sheet (MDS - a federally mandated resident assessment tool) discharge assessment was incomplete and not submitted. These failures led to inappropriate discharge of Resident 1 from the facility and reduced the facility's potential in discharging Resident 1 safely.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident safety for one out of three sampled residents (Resident 1) when Resident 1 eloped from the facility and failed to implement interventions per facility policy. This failure reduced the facility's potential in keeping Resident 1 safe from harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food preferences were accommodated for three of three sampled residents (Resident 1, Resident 2, and Resident 3), when:Resident 1 did not receive double portions of protein;Resident 2 did not receive salad; andResident 3 did not receive fresh fruit for lunch on 7/8/25 as listed in the meal tickets. These failures had the potential to negatively impact the residents' nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary condition for a census of 109 residents, when:Two boxes of 48 cups of four ounces (oz, a unit of measurement) of yogurt were left in the kitchen floor at room-air for more than three hours; andThe freezer's temperature was not monitored on 7/7/25 in the evening shift. These failures had the potential to cause foodborne illness among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the rights to be free from abuse for 1 of 4 sampled residents (Resident 1) when staff witnessed Resident 2 hitting Resident 1 ' s hand. This failure resulted in Resident 1 experiencing abuse including physical pain and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents, rights to personal privacy and confidentiality of their personal and medical records when 16 resident meal tickets were left unattended in the facility's memory unit dining area. This resulted in the facility's failure to protect the residents' rights to personal privacy and confidentiality of their personal and medical records relating to sensitive information about residents' names, allergies and therapeutic diets.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided according to accepted professional standards of clinical practice when: 1. The licensed nurse (LN) did not administer medications in a timely manner for Resident 16, Resident 19, Resident 37, Resident 59 and Resident 71. 2. The LN did not check the residents' identity and did not explain the medications administered for (Resident 15, Resident 23, Resident 222, and Resident 102) and; 3. The Licensed Nurse failed to follow physician orders for continuous gastrostomy feeding for Resident 18 for a census of 104. These failures had the potential to result in medication errors and for Resident 15, Resident 16, Resident 18, Resident 19, Resident 23, Resident 37, Resident 59, Resident 102 and Resident 222 not meeting their highest practicable well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to follow scheduled mealtimes comparable to mealtimes in the community and in accordance with resident preferences for five of 33 sampled residents (Resident 81, Resident 94, Resident 30, Resident 69 and Resident 3). This failure resulted in residents' dissatisfaction with their meals and had the potential for decreased food intake leading to unplanned weight loss and nutritional deficiencies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food service staff adhered to current standards of practice for food service safety when: 1. Staff failed to label, date, and monitor refrigerated and frozen food when expired food was found in 2 out of 4 refrigerators, food without expiration dates were found in 2 out of 4 refrigerators and 2 out of 3 freezers, and temperature logs were incomplete for 4 out of 4 refrigerators and 3 out of 3 freezers; 2. The facility failed to keep non refrigerated foods in a clean dry environment safe for consumption when fruit flies and flies were present and flying in the dry storage room over a container of uncovered sugar, two boxes of opened and unsealed dry instant hot cereal mix, a bag of unsealed oats with a ripped opening, a bag of unsealed Raisin Bran cereal with a ripped opening; and, 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its facility assessment and ensure staff adherence to the established contingency plan during an electronic health record (EHR) system downtime when nursing staff were not provided timely direction and were unaware of procedures to follow when the EHR was inaccessible for a census of 104. This failure resulted in the facility's EHR inaccesibility, which resulted delays in medication administration and the potential to affect the residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective and comprehensive Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) program was performed for a census of 104, when the facility did not maintain documentation and did not present evidence of the previous three quarterly meetings. This failure had the potential to result in quality care improvement activities to not be evaluated and revised as needed and had the potential to negatively impact the quality care for the residents.

Inspectors wrote3. During a review of Resident 97's AR, indicated Resident 97 was readmitted in early 2025 with diagnoses which included pneumonia (an infection/inflammation in the lungs) and respiratory failure (lungs cannot properly exchange gases causing abnormal levels of carbon dioxide and/or oxygen). During a review of Resident 97's OSR, dated 3/29/25, the OSR indicated, O2 [oxygen] 5 L/min [liters per minute] via T [trach]-mist continuous at night as needed. During an concurrent observation and interview on 4/15/25 at 9:35 a.m. in Resident 97's room, Resident 97 sat in bed, awake and verbally responsive, with a trach collar (a soft adjustable neck device that secures a tracheostomy tube in place) connected to an oxygen tubing with no label or date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain kitchen equipment in safe operating condition when: 1. Frozen brownish residue on the bottom shelf of Freezer 1 was present; 2. Boilerless Steamer was found leaking clear liquid onto the floor pooling at the base of a metal panel; and, 3. Two ovens with brownish black residue, and all four stove burners were observed with food and black burnt residue. These failures had the potential for mold growth and food contamination of resident food stored in the freezer and prepared in the steamer, oven, and stovetop.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure communication boards were available at the bedside for three of 33 sampled residents (Resident 19, Resident 24 and Resident 58) who did not speak English. This failure had the potential to result in reduced ability for the residents to express their needs, preferences, and choices, placing them at risk for unmet care needs and taking away their right to participate in decisions about their care.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a homelike environment when: 1. Shower room [ROOM NUMBER] was found to have a dark brown substance on the floor; and, 2. Four out of 11 rooms (C15, C17, C18 and C21) in the memory care unit had curtains by the sliding doors that were worn and had visible brown discolorations on them. These failures reduced the facility's potenital to provide residents with a homelike environment and had the potential to negatively impact the resident's quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pressure injury prevention consistent with the professional standards of practice for one of 33 sampled residents (Resident 106), when regular and timely turning and repositioning was not implemented. This failure had the potential risk to result in skin breakdown and Resident 106 not attaining his highest practicable physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 33 sampled residents (Resident 58) significant weight loss was addressed and monitored. This failure resulted in further weight loss for Resident 58.

Inspectors wrote2. During a review of Resident 6's AR, the AR indicated, Resident 6 was admitted on [DATE] with diagnoses which included other intervertebral disc degeneration (natural breakdown of discs between the bones of the spine), chronic pain syndrome, rheumatoid arthritis with rheumatoid factor of multiple sites (immune system is attacking the joints causing pain, swelling and stiffness), unilateral primary osteoarthritis (joint pain and degeneration affecting only one side of the body), varicose veins of bilateral lower extremities with pain (swollen, twisted veins in the legs that can cause discomfort like aching, throbbing or burning). During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had no memory impairment. During an observation and interview on 4/15/25 at 9:35 a.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to adequately maintain pharmacy services for 11 residents out of a census of 104 when: 1. The facility did not have a complete controlled drug (medication that may be abused or cause addiction) destruction record log, and; 2. The facility did not reconcile the controlled drug records when the original controlled drug sheets went missing for medication cart A2. These failures had the potential to cause inaccurate accountability of controlled medications and the potential to result in residents' controlled meedication diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed for a census of 104 to ensure : 1. Observed in the medication room [ROOM NUMBER]: -Treatment supplies had expiration dates. - Expired Tube feeding formulas were removed. 2. Observed in the medication carts A1 and A2: -Narcotic cabinet is used only for narcotics in accordance with facility policy and procedure, -Expired and discharged resident medications were disposed accordingly -Medications and over the counter products were appropriately labeled with open and discard dates. 3. Narcotic count sheets are signed by both incoming and off going shift's licensed nurses in accordance with facility policy and procedure. These failures decreased the facility's potential to provide an updated treatment and nutrition supplies, and prevent medication administration errors.

Inspectors wroteBased on interview and record review, the facility failed to administer insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) as prescribed for one of three sampled residents (Resident 3). This failure had the potential for ineffective drug therapy.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sanitary practices in the kitchen were established for residents in the facility for a total census of 106 when: 1. Freezer temperatures were not maintained in acceptable food range; 2. Unsafe infection control practices were observed in the kitchen. These failures had the potential to lead to food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the availability of routine medications for one (Resident 1) of four sampled residents, when Resident 1 ' s medication was not in stock for administration. This failure had the potential for not meeting Resident 1 ' s therapeutic needs or for worsening of the resident's medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of food safety for a census of 102, when two packages of frozen salmon filets and two packages of frozen cod filets were not thawed according to food safety standards, and nine opened bottles of dry spices, one opened bottle of beef base, and one bag of opened pink lemonade powder were unlabeled. These failures had the potential to cause foodborne illnesses for residents eating facility prepared meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain equipment in safe operating condition for a census of 102, when a kitchen freezer was found with ice build-up on its ceiling and a broken seal gasket (rubber lining around freezer doors to keep outside air out and maintain a consistent temperature). This failure had the potential of leading to food borne illness for the residents eating facility prepared meals.

Inspectors wroteBased on interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of eight sampled residents (Resident 5) when facility staff witnessed Resident 4 punch Resident 5. This failure resulted in Resident 5 not being free from abuse and had the potential for Resident 5 to feel afraid and scared.

Inspectors wroteBased on interview and record review, the facility failed to provide monitoring and supervision for one of eight sampled residents (Resident 5) when Resident 5, who has a history of disruptive behavior, was hit by Resident 4 while out in the courtyard unsupervised. This failure resulted in Resident 5 getting punched and had the potential for harm to other residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of 30 sampled residents (Resident 43) received services to maintain mobility when Restorative Nursing Aide services (RNA, provides residents with exercises to improve or maintain mobility and independence) were not provided to Resident 43 as recommended by a Physical Therapist (PT, a healthcare professional who specializes in helping residents improve their physical functioning). This failure resulted in Resident 43 not receiving services to maintain her highest practicable physical level of functioning and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect resident information when meal tickets (containing resident information) were discarded into the garbage and subsequently into the outside dumpster. This failure had the potential of compromising resident information for 103 residents receiving facility provided meals for a census of 109.

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents (Resident 80 and Resident 93) of 30 sampled residents had adequate indications for the use of psychotropic medications (drug prescribed to affect the mind, emotions, or behavior) when: 1. Resident 80 was administered olanzapine (a psychotropic medication indicated for psychosis); and, 2. Resident 93 was administered aripiprazole (a psychotropic medication indicated for psychosis). This failure decreased the facility's potential to prevent residents from experiencing adverse effects such as sedation, falls and abnormal involuntary movements from the use of antipsychotic medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medication error rate did not exceed 5% (five percent) for one resident (Resident 712) of 30 sampled residents when Licensed Nurse 3 (LN 3) administered Resident 712's medications not in accordance with standard nursing principles and practices or the facility policy. This failure resulted in a medication error rate of 30.3%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in a clean and sanitary environment and labeled correctly with open and discard dates, when: 1. A loose pill was found in medication cart 2; 2. A medication cup was found stored in the top drawer of medication cart 2, containing 11 loose pills and was not labeled with resident's name or drug identifiers; 3. An opened inhaler and eye drops were not dated with open or discard dates in medication cart 2; and, 4. A medication blister pack found displaced and in the back of medication cart 1. These failures decreased the facility's potential to prevent drug diversion and medication administration errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food service safety when: 1. There were no functional thermometers for dry storage room monitoring and for internal temperature monitoring for freezer #1; 2. There were incomplete records of daily temperature logs for refrigerators, freezers, and dry storage area; 3. Food items were not properly labeled or sealed and expired foods were not discarded; 4. The racks in refrigerator #2 and refrigerator #3 had rust on the surface and were unable to be readily sanitized; 5. The facility did not install or maintain a drain air gap in the sink used to prepare fruits and vegetables; 6. The facility did not maintain a clean can opener; 7. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to obtain informed consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) on the use of psychotropic medication (drugs that affect a person's mental state) from the resident's Responsible Party (RP, a person designated to make decisions for the resident who is unable to make decisions for himself) for one resident (Resident 73) of 30 sampled residents. This failure decreased the facility's potential to ensure residents and RPs were aware of the risks, benefits, and alternatives of treatment offered to them.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to develop and implement person-centered comprehensive care plans for three residents (Residents 30, 53, and 73) out of 30 sampled residents. This failure decreased the facility's potential to provide appropriate interventions in order for residents to maintain their highest medical and physical practicable level of function.

Inspectors wroteBased on observation, interview and record review the facility failed to revise care plans for two residents (Resident 38 and 82) out of 30 sampled residents when the care plans were not revised within a timely manner. This failure decreased the facility's potential to provide appropriate interventions for the residents to maintain their highest medical and physical practicable level of function.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nursing care was provided per professional standards of quality for one resident (Resident 73) of 30 sampled residents when Licensed Nurses (LNs): 1. Did not ensure informed consent was obtained from Resident 73's Responsible Party (RP, a person who has legal authority to make health care decisions for a person who is unable to for himself) prior to the administration of psychotropic medication (medications that affect the mind, emotions, and behavior); 2. Did not obtain a physician's order to flush Resident 73's midline catheter (a thin, flexible tube inserted into the larger veins in the upper arm used to administer intravenous medication); and, 3. Did not follow the prescribed physician's order for oxygen administered to Resident 73. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 109 residents, when a medication was improperly disposed of in an opened, regular trash can on the side of the medication cart. This failure decreased the facility's potential to prevent: unauthorized staff, residents, and visitors access to prescription drugs, the potential for drug diversion, and medical adverse consequences.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pureed (cooked food blended to the consistency of a cream paste) foods were prepared in a manner that conserved nutritive value and palatability (taste) when foods were thinned with an unmeasured amount of tap water or liquid from the can containing the food. This failure decreased the facility's potential to ensure food met resident nutritional needs and was flavorful.

Inspectors wroteBased on observation, and interview, the facility failed to maintain two reach-in freezers (freezer #1 and #3) and two reach-in refrigerators (refrigerator #2 and #3) in safe operating condition when door seals were observed with tears or gaps and did not provide a complete seal. This decreased the facility's potential to ensure food safety and quality for 103 residents who ate facility prepared meals with a census of 109.

Inspectors wroteBased on interview and record review, the facility failed to ensure rehabilitative services were adequately provided for three of three sampled residents (Resident 1, Resident 2 and Resident 3) when occupational therapy (OT) was not performed according to their plans of care. This failure had the potential to result in the residents failing to attain their highest practicable level of physical and functional well-being.

Inspectors wroteBased on interview, record review and facility document review, the facility failed to ensure 1 of 3 sampled residents (Resident 2) was free from abuse when Resident 1 slapped and punched Resident 2 in the face and nose. This failure resulted in Resident 2 sustaining a swollen and reddened nose and a lump on the right temple.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from abuse when she was struck in the face by Resident 2. This failure resulted in Resident 1 sustaining a small, reddened area to her forehead and a bloody nose.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy for two of five sampled residents (Resident 1 and Resident 2) when the results of the investigation of an alleged abuse incident between the residents were not reported to the Department within 5 working days of the incident. This failure could have potentially caused a delay in the investigation of the alleged event.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received care which met professional standards when she was involved in a resident-to-resident altercation, sustained a bloody nose and it was not documented in the nursing assessment. This failure resulted in inaccurate assessment documentation and had the potential to result in unmet nursing needs for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from abuse, when Resident 2 punched Resident 1 in the face and pulled her hair. This failure resulted in injury to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the health, safety and security of one of three residents (Resident 1) when the facility failed to report an alleged resident to resident altercation involving Resident 2. This failure had the potential to endanger the health and well-being of all 101 residents in the facility.