Covenant Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician (PHY) was notified promptly of a change in condition for one of three sampled residents (Resident 1) when Resident 1 sustained a fall on 3/23/26 at 9:00 p.m. and the resident's mental status declined from alert to unresponsive within one hour of the fall. The resident was sent out to the acute care hospital at 10:45 p.m. This failure resulted in Resident 1's delayed transfer to the acute care hospital (ACH) due to the change in mental status and placed the resident at risk of death from delayed treatment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) were free from physical restraints when Resident 3 had a position change alarm (bed/chair alarm-alerting device intended to monitor a resident's movement that emits an audible loud sound when the resident moves) put in place for staff convenience, without the resident or responsible party's (RP) consent, medical justification or assessment to evaluate the affect the alarm had on the resident. This failure resulted in Resident 3's movement being restricted because the alarm would sound with small movements which made the resident to feel embarrassed and her privacy was violated causing her to lie in the same position for extended periods of time to prevent the alarm from sounding. During a concurrent observation and interview on 4/7/26 at 10:16 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their written policy and procedure when Resident 1 had a unwitnessed fall on 3/4/26 that resulted in a hip fracture and required surgical intervention and the facility did not report the injury until 3/18/26 (14 days later) for one of three sampled residents. This failure resulted in a delay in investigating the unwitnessed fall with severe injury and the potential for abuse to go undetected. During a concurrent observation and interview on 3/24/26 at 10:55 a.m. with Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1's bed was empty without out linen with a call light sitting on top. CNA 1 stated Resident 1 was not currently in the facility. During an interview on 3/24/26 at 1:17 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a comfortable and homelike environment for one of three sampled residents (Resident 1) when the toilet in her room was not functional, and she had to use a bedside commode (BSC-a portable toilet designed for individuals with limited mobility to use as a toilet in close proximity to their bed) for toileting. This failure resulted in an environment that was not homelike and caused Resident 1 to feel unimportant. During a concurrent interview and record review on 3/5/26 at 8:46 a.m. with Resident 1, Resident 1's room, Resident 1 was lying in bed, dressed. Resident 1 stated, my toilet has not worked since I got into this room. Resident 1 stated, I can't even use the toilet. Resident 1 stated she had to use a bedside commode in the bathroom when using the restroom instead of the toilet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for one of three sampled residents (Resident 1) when Resident 1 was assessed as having physically aggressive behaviors towards other residents and staff, was supposed to be on one on one supervision (1:1-staff provide constant, close oversight for resident needing extra safety due to cognitive issues [problems with mental functions like thinking, learning, memory and judgment], behavioral problems [disruptive patterns of action or conduct] or potential self/other harm) monitoring when out of his room and on 12/23/25 the staff assigned to Resident 1 left the resident unattended in his room and Resident 1 left his room unnoticed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an injury of unknown origin (any injury without a reason the injury could have or did occur) in accordance with their abuse policy and procedure (P&P) for one of three sampled residents (Resident 1) when Resident 1 was found with discoloration (a different color than normal) around his right eye on 4/12/25 and the injury was not reported to the California Department of Public Health (CDPH) and adult protective services until 4/14/25. This failure led to the delay of the investigation into the cause of Resident 1 ' s injury to rule out the potential for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when one of two facility boiler systems (a device that heats the facility ' s water and/or ventilation system) stopped working and the laundry was washed in temperatures below the minimum water temperatures according to the facility ' s policy and procedure (P&P). This failure placed the 117 residents at risk for cross contamination from laundry not properly washed and sanitized according to the P&P.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain essential equipment in a safe operating condition when one of two boiler systems (a device that heats the facility ' s water and/or ventilation system) was not monitored, maintained and failed to operate from 3/15/25 to 3/18/25. This failure resulted in a non-functioning boiler system, unable to heat water throughout the facility including the laundry, kitchen, showers and sink faucets and placed the residents at risk for poor hygiene, infectious disease and discomfort. The facility ' s residents were unable to shower for three days, had to eat with disposable flatware and Styrofoam trays, and clothing and linens were washed in subpar (below normal) temperatures according to the facility policy and procedure (P&P). (cross reference F880, F584)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for one of five sampled residents (Resident 1) when the facility ' s boiler system (a system of vessels and tubes, in which water is heated) was not functional, Certified Nursing Assistant (CNA) 2 gave Resident 1 a bed bath with cold water. This failure violated Resident 1 ' s right to a homelike environment and caused him to feel uncomfortable and chilled during the bed bath.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure resident Minimum Data Set (MDS) assessments were accurate for 4 (Residents #19, #64, #68, and #217) of 28 residents reviewed for MDS accuracy.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was completed and transmitted for 1 (Resident #30) of 2 residents reviewed for discharges.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure reusable resident care equipment was cleaned and disinfected after use and failed to ensure enhanced barrier precautions (EBP) were used for 1 (Resident #64) of 1 resident observed during wound care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure licensed nurses (LN) administered medications in accordance with professional standards of practice for one of seven sampled residents (Resident 5), when: 1. Resident 5's morning medications were left at the bedside unattended and not administered as prescribed by the physician on 9/16/24. This failure resulted in Resident 5 not receiving the medications as prescribed by the physician, which had the placed Resident 5 at risk for thrombosis (clotting of the blood), embolism (obstruction or blockage in a blood vessel) and had the potential for other facility residents to ingest the medications that were left unattended. 2. One of Two Licensed Nurses failed to lock the medication cart when the cart was out of the nurse ' s sight, according to the facility ' s policy and procedure (P&P). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with dignity and respect when Resident 1's call light was removed from the wall and taken away from her on 2/20/2024. This failure violated Resident 1's right to have her call light accessible and within reach and resulted in Resident 1 to feel isolated and alone and without the ability to call staff for assistance.

Inspectors wroteBased on interview and record review, the facility failed to follow its transfer and discharge policy and procedure for one of three sampled residents (Resident 1) when the facility failed to comply with the legal requirements to provide Resident 1 with sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. This failure had the potential to result in Resident 1's unsafe discharge and increased likelihood of preventable re-admissions.

Inspectors wroteBased on observation, interview, facility document and Policy and Procedure review, the facility failed to identify and address complications related to an enteral feeding (complete nutrition delivered via a feeding tube directly into the stomach) for one of one sampled residents (Resident 21) when dehydration risk was not care planned and monitored for Resident 21 who received enteral feedings as the sole means of nutrition and fluid. This failure caused dehydration in Resident 21 which could lead to further medical complications including but not limited to confusion, weakness, low blood pressure, kidney problems and in severe incidences, death.

Inspectors wroteBased on observation, interview and record review, the facility failed to contain garbage and refuse (nonhazardous solid waste) properly when two out of three dumpsters were found to not have securely closing lids. This failure had the potential to attract rodents, insects and flies and could spread infection which placed residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to follow its hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) policy and procedures for seven of seven sampled residents (Residents 1, 22, 24, 36, 64, 81, and 367) when: 1. Resident 81 was receiving hospice services without a written physician order. 2. Resident 22 , Resident 367 and Resident 64 were receiving hospice services with unsigned hospice agreement. 3. Hospice personnel caring for residents under hospice services were not provided orientation to the facility's policies and procedures. These failures had the potential to place Residents 1, 22, 24, 36, 64, 81, and 367 at risk of not receiving appropriate medical, physical, psychosocial, and spiritual support to manage symptoms associated with terminal illness.

Inspectors wroteBased on interview and record review, the facility failed to establish and implement a comprehensive antibiotic (ATB) stewardship (program designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) and surveillance program to identify, track, and monitor resident antibiotic use when the facility's ATB stewardship and surveillance program was not conducted for January 2023 and February 2023. These failures had the potential to place residents at risk for an adverse effect of antibiotics and/or develop an antibiotic-resistant (not effective to treat infection) organisms from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity consistent with enhancing each resident's quality of life for three of 10 sampled residents (Residents 1, 366, and 21) when: 1. Resident 1 and Resident 366's fingernails were long with black and brown matter under the fingernails. 2. Resident 21's lips were dry and crusty and her teeth and tongue were covered with thick yellow and brown substance. These failures resulted in the facility not promoting the rights of Resident 1, 366 and 21 to a dignified and respectful existence and had the potential to compromise their health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's current status for two of five sampled residents (Resident 75 and 59) when: 1. Resident 75's MDS assessment for hearing, speech and vision was not coded accurately. This failure had the potential for Resident 75 not being provided with the necessary care and services to meet her healthcare needs. 2. Resident 59's smoking status was not coded accurately in the MDS assessment. This failure had the potential for Resident 59's smoking safety and identified care needs to go unmet.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered baseline care plan within 48 hours of resident admission in the facility for 6 of 12 sampled residents (Residents 60, 80, 81 82, 84, and 107) when: 1. Resident 60 was sent out to general acute care hospital (GACH) on 2/18/23 for a high blood sugar, returned the following day and was sent to the hospital again on 2/23/23 for a swelling and bruising to right elbow as a result of altercation with another resident; care plans were not developed to prevent rehospitalization and keep her safe. This failure had a potential for Resident 60's blood sugar level and right elbow's swelling and bruising to not be monitored. 2. Resident 80 did not have a care plan in place for a critical lab result and received blood transfusion. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely revise and implement a person centered comprehensive care plan for two of four sampled residents (Resident 13 and 84) when: 1. Resident 13's nutrition care plan was not revised with seven days to include significant weight losses on 12/18/22 or 2/1/23. This failure placed Resident 13 at risk for complications due to care needs not being planned by licensed nurses and the interdisciplinary team to determine if interventions needed to be added, changed or completed. 2. Resident 84's care plan was not revised within seven days to reflect the physician's order for diet and oral intake. This failure had the potential for Resident 84's nutritional needs to go unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice for seven of 12 sampled residents (Residents' 80, 82, 81, 83, 84, 38 and 107) when: 1. Licensed Nurse failed to follow the facility Change in a Resident's condition or status policy and procedure when Licensed Nurse did not conduct change in resident's condition assessment prior to sending Resident 80 out to general acute care hospital (GACH). This failure had the potential for Resident 80's change of condition to not being addressed by the nursing staff which could lead to delay of treatment and/or services. 2. Resident 81 was administered oxygen without following physician's order. This failure resulted in Resident 81 to receive a high dose of oxygen and had the potential to experience oxygen toxicity (a lung damage that happens from breathing too much supplemental oxygen; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care, services and activities of daily living (ADLs -activities related to personal care: bathing, oral care, brushing hair, shaving) for four out of 11 residents (Residents 32, 59, 71 and 91) when the facility did not routinely provide personal hygiene assistance according to the residents needs and preferences. This failure had the potential to result in oral infections, loss of teeth, body odor and skin irritations and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) were provided to maintain good grooming for two of 10 sampled residents (Resident 1 and Resident 366) when: 1. Resident 1 and Resident 366's fingernails were long with black and brown matter under the fingernails. This failure resulted in Resident 1 and Resident 366's fingernails not being well groomed and the potential for harboring microorganisms (bacteria, virus, or fungus) or infection. 2. Resident 21's lips were dry and crusty and her teeth and tongue were covered with thick yellow and brown substance. This failure resulted in Resident 21's mouth not being clean and the potential for causing oral pain, harboring microorganisms or infection. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents remained free from accidents and accident hazards as is possible, for one of 12 sampled residents (Resident 47), when: 1. Resident 47 had an unwitnessed fall on 12/9/22, and the facility did not assess Resident 47's risk for falls; did not conduct a change in condition (CIC, a process of evaluation to identify and promptly report and communicate a resident's change of condition to appropriate healthcare personnel), and the interdisciplinary team (IDT, a group of healthcare professionals who work together to assess, develop, implement, and evaluate each resident's treatment plan) did not review or discuss the root cause of Resident 47's fall in order to make recommendations for appropriate resident-centered care plan interventions that could prevent further falls and injuries. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the policy and procedure for dialysis (procedure to remove wastes and excess fluids from the body) was followed and professional standards of quality were met for one of four sampled residents (Resident 10) when Resident 10 did not have documentation of completed post-dialysis assessments of access sites (site used for dialysis) and monitoring for complications on multiple dates. This failure placed Resident 10 at risk for delayed detection, reporting, and/or management of complications from the hemodialysis (dialysis done through the blood vessel) access sites.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of six sampled residents (Resident 212 and Resident 366) were assessed for bed rail risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars that attach to the bed) prior to bed rail installation. Facility failed to obtain informed consent (form signed by resident or family explaining the risks of side rail use), physician order with indication for use, and care plan prior to the use of bed rails when Resident 212 and 366 had two raised upper bed rails. This failure had the potential to place Resident 212 and Resident 366 at risk for decreased freedom of movement, entrapment and/or injury.

Inspectors wroteSurveyor: [NAME] Surveyor: [NAME], [NAME] Based interview and record review the facility failed to periodically and accurately reconcile controlled substances (CS-medication which can be easily abused and under strict government control) when nursing staff did not ensure accurate controlled substance accountability for two of three resident's CS records (Resident 75 and 211). This failure had the potential for Resident 75 and 211 not to be adequately treated for their pain and had a potential for diversion (used illegally) of controlled substance medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of four sampled residents (Resident 4, 73, 99, 261) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behaviors) medications including quetiapine (antipsychotic medication),olanzapine (antipsychotic medication for bipolar disorder, depression, and schizophrenia) and escitalopram(an antidepressant medication for depression, alcoholism, and schizophrenia) when: 1. Resident 73 was administered olanzapine with no resident specific non-pharmacological interventions were implemented prior to and during use of olanzapine, and no annual gradual dose reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose of if the dose or medication can be discontinued) was attempted. 2. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with current accepted professional standards of practice for a facility of 109 when: 1. Medications for Resident 1, 59, 74, 89, 96, 97, 411, 412 did not have patient identifiers. 2. Two tuberculin (used tuberculosis screening) 1 ml (milliliter- unit of measure) vials were found open, partially used and expired, and one Influenza vaccine (a vaccine that protects against the flu) 5 ml vial did not have an open or discard date. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed when: 1) the Fried [NAME] puree recipe for the lunch meal on 3/23/23 for 17 of 110 residents (Residents 1, 4, 13, 20, 22, 24, 42, 43, 50, 64, 68, 70, 77, 82, 366, 367, 368) was not followed. 2) the Stir Fry Vegetables puree recipe for the lunch meal on 3/23/23 for 17 of 110 residents (Residents 1, 4, 13, 20, 22, 24, 42, 43, 50, 64, 68, 70, 77, 82, 366, 367, 368) was not followed. This failure had the potential to result in not meeting the nutritional needs of the residents and further compromising their medical status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards for food safety guidelines were followed when: 1. The ice machine filter screen was on the floor with paper debris, gloves, and dirt; the filter was covered with off-white dirt residue, the ice machine's interior cover had light pink and off-white to light brown color substance in the interior cover; and one rectangular ice machine swithbox was on top of the counter next to a bowl of cut apples and a tray holding special drinking glasses to be used by residents requiring these special devices. 2. Thirty-two (32) cooking and serving utensils were stored inside a rubber lined wooden drawer that was covered with unidentified black spots, food debris, dirt and moist area. Some of the utensils had caked-in substances on its grooves and/or handles. [...]

Inspectors wroteF813 Based on observation, interview, facility document and policy and procedure review, the facility failed to ensure a policy regarding use and storage of foods brought to residents by family and other visitors was followed to ensure safe and sanitary storage, handling, and consumption. This failure had the potential to limit the resident's rights and enjoyment of food brought in by family or visitors.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible for four of 12 sampled residents (Residents 107, 108, 211 and 71) when: 1. Resident 107's copy of Physician Orders for Life-Sustaining Treatment (POLST) form (a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) was not signed and readily available as part of Resident 107's current medical records. 2. Resident 108's copy of Consent to Treat, Bed Hold Notification and Influenza-Pneumococcal Immunization Consent or Declination Form were not signed and readily available as part of Resident 108's current medical records. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. Two of six sampled residents' (Resident 14 and 81) oxygen concentrator (a device that concentrates the oxygen from the ambient air) were found covered with lint and dust. This failure placed Residents 14 and 81 at an increased risk to develop respiratory and healthcare-associated infections. 2. The Maintenance Supervisor (MS) failed to call pest control on 3/21/23 and 3/22/23 when pest were seen in the facility. This failure potentially placed facility residents at an increased risk for foodborne-related illness. 3. Licensed Vocational Nurse (LVN) 4 failed to properly disinfect resident shared blood pressure cuff (a device used to measure blood pressure) prior to and after resident care. [...]

Inspectors wroteBased on observation, interview and facility policy and procedure review, the facility failed to ensure kitchen equipment was maintained in safe operating condition when: 1. The ice machine manufacturer cleaning instructions were not followed, 2. The walk-in refrigerator interior wall was not a cleanable surface, and 3. A food preparation sink was not in proper working order. These failures had the potential to affect the equipment not functioning in the way it was intended which could affect the health status of the residents. 4. One of six sampled residents' (Resident 14) oxygen concentrator was found operating without a filter. This failures placed Residents 14 at an increased risk to develop respiratory and healthcare-associated infections.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 75) personal eyeglasses were not inventoried upon admission. This failure resulted in Resident 75's loss of personal eyeglasses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing activity program to meet the needs, for one of six sampled residents (Resident 89) when Resident 89, who was identified as needing exercise-focused activities due to morbid (severe) obesity (overweight) related to depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and physical sedentary (way of life characterized by too much sitting, lying in bed, and having little or no physical exercise), was not provided with exercise-focused activities as recommended by the Registered Dietitian (RD, a health professional trained in diet and nutrition to help people improve their health and well-being through healthy diet, good eating habits, and exercises for weight control). [...]

Inspectors wroteBased on observation, interview, record review, and manufacturer's guidelines for use, the facility failed to maintain sanitary conditions when preparing and distributing food in accordance with professional standards for food service safety when: 1. A bucket containing sanitizing solution used in the kitchen did not meet manufacturers guidelines and 2. Kitchen staff did not wash hands after touching food and prior to plating food in the tray line. These failures had the potential for food preparation and distribution to not occur under sanitary conditions.

Inspectors wroteSurveyor: [NAME] Based on interview and record review, the facility failed to develop a comprehensive person centered care plan to establish care needs, interventions and measurable objectives for three of 69 sampled residents (Resident 78 and 302) when: 1. Resident 78 did not have a care plan with measurable goals and interventions for the diagnosis and treatment of pneumonia (lung infection). 2. Resident 302 did not have a care plan with measurable goals and interventions for the diagnosis of Clostridium difficile (C. diff) (infection of the colon-large intestine). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and a comprehensive person-centered care plan for two of 69 sampled residents (Resident 10 and Resident 462) when: 1. Resident 10's physician did not provide, and licensed nurses did not clarify, the blood glucose (sugar) parameters for which to notify and alert the physician after elevated blood sugar values continued for three months. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (drugs that affect a person's mental state) drug use when: 1. Psychotropic medications were administered longer than 14 days as a PRN (as needed) designation rather than for a limited time period for one of 69 sampled residents (Resident 29). 2. There was no reduction done as ordered for one of 69 sampled residents (Resident 91) when Resident 91's physician order to reduce the medication Abilify (psychotropic medication) was not followed. These failures had the potential to result in Resident 29 and Resident 91 receipt of medications without the benefit of a physician assessment for the extended need. This failure placed Resident 29 and Resident 91 at potential risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional standards when: 1. Expired medications were found in the medication cart, and in the Automated Dispensing Unit (ADU; a drug storage device used to track drug distribution), 2. Medications that were required to be dated when opened were found in the medication cart opened and undated, 3. Resident's medications from home were found opened and unlabeled in the medication cart, and 4. A medication refrigerator temperature log was not completed. This failure resulted in four of 69 sampled residents, Residents 54, 27, 38, and 78, receiving expired and potentially expired medications; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection control program for four of six sampled residents (Resident 51, Resident 86, Resident 77, and Resident 69) when: 1. Resident 51's nebulizer tubing (drug delivery device used to administer medication in the form of mist inhaled into the lungs through a mouth piece or face mask) was undated. Resident 51's Continuous Positive Airway Pressure (C-pap; forces air into the nasal passages at pressure high enough to overcome obstruction in the airway and stimulate normal breathing) face mask had brownish yellow residue. 2. Resident 86's shared bathroom had an unlabeled urinal; Resident 77 and Resident 69's urinals (portable receptacles used by men for urinating at bedside) were on top of the night stand unlabeled. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for one of 69 sampled residents (Resident 41) when Resident 41's gastrostomy tube (g-tube) (a tube inserted through an incision in the abdomen that delivers nutrition directly to the stomach) was visible while Resident 41 was asleep in the facility's hallway. This practice failed to provide Resident 41 with privacy to ensure dignity and respect which resulted in Resident 41's g-tube to be visible to other residents and visitors in the facility and violated Resident 41's right to keep her nutritional status confidential.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services which meet professional standards of quality for three of 69 sampled residents (Resident 10, Resident 51 and Resident 36) when: 1. Resident 10's physician did not provide, and licensed nurses did not clarify, the blood glucose (sugar) parameters for which to notify and alert the physician after elevated blood sugar values continued for over 30 days. 2. Licensed nurses did not clarify with Resident 51's physician the flow rate for supplemental oxygen (O2) administration and administered supplemental O2 without a complete physicians order. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report medication irregularities for one of 69 sampled residents (Resident 66) when Resident 66 was given a Duloxetine (an antidepressant medication) 40 milligrams (mg- a unit of measurement) from 12/9/18 to 1/22/19 instead of the physician's ordered dose of 30 mg. daily. This failure resulted in Resident 66's receipt of a higher dose of medication than the physician ordered daily from 12/9/18 through 1/22/19 which placed the resident at risk of adverse reactions from the higher dosage.

Inspectors wroteBased on observation, interview and record review, the facility failed to report medication irregularities for one of 69 sampled residents (Resident 66) when Resident 66 was given a Duloxetine (an antidepressant medication) 40 milligrams (mg- a unit of measurement) from 12/9/18 to 1/22/19 instead of the physician's order dose of 30 mg. This failure resulted in Resident 66 to receive more than the physican prescribed dose of Duloxetine medication daily from 12/9/18 through 1/22/19 which placed the resident at risk of side effects of a high dose of medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 69 sampled residents (Resident 66) was free from significant medication error when Resident 66 was given a Duloxetine (an antidepressant medication) 40 milligrams (mg- a unit of measurement) from 12/9/18 to 1/22/19 instead of the physician's ordered dose of 30 mg daily. This failure resulted in Resident 66's receipt of a higher dose of medication than the physician ordered daily from 12/9/18 through 1/22/19 which placed the resident at risk of adverse reactions from the higher dosage.