Coventry Court Health Center

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to ensure the plan of care was revised for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1's plan of care was revised to address the resident's poor fluid intake after 4/21/26. This failure posed the risk for Resident 1 not to receive the person-centered care and services required to attain or maintain her highest level of physical and mental well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the care plan reflected the individual care needs for one of six sampled residents (Resident 1). * The facility failed to provide adequate monitoring when Resident 1 was continually wandering around the facility to prevent elopement and/or accidents. In addition, the facility failed to develop a person-centered care plan to address Resident 1's high risk for elopement and fall. This failure resulted to Resident 1 being unsupervised and had a fall with injury in the patio.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current care needs and interventions for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1's plan of care was revised to address Resident 1's refusal of insulin as ordered by the physician for the management of diabetes mellitus. This failure has the potential to pose the risk of not providing Resident 1 with appropriate and individualized care.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained their highest practicable physical well-being. * The facility failed to notify the physician when Resident 1 consistently refused insulin as ordered. This failure posed the risk of Resident 1 not being provided with appropriate care and monitoring of possible complications associated with diabetes mellitus.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to establish and maintain an infection control program designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the monthly infection surveillance documents were summarized and analyzed accurately reflect the total number of CAI (Community-Acquired Infection) in the facility for April and May 2025. * The facility failed to develop a water management program which included the process to identify, test, and prevent Legionella (a bacteria which can cause a serious type of lung infection) and other opportunistic waterborne pathogens. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 84) observed during medication pass observation. * Resident 84 was assessed not for safe self-administration of the medications when Resident 84 was observed with a Cepacol Extra-Strength Sore Throat Benzocaine 15 mg/menthol 2.6 mg lozenges (lozenges containing medication to relieve sore throat and pain) at the resident's bedside. In addition, the facility failed to ensure a care plan was developed to address the self-administration of the medications for Resident 84. These failures had the potential for Resident 84 to self-administer the medications inaccurately and negatively affect Resident 84's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents (Residents 7, 71, and 109) reviewed for unnecessary medications were free from the unnecessary psychotropic medications. * The facility failed to ensure Resident 109's physician's order and informed consent for the use of the quetiapine (antipsychotic medication) and risperidone (antipsychotic medication) medications included the diagnoses and the specific behavior manifestation; and the psychoactive medication evaluation and care plan were initiated for the use of the quetiapine and risperidone medication. In addition, the facility failed to ensure the physician's order for the use of the PRN alprazolam medication (antianxiety) had a stop date. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of four sampled residents (Residents 10 and 71) reviewed for PASRR were accurately screened. * The facility failed to ensure Level II PASRR screenings were completed following a positive Level I PASRR screening. This failure posed the risk for Residents 10 and 71 being not properly screened, and the risk of not receiving adequate level of services, comprehensive assessment, and intervention.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for two of 19 final sampled residents (Residents 1 and 24). * The facility failed to develop a care plan to address Resident 1's refusal of the COVID-19 vaccine. * The facility failed to develop a care plan to address Resident 24's noncompliance with the continuous use of oxygen via nasal cannula as ordered by the physician. These failures posed the risk of the residents not receiving the appropriate treatment and services.

Inspectors wroteBased on interview, observation, and facility P&P review, the facility failed to properly conduct a post fall monitoring and communication for one of three residents (Resident 84) reviewed for accidents. * Resident 84's fall was not communicated to the dialysis center for continued monitoring. * Resident 84's post-fall neurological checks were not completed accurately and for the full 72 hours. These failures put the resident at risk for increased injury as well as a potential delay in the identification and provision of necessary interventions if the resident had any change in condition.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 19 final sampled residents (Residents 24 and 95) were provided with the appropriate respiratory care when: * The facility failed to ensure Resident 24 received continuous oxygen at 2 LPM via nasal cannula as ordered by the physician. * The facility failed to change the oxygen tubing, nebulizer, and mask for Resident 95 per facility's protocols. These failures had the potential to negatively impact the residents' medical conditions.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for two of two final sampled residents (Residents 50 and 95) reviewed for pain management. * The facility failed to ensure the nonpharmacological interventions, and its effectiveness were consistently documented prior to the administration of the acetaminophen (pain medication) for Resident 50. In addition, the facility failed to document the complete pain assessment as per the care plan for Resident 50. * The facility failed to document the complete pain assessment, as per the care plan for Resident 95. These failures have the potential to put Residents 50 and 95 at risk for the resident's pain being improperly managed.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the competency of two licensed nurses (LVNs 7 and 8) and the DSD interviewed regarding the facility's glucometer operation and protocols. * LVNs 7 and 8, and the DSD were not aware of how long the glucose control solutions used to do Quality Control checks for the glucometers are good for from the date they were opened. In addition, LVNs 7 and 8, and the DSD were not able to verbally state the facility's protocol on when to conduct the quality control checks and the process to conduct quality control checks for the glucometer. These failures had the potential of not providing care to the residents in a safe and competent manner.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medication was administered as ordered by the physician for one of two residents (Resident 84) investigated for dialysis. * The facility failed to administer Resident 84's furosemide (a diuretic medication) as per the physician's order. This failure had the potential for the resident to have an adverse outcomes related to the diuretic not being administered as ordered.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the pharmacist consultant performed a monthly MRR (Medication Regimen Review) to identify potential irregularities for two of five sampled residents (Residents 4 and 7) reviewed for unnecessary medications. * The facility failed to ensure Resident 4 had a monthly MRR completed by the pharmacist consultant for May 2025. * The facility failed to ensure Resident 7's MRR for June and July 2025 conducted by the pharmacist consultant addressed the use of two antidepressant medications (mirtazapine and bupropion) for the same manifested behavior of verbalization of sadness. These failures put the residents at risk for adverse outcomes related to the medications the residents were receiving.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.14%. One of the two licensed nurses (LVN 7) observed during the medication administration was found to have made errors. * LVN 7 failed to ensure the sevelamer medication (phosphate binder) was administered to Resident 84 on time and with a meal as per the physician's orders. LVN 7 failed to ensure the furosemide medication (diuretic) was administered to Resident 84 as ordered. These failures created the risk for the resident to have potential side effects or complications related to the medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications. * The facility failed to ensure the expired medications were removed from the Medication Room. In addition, the facility failed to ensure medications used for different routes were not stored together in one container, and the medications were labeled. * The facility failed to ensure the expired medications were removed from Medication Carts B and C. * The facility failed to ensure the supplies were labeled for Medication Cart C. * The facility failed to ensure the three sachets of Calazinc body shield (skin protectant) were not kept at Resident 24's bedside. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The facility failed to ensure the kitchen staff were wearing hair restraints and clothing that covers body hair. * The facility failed to ensure the pitchers and pitcher covers were properly air dried. * The facility failed to ensure one of the multiple pitchers was clean and free of particle. * The facility failed to ensure the sanitary condition of the kitchen hood over the stove was maintained. These failures had the potential to cause foodborne illnesses in a highly susceptible residents population of 88 facility residents who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure one glucometer (Glucometer A) from one of two medications carts (Medication A) inspected with the glucometers, was maintained in safe operating condition. This failure had the potential for residents requiring glucose checks to have inaccurate readings.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 contained complete information for one of three nonsampled residents (Resident 110) reviewed for beneficiary notices. The SNF ABN Form CMS-10055 is used to inform residents of the potential financial liability and appeal rights and protections should they wish to receive care and services that may not be covered by Medicare. This failure had the potential of not allowing the residents to make an informed decision regarding their Medicare services.

Inspectors wroteBased on interview and medical record review, the facility failed to complete the timely discharge MDS assessments for two of two nonsampled residents (Residents 6 and 76) investigated for resident assessments. This failure resulted in a delay of submitting the data to CMS regarding the residents' health and functional status at the time of their discharge from the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of 19 final sampled residents (Resident 54). * The facility failed to follow-up in scheduling Resident 54's outside urology consultation as ordered by the physician. This failure had the potential to result in Resident 54 not receiving appropriate services, treatment, and care.

Inspectors wroteBased on interview, personnel file review, and facility P&P review, the facility failed to ensure the annual skill performance evaluations for three of three staff members (CNAs 1, 2, and 3) reviewed were complete. This failure had the potential for the residents to not receive the proper and safe care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the laboratory services for one of five final sampled residents (Resident 71) reviewed for unnecessary medication. The facility failed to schedule the laboratory testing as ordered by the physician for Resident 71. This failure had the potential for Resident 71's laboratory test to be missed and adversely affect the resident's physical health and well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the safe food handling guidelines for the food brought in by families/visitors were implemented for one of 19 final sampled residents (Resident 95). * The facility failed to ensure the food brought in by families/visitors for Resident 95 were labeled. This failure had the potential to result in unsafe food handling and could cause foodborne illnesses in residents who received food brought in by families/visitors.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were coordinated to meet the resident's needs when discharged from the facility for one of two sampled residents (Resident 1). This failure resulted in Resident 1 not having appropriate care at home, which had the potential to negatively affect Resident 1's health.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The facility failed to ensure the kitchen utensils and equipment were clean and stored in sanitary conditions. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the personnel entering the kitchen donned hair covering in the kitchen. * The facility failed to ensure the proper labeling and dating of the foods in the kitchen was utilized once the food item was opened. * The facility failed to ensure the fan unit inside the walk-in refrigerator was clean and free of buildup. These failures had the potential to cause foodborne illnesses in a highly susceptible resident population of 88 facility residents who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented as evidenced by: * The facility failed to implement their infection control surveillance program for August 2023 through June 2024. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobials. Residents who were not prescribed antimicrobials were not included in the facility's infection control surveillance program. * The facility failed to accurately track and monitor for the infections for April and May 2024. * The facility failed to ensure the staff performed hand hygiene before and after meal tray distribution. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their antibiotic stewardship program when the facility failed to conduct an assessment for the McGeer's criteria to determine the true infection. This failure had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antimicrobials.

Inspectors wroteBased on interview and medical record review, the facility failed to obtain the informed consent for the use of psychotropic medication (medications affecting brain activity) for one of five final sampled residents (Resident 37) reviewed for unnecessary medications. * The facility failed to ensure an informed consent was obtained when alprazolam (antianxiety medication) was prescribed for an extended period for Resident 37. This failure posed the risk for Resident 37 and her responsible party to not be informed of the potential risks and benefits of the alprazolam medication.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide and document in the medical record the information regarding their rights to formulate the advance directives and to ensure the POLST was accurate for three of 20 final sampled residents (Residents 2, 54, and 74). * Resident 2's POLST showed DNR status; however, the resident's medical record showed full code status. * Resident 74's responsible party had not been provided the information regarding their rights to formulate the advance directive. * Resident 54's POLST and code status did not match the resident's advance directive. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 2) was free from the physical restraints. * The facility failed to obtain the informed consent and the restraint assessment was conducted prior to applying a compression glove (helps provide support, relief and recovery from sore muscles andpainful joint stiffness in the wrists, palms, and fingers. It also helps to push the excess fluid out of the hand) on Resident 2's right hand. This failure posed the risk of compromising the resident's independence and psychosocial well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to report the allegation of sexual abuse between two nonsampled residents (Residents 19 and 21) to the CDPH L&C and LTC Ombudsman Programs as per the facility's P&P. This failure had the potential for the residents to be vulnerable for further abuse.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was implemented to reflect the individual care needs for one of 20 final sampled residents (Resident 54). * The facility failed to ensure Resident 54's left ½ (half) side rail was elevated as an enabler as per the care plan. This failure had the potential for Resident 54 to not be provided with appropriate, consistent, and individualized care.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the services to attain or maintain the highest practicable well-being for one of five sampled residents (Resident 69) reviewed for unnecessary medications. * Resident 69 was administered midodrine (antihypotensive medication used to treat low blood pressure) medication when Resident 69's systolic blood pressure was above the parameter prescribed by the physician. This failure had the potential to negatively affect Resident 69's health condition and well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 28) and two nonsampled residents (Residents 21 and 47) reviewed for Wander Guard use were remained free from the accident hazards. * The facility failed to monitor the Wander Guard for functionality for Residents 21, 28, and 47. This failure had the potential to place the residents at risk for serious injuries and posed the risk for not having accurate information documented to prevent further accidents and or injuries to the residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to maintain the IV access for one of one final sampled resident reviewed for IV care (Resident 79). * The facility failed to ensure the initial PICC line external catheter measurement was documented in the medical record and failed to confirm baseline measurements of the PICC line external catheter and arm circumference measurements prior to administration of IV antibiotics. These failures had the potential to delay the identification of catheter related complications for this resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the safe respiratory care for three of three final sampled residents (Resident 8, 50, and 61) and one nonsampled resident (Resident 687) reviewed for respiratory care. * The facility failed to ensure Resident 8's CPAP machine was cleaned as per the manufacturer's user cleaning guidelines. * The facility failed to ensure Resident 61's oxygen tubing was not touching the floor. * The facility failed to ensure Resident 50's nebulizer tubing was dated and mask was stored in a bag when not in use. * The facility failed to ensure Resident 687 was administered the oxygen as ordered by the physician. Additionally, the facility failed to ensure the nebulizer tubing and oxygen tubing were changed and labeled as per the facility's P&P. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to provide the adequate and appropriate pain management for one of five final sampled residents (Resident 69) reviewed for unnecessary medication use. * The facility failed to ensure the pain medication was administered as per the physicians' orders for Resident 69. This failure had the potential for Resident 69 to not receive effective treatment for pain.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of nine final sampled residents reviewed for side rail use (Residents 50 and 54) remained free from the accident hazards associated with the use of elevated side rails. * The facility failed to obtain a physician's order and informed consent and failed to conduct a side rail evaluation prior to the use of the right half side rail for Resident 54. * The facility failed to ensure the proper assessment for Resident 50 prior to the use of the side rails. These failures have the potential to put Residents 50 and 54 at risk for serious injuries.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure two of five final sampled residents (Residents 14 and 37) reviewed for unnecessary medications were free from the unnecessary psychotropic medications. * The facility failed to ensure the physician's documentation of the rationale for extending the use of alprazolam (antianxiety medication) beyond the 14-day duration for Resident 37. * The facility failed to monitor Resident 14 for signs of orthostatic hypotension for the use of antipsychotic medication. These failures had the potential to place Residents 14 and 37 at risk for receiving unnecessary medication and increased risk of serious adverse reactions from the medications.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the proper storage and disposal of medications for one of one medication storage room, three of four medication carts inspected for medication storage and labeling. In addition, the facility failed to ensure the medications were not stored at the bedside for one of 20 final sampled residents (Resident 35) and one nonsampled resident (Resident 66). * The facility failed to ensure the oral medications were stored separate from externally used medications in the medication room. * The facility failed to ensure the medications in the bubble packs (type of pre-formed, plastic packaging that seal individual tablets until they are taken) were secured, sealed and free from tears or damage for two nonsampled residents (Residents 1 and 88). [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the education was provided to the staff and family/visitor on safe food handling of outside food as per the facility's P&P. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for four of 20 final sampled residents (Residents 14, 17, 20, and 50) were accurate and complete. * The facility failed to ensure Resident 50's RNA documentation was complete. * The facility failed to ensure Resident 17's Smoking Evaluation was accurately completed. * The facility failed to ensure Resident 50's RNA documentation was complete. * The facility failed to ensure Resident's TARs regarding the indwelling urinary catheter securement and monitoring Resident 14's edema were completed. * The facility failed to ensure Resident 14's medical record did not contain another resident's health information. These failures had the potential for the residents' care needs not being met as their medical information were inaccurate.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer and provide the education for influenza and pneumococcal immunizations for two of five final sampled residents (Residents 20 and 35) reviewed for immunizations. * The facility failed to obtain the consent and provide education on the influenza vaccine to Residents 20 and 35. * The facility failed to ensure Resident 35's Immunization Record was accurate for receiving the pneumococcal vaccine. These failures had the potential for the residents to be uninformed of the risks and benefits of receiving the influenza vaccine and potentially affect care provided.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete for six of nine sampled residents (Residents 14, 20, 37, 50, 54, and 69) reviewed for side rails use. * The facility failed to ensure Residents 14, 20, 37, 50, and 69's entrapment assessments were accurate. * The facility failed to ensure Resident 14's bed entrapment assessment was complete. * The facility failed to ensure Resident 54's bed entrapment assessment was completed for the right half side rail prior to use. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS for one of 20 final sampled residents (Resident 61) and one of three closed sampled records (Resident 487) were accurate. * Resident 487's fall was not identified on the MDS. * Resident 61 use of the chair and bed alarm was not identified in the MDS. These failures posed the risk of Residents 61 and 487 not being provided the necessary care to meet their specific needs.

Inspectors wroteBased on observation, interview, and facility P&P, the facility failed to ensure the garbage and refuse were properly stored in two out of three garbage dumpsters. The garbage dumpsters was observed overflowing with garbage which prevented the lids from fully closing. This failure had the potential to attract pests/rodents that carry diseases.

Inspectors wroteBased on observation and interview, the facility failed to ensure the equipment was maintained in a safe operating condition. * The facility failed to ensure there was no ice buildup in the freezers of Medication Refrigerators A and B in Medication Room A. This failure had the potential for the equipment to not function in the way it was intended.

Inspectors wroteBased on interview and medical record review, the facility failed to arrange for the transportation to and from ophthalmology appointments for one of two sampled residents (Resident 1). This posed the risk of the resident not receiving the necessary vision related care and treatment.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record for one of two sampled residents (Resident 1) was accurate and complete. * The facility failed to ensure Resident 1's rehabilitative evaluation was documented. This had the potential for the resident's care needs not being met as their medical information was inaccurate and incomplete.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for one of three sampled residents (Resident 2). * Resident 2's care plan for hearing had an incorrect intervention. This failure had the potential risk of not providing the appropriate and individualized care for Resident 2.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) maintained his highest practicable physical well-being. * The facility failed to administer acetaminophen (a fever and pain reducing medication) as prescribed by the physician for Resident 1. This failure had the potential to negatively impact Resident 1's well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the proper labeling and dating of the foods in the kitchen was utilized once the food item was opened. * The facility failed to ensure the ice machine's ice maker was free from black residue. * The facility failed to ensure the quaternary sanitizing strips to measure the concentration of ammonium compound the sanitizing solution for the manual ware washing and sanitization buckets were not expired. * The facility failed to ensure the kitchen equipment was clean. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment; and prevent the transmission of diseases and infections to all residents. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. * The facility failed to ensure RN 4 provided the sanitary condition during the medication administration. * The facility failed to ensure RN 3 performed hand hygiene during the medication administration. * The facility failed to ensure CNAs 4 and 5 performed hand hygiene when passing the lunch trays and assisting in between the residents. These failures posed the risk for transmission of disease-causing microorganisms.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete; and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for all 80 residents with side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to ensure resident care was provided in a manner to promote dignity and respect for one of 18 final sampled residents (Resident 82) and one nonsampled resident (Resident 71). * The facility failed to ensure the staff sat next to Residents 71 and 82 while assisting them to eat. This had the potential to negatively impact the residents' feelings of self-worth and well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide one nonsampled resident (Resident 28) trust fund statements quarterly. This failure had the potential for loss and misuse of Resident 28's personal funds.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the information on how to formulate an advanced directive and maintain a copy of the resident's advance directives in the medical record for four of 18 final sampled residents (Residents 4, 16, 18, and 38) and one nonsampled resident (Resident 7). These failures have the potential for the residents' decision regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDSs for two of 18 final sampled residents (Residents 4 and 16) and one nonsampled resident (Resident 85) were accurate. This posed the risk of the residents not receiving an individualized plan of care based on the residents' specific needs.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of 18 final sampled residents (Residents 15 and 42). These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure two of 18 final sampled residents (Residents 33 and 82) and one nonsampled resident (Resident 12) attained and maintained their highest practicable well-being. * The facility failed to consult the physician when Resident 33 was administered the following medications at the same time: midodrine (antihypotensive or medication used to treat low blood pressure) medication and metoprolol (antihypertensive or medication used to treat high blood pressure), diltiazem (antihypertensive) and isosorbide dinitrate (used to prevent chest pain and lowers blood pressure). In addition, the parameters for midodrine, metoprolol, and diltiazem were not followed when administering these medications. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of 18 sampled residents (Resident 336). The facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record for Residents 336. This failure had the potential to delay identification of catheter related complications for the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for one of 18 final sampled residents (Resident 336). * The facility failed to ensure Resident 336's nasal cannula (flexible tube to deliver oxygen into the nose) tubing was dated as per the facility's P&P. In addition, a CNA was observed turning on and off the concentrator machine. These failures posed the risk for the resident's oxygen equipment to become contaminated which had the potential to negatively affect the residents' medical conditions.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure dialysis care was provided for two of 18 final sampled residents (Residents 4 and 33). * The facility failed to implement and monitor the fluid intake for Resident 33 as per the physician's order. There were two physician's orders for fluid restrictions for Resident 33 with different fluid breakdowns for nursing and dietary. There was no documentation by the nursing staff for the actual fluid intake by Resident 33, and the CNA's documentation of the resident's fluid intake showed the resident took more than the prescribed fluid intake. * The facility failed to ensure the physician's order for 1000 ml fluid restriction (a diet which limits the amount of daily fluid consumption) was followed and carried out accordingly for Resident 4. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Resident 51) remained free from accident hazard due to the use of side rails. * The facility failed to ensure the assessments for the risk for entrapment were completed for Resident 51 prior to the use of bilateral half side rails. In addition, the facility failed to obtain informed consent for the use of the side rails. This failure had the potential to put the resident at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration and storage as evidenced by: * The facility failed to ensure the electronic MAR for Resident 636 was not signed prior to the medication administration. * The facility's medication error rate was 3.45%. One of two licensed nurses (LVN 1) who were observed during the medication administration was found to have an error. LVN 1 failed to administer one of Resident 12's medications. * The narcotic medication was not properly stored. These failures had the potential to negatively impact the residents' health outcomes.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for one of 18 final sampled residents (Resident 33). * The Pharmacy Consultant recommended to verify the diagnosis and behavior for the prescribed risperidone (antipsychotic) medication for Resident 33 was not acted upon. This failure had the potential to put Resident 33 at risk for adverse consequences related to the medication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 18 final sampled residents (Residents 16, 33, and 43) was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 16's episodes of behaviors for the use of quetiapine (a medication use to treat symptoms of schizophrenia or bipolar disorder (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and clonazepam (antianxiety medication) were summarized and made available to the prescriber on a monthly basis to serve as reference for gradual dose reduction. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the staff implemented the proper disposal and storage of medications in a safe manner as evidenced by: * The facility failed to ensure the discontinued medications were properly disposed. * The facility failed to ensure the oral and suppository medications were properly stored in the medication cart. * The facility failed to ensure the medication carts were properly locked and secured. Medication Cart 2 was left unlocked and unattended. This had the potential for unauthorized persons to have access to the medications inside the medication cart. These failures had the potential for the drug diversion and to result in an unsafe handling and storage of the residents' medications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu for the pureed garlic bread sticks was followed when the wrong scoop size was used to serve the pureed bread for the residents on pureed diet. This failure had the potential for the residents to not receive adequate nutrition and appropriate servings to meet their individual needs.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food preferences were followed for one of 18 final sampled residents (Resident 4) and one nonsampled resident (Resident 12) as evidenced by: * Resident 4 disliked broccoli and cauliflower but was served with California vegetable blend with broccoli and cauliflower. * Resident 12 liked a double portion of salad and fruit but was only served a single serving of salad and fruit. These failures had the potential to negatively impact the residents' well-being.