Crescent City Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported to the California Department of Public Health (the Department) within the required timeframe for one (1) of four (4) sampled residents (Resident 1), when the facility did not report an allegation of abuse involving Resident 1 within two (2) hours after the allegation was made. This failure had the potential to result in delayed abuse identification and intervention, compromising the well-being and protection of vulnerable residents within the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an abuse allegation involving staff and one (1) of four (4) sampled residents (Resident 1). This failure had the potential to delay the implementation of necessary protective measures and oversight to safeguard the health and safety of Resident 1 and other residents of the facility. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 1) when a certified nurse assistant (CNA 1) disregarded the resident's right to refuse care and showered her despite her clear refusal. This failure resulted in a diminished sense of dignity and autonomy for Resident 1, causing anger, frustration, and anxiety, undermining her trust in caregivers, and creating the potential for psychological trauma and future reluctance to accept necessary care. A record review of Resident 1's admission Record (facility demographic), indicated her admission to the facility on 1/24/23 from an acute care hospital with diagnoses including but not limited to the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) received treatment and care in accordance with the resident's goals of care and professional standards when Resident 2's skin treatment ordered by the physician was not provided for 11 days of the month. This failure had the potential to result in worsening of the skin condition and leaving the skin unprotected and broken rendering it susceptible to secondary infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported to the California Department of Public Health (the Department) within the required timeframe for one of two residents (Resident 1) when the facility did not report an allegation of abuse involving Resident 1 within two hours after the allegation was made. This failure had the potential to result in the allegation not getting investigated timely, and can result in physical, mental, or psychosocial harm to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents requiring oxygen were provided humidifiers (bottled water that attaches to an oxygen concentrator and moistens the oxygen, preventing dry nose and throat), clean concentrators (a medical device that provides supplemental oxygen to people with breathing-related conditions by pulling in ambient air, filtering out nitrogen, and delivering purified oxygen) and orders for therapy for 13 of 15 residents (Residents: [...]

Inspectors wroteBased on observation, interview and record review, staffing was not sufficient to meet the needs of thirteen Sampled Residents (Resident #6, Resident #29, Resident #55, Resident #9, Resident # 35, Resident #86, Resident #53, Resident #3, Resident # 34, Resident 54, Resident 81, Resident #5, and Resident #67 when:There was no staff assistance with dining for Sampled Residents #9, #86 and #35 and resulted in no lunch eaten by all three residents; and Sampled Resident #86 was not turned every two hours. Staff did not provide activities of preference for Sampled Resident #34, did not provide nail care for Residents #6, #29. #55, #54 and Resident #81, and did not get Resident #81, Resident #5 and Resident #67 out of bed. Sampled Residents #3, #6 and #53 were observed to not have call lights lights within reach on multiple occasion. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a census of 87 residents with a well balanced diet that met their daily nutritional and special dietary needs, while honoring individual food preferences when:The facility did not maintain current and complete dietary preference documentation, as only 5 of 87 residents had documented preferences; and The facility did not provide staff with accurate and up to date diet order information, as dining room staff relied on a diet roster that was two weeks outdated. These failures had the potential to place residents at risk for decreased meal satisfaction, leading to reduced intake and missed therapeutic diets, potentially resulting in medical complications.1. During a record review of the facility's 85 lunch tray tickets dated 3/24/26, only five of the tray tickets had documented preferences.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide support personnel to safely and effectively carry out the functions of the food and nutrition services department for a census of 87 residents when the Dishwasher (DW) operated the dishwashing machine at 108 degrees Fahrenheit and could not identify the required operating temperature or describe how to test for chlorine sanitation. This failure had the potential to affect the facility's ability to maintain effective sanitation practices for all residents and to cause foodborne illnesses in a vulnerable resident population. During an interview on 3/25/26 at 10:33 a.m., with the DW, the DW stated he was a new employee and remained in training. The DW could not specify the temperature at which the dishwashing machine should operate. The DW also could not describe how to test for chlorine sanitation. [...]

Inspectors wroteBased on interviews, and record review the facility failed to ensure an effective system was in place to accurately identify and communicate residents' food allergies, preferences and substitutes for a census of 87 residents when the facility's tray tickets listed residents' allergies under the dislikes section rather than under a clearly defined allergies designation, and preferences were not assessed, documented on meal tickets or honored for three residents (Resident 35, Resident 86, and Resident 89). This failure placed residents at risk for exposure to allergens due to staff's inability to reliably identify and accommodate allergy restrictions, and left residents frustrated due to their preferences not being honored. During an interview on 3/23/26 at 9:15 a.m. Resident #35 stated he did not get what he needed for breakfast. He stated he told someone and he still didn't get it. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food service safety for a census of 87, when:Several food items were found in the walk-in refrigerator past their use by dates;Several food items were found in the dry storage area past their use by dates;The scoop was left in the large bin container which stored the flour;Facility provided snacks were found in the resident refrigerator past their use by date; andFacility provided snacks were found in the resident refrigerator without date labels. These failures had the potential to contribute to the spread of foodborne illnesses among a vulnerable resident population.1. During a concurrent observation and interview on 3/23/26 beginning at 8:34 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store resident food in a safe and sanitary manner for a census of 87 when staff stored several perishable food items unlabeled and undated in the facility pantry designated for resident food. This failure had the potential to cause foodborne illnesses in a vulnerable resident population. During an observation on 3/24/26 at 8:23 a.m. in the clean utility room, which contained cabinets designated for resident personal food items, one clear plastic scalloped edge bowl containing three large porous pieces of bread sat directly on the cabinet shelf. The bread remained unprotected and exposed to the environment because the container was uncovered. At the same time and location, one large red and white commercially wrapped food item rested on the same shelf approximately two inches from the uncovered bread. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all responsibilities of the Medical Director were effectively performed to ensure resident attained and maintained the highest practicable physical, mental and psychosocial well-being when the Medical Director did not fulfill his responsibility for the coordination of medical care in the facility. This failure resulted in Gradual Dose Reductions (GDR) not being addressed and communication between the Medical Director and care teams being ineffective which could result in delayed resident care, unnecessary medication use, and potentially poor resident outcomes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that essential kitchen equipment was in safe operating condition for a census of 87 residents when:1. The low temp dishwashing machine was operated at 108 degrees Fahrenheit multiple times; and2. A food thermometer was not readily available for use. These failures had the potential to compromise the facility's ability to maintain effective sanitation practices for all residents and increase the risk of serving food that had not been verified to be at a safe temperature.1. During an observation on 3/25/26 at 10:37 a.m., the Dishwasher (DW) operated the low temp dishwasher multiple times, and the temperature gauge showed 108 degrees to 110 degrees Fahrenheit.2. During a concurrent interview and observation on 3/25/26 at 10:59 a.m. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to honor the rights of three residents (Resident 81, Resident 34 and Resident 54) out of twelve residents sampled for Advanced Directives (ADR), when they neglected to provide the Resident's and/or their representatives with a consultation upon admission to the facility. This failure had the potential to result in the resident's wishes for life sustaining treatment during an emergency not being honored. A review of Resident 81's admission record indicated she was admitted on [DATE] with the diagnoses of history of breast cancer, repeated falls, osteoarthritis and osteoporosis ( diseases causing decrease in bone density and pain in joints), and Bipolar Disorder (a chronic mental health condition characterized by intense, alternating mood swings between extreme high energy (mania or hypomania) and deep depression). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two allegations of abuse were reported to the Department within the required timeframe for three of 38 sampled residents (Resident 12, Resident 84 & Resident 99) when:The facility did not report an allegation of abuse involving Resident 99, and;The facility did not report a resident-to-resident altercation between Resident 12 and Resident 84. These failures had the potential to result in delayed identification and intervention regarding abuse, increased risk to resident safety, and noncompliance with regulatory reporting requirements, potentially compromising the well-being and protection of vulnerable residents within the facility. A review of Resident 99's admission Record (facility demographic) indicated Resident 99 was admitted to the facility on [DATE] and passed away on 3/13/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive, person-centered nursing care plans for two of two sampled residents (Resident 26 and Resident 43), related to:Lack of post-fall care plan interventions for Resident 26,Repeated medication refusals by Resident 26, and;Resident 43's fluctuating psychosocial (define) and behavioral patterns, including prolonged bed stay and limited activity participation. These findings may have resulted in Resident 26 being placed at increased risk for additional falls, injuries, or even death. The lack of appropriate interventions could have contributed to ongoing medication refusals, which may have worsened Resident 26's chronic health issues. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of six sampled residents (Resident 26, Resident 54 and Resident 81) remained free of accidents when they did not received adequate supervision to prevent falls, resident-centered nursing care plans were not developed prior or after the falls, post-fall assessments or neurological checks (rapid nursing assessments to detect brain injuries or spinal issues after a fall) were not completed, and interdisciplinary team meetings (IDT) were not held to identify the root cause of the falls. These failures could have resulted in serious harm or injury to the residents, including increased risk of falls, potential physical trauma, prolonged recovery times, and diminished quality of life. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents' nutritional needs were recognized and evaluated upon admission for four out of six sampled residents (Resident 20, Resident 31, Resident 78, and Resident 79) when the clinical record for each resident lacked evidence of a nutritional assessment completed at or shortly after admission as required to identify weight history, diet orders, allergies, swallowing risks, and nutrition related diagnoses. This failure resulted in delayed evaluation of dietary requirements, risk factors, and nutritional status for four residents and placed them at risk for unmet nutritional needs, delayed therapeutic diet implementation, and decline in nutritional status. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pain was adequately assessed, monitored, and managed for two of 38 sampled residents (Resident 26 & Resident 64) who suffered from high levels of pain. These findings may have resulted in the residents experiencing untreated or undertreated pain, delayed recognition of injury, decreased comfort, and reduced functional ability. A review of Resident 26's admission Record (facility demographic) indicated she was admitted to the facility on [DATE] with diagnoses which included dementia (a significant decline in memory and thinking abilities that disrupt daily activities), history of falls, and difficulty walking. Record review of a nursing progress note dated 3/19/26 at 2:20 a.m. indicated Resident 26 was found on the floor next to the bathroom door. [...]

Inspectors wroteBased on interview and record reviews, the facility did not engage in a program to prevent or minimize adverse consequences related to medication therapy for five Residents (Resident #86, Resident #4, Resident #78, Resident #5, and Resident #81), when there was a lack of documented engagement and response between Pharmacy, Nursing and Medical Director for the Monthly Medication Review. This failure had the potential to lead to ineffective management of resident medications and ineffective communication among the resident care team. During a concurrent interview and record review on 3/25/26 at 4:15 p.m., with DON (Director of Nursing), the Gradual Dose Reduction (GDR) Request Binder document indicated the following Pharmacist Recommendations: Resident #4 GDR requests on 5/25, 6/25, 2/26 were not documented as either agree or disagree by Medical Director. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were implemented as required for six of six sampled residents (Resident #7, Resident #12, Resident #41, Resident #45, Resident #69) when:Ten missed hand hygiene opportunities were identified during medication pass observations, in which licensed nursing staff did not perform hand hygiene before or after resident contact and before medication preparation or administration, and;A Licensed Nurse failed to change gloves after contact with soiled materials during a tube feeding medication pass, when she handled a soiled towel and then proceeded to administer medications without removing gloves and performing hand hygiene. These deficient practices had the potential to contribute to the spread of infections among a vulnerable resident population. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an abuse allegation involving staff and one of one sampled resident (Resident 99). This failure had the potential to delay the implementation of necessary protective measures and oversight to safeguard the health and safety of Resident 99 and other residents of the facility. A review of Resident 99's admission Record (facility demographic) indicated Resident 99 was admitted to the facility on [DATE] and passed away on 3/13/26. A review of the Social Services Progress Note dated 2/03/26 at 9:08 a.m., indicated the facility was made aware of an allegation relayed by Life Partner 1 that Resident 99 reported two staff members were arguing, got into her face, and spit in her face. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the transfer and discharge of Sampled Resident #94 was documented in the resident's medical record, and appropriate information was communicated to the receiving health care institution and Ombudsman (advocacy agency). This failure had the potential to cause miscommunication, inadequate care and lack of advocacy. During an interview and record review with Medical Records (MR) on 3/25/26 at 12:50 p.m., MR stated Resident #94 was admitted [DATE] and discharged on 12/29/15. She stated the Social Services note indicated he was transferred to the hospital. She stated there was no physician order to transfer, no nursing progress note, no notification to the Ombudsman, and no documentation of where the personal belongings of the resident went. She stated there should be an order from the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #12's enteral feeding (liquid nutrition delivered directly into the stomach or small intestine via a tube for individuals unable to eat enough by mouth to meet their nutritional needs) was administered according to the physician's order and failed to ensure the glucose solution used with the resident's enteral feeding setup was properly labeled. These failures had the potential to result in improper nutrition delivery, contamination, and adverse health outcomes.

Inspectors wroteBased on interview and record review the facility failed to ensure behavioral and mental health services for one of two Sampled Residents (Resident #49). This failure had the potential to affect Resident 49's wellbeing and the potential to cause further trauma. A review of Resident 49's admission record indicated he was admitted on [DATE] with diagnoses of Major Depressive Disorder (a serious mental health condition characterized by persistent sadness, loss of interest in activities, and low energy) and Delusional Disorder (a chronic, rare psychotic condition defined by holding one or more fixed, false, and non-bizarre beliefs). A review of Resident 49's Minimum Data Set (MDS-a resident assessment tool) dated 3/4/26 indicated Resident 49 had a BIMS score of 15 indicating no cognitive impairment. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that medications were stored in a secure manner when 1. medications were left unattended on a medication cart, 2. loose pills were found at the bottom of multiple medication carts, 3. an open date on a medication was illegible, 4. a Licensed Nurse did not know how to dispose of wasted medications, 5. medication carts were observed unlocked and unattended on two occasions, and 6. an emergency medication kit (E Kit) was observed open and accessible. This deficient practice has the potential to affect all residents who rely on the integrity and safety of the facility's medication supply when residents, staff and visitors could access unattended medications which could result in accidental ingestions of medications and medications getting lost and misplaced and not available for residents who need them.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident 64 could attend a much-needed medical appointment when no transportation was arranged causing the appointment to be cancelled and subsequently never rescheduled. This failure directly affected Resident 64's access to care and a pain management program. A review of Resident 64's admission record indicated he was admitted on [DATE] with the diagnoses of person injured in an MVA (motor vehicle accident), multiple fractures of ribs, pain in unspecified joint, pain in both shoulders, muscle spasm, and dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide privacy and confidentiality for one of four sampled residents (Resident 2), when the facility physician conducted Resident 2's medical examination in a group setting, in front of other residents. This practice resulted in Resident 2 feeling embarrassed and unsatisfied with physician services, constituted a breach of Resident 2's confidentiality and may have adversely affected the quality of the diagnostic process. A review of Resident 2's admission Record (a facility demographic), dated 2/25/26, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including morbid obesity (an abnormally high body mass), depression (persistent, overwhelming feelings of sadness) and epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan focused on safety and monitoring for one of three sampled residents (Resident 1), who had reported experiencing suicidal thoughts (suicidal ideation). This finding may have resulted in failure to identify warming signs, insufficient risk reduction strategies, inadequate supervision and lack of essential safety measures, which could have contributed in Resident's suicide occurring just weeks after expressing suicidal ideation. A review of Resident 1's admission Record (facility demographic), dated 2/24/26, indicated he was admitted to the facility on [DATE], with diagnoses including malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it receives), difficulty walking, muscle weakness, and repeated falls. Resident 1 was [AGE] years of age. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement measures to prevent an elopement for one of three sampled residents (Resident 1), when he was observed in front of the facility without staff assistance. This failure had the potential for injury from falls and other negative impacts on Resident 1's safety and security.

Inspectors wroteBased on interview and record review the facility failed to follow their smoking policy for one out of two sampled residents (Resident 3), when one unlicensed staff was vaping (the action of inhaling and exhaling vapor containing nicotine and flavoring produced by device designed for this purpose) in Resident 3 ' s room. This failure had the potential for Resident 3 to have vapor inhalation health consequences.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services that meet the needs of the residents when two of four sampled residents (Residents 1 and 2) did not receive their medications in a timely manner. These failures were not in alignment with the facility policy and procedures and had the potential to not meet the residents' therapeutic needs which could lead to the worsening of their health conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 24 sampled residents (Resident 28 and Resident 15) and one discharged resident (Resident 233) who were at risk for falls and had a history of falls, were provided with supervision by direct care staff, and had effective revisions and implementation of their nursing care plans to prevent further falls to keep them safe. Facility policies on safety and management of falls were not followed. As a result, Resident 28, Resident 15 & Resident 233 suffered falls with major injuries at the facility. This may have contributed to Resident 233's death, and Resident 28's dramatic decline, as she is now expected to pass away within 6 months. [...]

Inspectors wrote5. Record review indicated Resident 25 was admitted to the facility on [DATE] with medical diagnoses including Dementia (Memory loss) and Heart Failure (Inability for the heart to pump enough blood to meet the body's needs) according to the facility Face Sheet. During a dining observation on 6/10/24 at 1:03 p.m., Resident 25 had just finished eating, and was observed leaving the social dining room. Resident 25 had consumed approximately 10% of her lunch meal. Resident 25 appeared extremely thin and frail, with merely skin covering her bones. Record review of a facility document titled, Weights and Vitals Summary, indicated Resident 25's weights were the following: 12/05/23: 110.1 lbs. 1/04/24: 100.6 lbs. (Weight loss of 8.6%) 2/06/24: 100 lbs. 3/04/24: 92 lbs. (Weight loss of 8% in 28 days, 16.43 % weight loss since 12/05/23) 4/08/24: 91.3 lbs. 5/06/24: 88.9 lbs. [...]

Inspectors wroteFindings: Multiple observations, interviews and record reviews (Reference Federal Tags F550, F674, F584, F641, F656, F657, F658, F677, F687, F695, F710, F725, F761, F791, F800, F801, F804, F812, F835, F842, F865, F867, F868, F880 and Substandard Quality of Care Federal Tags F689 & F692) during the recertification survey conducted from 6/10/24 at 8:45 a.m. to 6/24/24 at 4:48 p.m., demonstrated the facility's actions, inactions and decisions, contributed to a facility in which residents were seriously harmed (F689 & F692), residents were not treated with dignity and respect (F550 and F584), residents did not receive the care and services they needed (F677, F687, F791 & F725), meals were not palatable, stored or prepared in a sanitary manner (F800, F804 & F812), medications were not stored properly (F761) and resident care plans were not created or revised (F657 & F658). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident food was stored, prepared, and served in a sanitary manner when the kitchen was found not clean, unorganized, containing expired, spoiled and moldy food items, and lacking documentation for the food thermometer calibtation log. These failures had the potential to result in foodborne illness and spread infections to 80 of the 81 residents living at the facility, with the exception of Resident 68, who received formula feedings (liquid nutrition delivered to the resident directly to the stomach using specialized medical equipment).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 15 out of 81 residents (Resident 25, Resident 68, Resident 6, Resident 12, Resident 55, Resident 29, Resident 40, Resident 35, Resident 3, Resident 65, Resident 21, Resident 46, Resident 50, Resident 2, & Resident 58) were treated with dignity and respect when: 1. The facility did not ensure Resident 25's sweater was changed after becoming soiled with food particles. 2. The facility did not ensure Resident 68 was given a timely notice, and agreed to a room change, prior to transferring him to a new room. 3. Resident 6's toenails were not trimmed for months, which caused her discomfort while wearing shoes. 4. Resident 12's soiled clothing and disposable brief were not changed for several hours. 5. [...]

Inspectors wroteBased on interview and records review, the facility failed to provide seven of seven residents (Resident 21, Resident 6, Resident 46, Resident 50, Resident 2, Resident 58, and Resident 25) the contact information of the California Department of Public Health where they can file complaints regarding possible abuse, neglect, exploitation, amongst other possible violation of state or federal regulations. This failure left the residents not knowing and deprived them their right to be able to formally file a complaint to the State about the care they were receiving at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the environment was kept free of offensive odors throughout the building. At all times of the day, an unpleasant smell which consisted of feces, urine and strong body odors permeated the air inside the facility. This finding had the potential to result in discomfort, headache, nausea, eye and nose irritations, among many other symptoms, to the residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS-a resident assessment and care screening tool) for one of 23 sampled residents (Resident 12) under Section K (Swallowing/Nutritional Status), by not indicating Resident 12 was on a physician-prescribed weight loss plan. This had the potential to cause errors in Resident 12's medical treatment in order for Resident 12 to maintain an ideal physician direct weight loss recommendation order below 200 pounds (160-190 pounds) and an appropriate care plan with the necessary interventions to address nutrition. This could have further caused increased debilitating conditions, affecting Resident 12's health and quality of life.

Inspectors wrote5. During initial tour and interview on 6/10/24, at 10:28 AM, Resident 127 was in bed with O2 via nasal canula dispensing oxygen at 2 LPM. There was no label on the oxygen tubing. During an observation on 6/10/24, at 5:25 PM, Resident 127 was seated in her wheelchair in the hallway across the nurses' station without oxygenation. During an observation on 6/12/24, at 12:20 PM, Resident 127 was not in her room, but her O2 concentrator continued dispensing O2 at 2LPM with the oxygen tubing and nasal canula lying on top of the bed cover. A review of Resident 127's Change of Condition Summary dated 6/7/24, indicated she had shortness of breathing (SOB) and had an O2 saturation of 77%. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure their policy was followed and comprehensive care plans for 2 of 24 sampled residents (Resident 28, Resident 51) were reviewed and revised after every fall at the facility. This failure resulted in the resident's care not being reviewed by the interdisciplinary team to mitigate additional falls, and had the potential to result in low quality of care, harm and death to the residents involved.

Inspectors wroteBased on interview and record review, the facility failed to monitor and follow the physician orders and facility's Protocol for Constipation for two of 23 sampled residents, (Resident 29 and Resident 33), leading to Resident 29 and Resident 33 not having a bowel movement (BM) for several days. This had the potential for Resident 29's and 33's abdomen feeling full, bloated, and in pain, hard stools causing hemorrhoids (swollen veins in your lower rectum), unexplained weight loss, amongst other health issues, which could lead to Resident 29 and Resident 33 being hospitalized .

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure seven of 23 sampled residents (Resident 232, Resident 14, Resident 67, Resident 4, Resident 12, Resident 20, and Resident 29) received assistance with activities of daily living (ADLs-Activities related to personal care such as showering, grooming, toileting, etc.,), when: 1. Resident 232 was left with a soiled disposable brief for a prolonged period of time, which damaged the skin underneath severely. This failure had the potential to result in infections and development of pressure injuries, and may have contributed to the severe pain Resident 232 suffered at the end of his life. 2. Resident 14, who required assistance with ADLs was not provided with frequent incontinence care (Cleaning and drying of the genital areas of a resident with loss of bowel and bladder control) and repositioning. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure they had enough staff to: 1. Promptly respond to call lights of 4 of 24 sampled residents (Resident 35, Resident 3, Resident 25, and Resident 50), and one unsampled resident (Resdient 40) causing residents to wait long periods of time. 2. To meet the ADLs (Activities of Daily Living: are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and assisted with eating or needing to be fed) needs of the residents, including Resident . 3. To provide prompt incontinence care (cleaning the private areas of residents with loss of bowel and bladder function) to one of 24 sampled resident (Resident 14) and discharged Resident 232. This failure resulted in: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 18 of 81 residents at the facility (Resident 41, Resident 7, Resident 28, Resident 13, Resident 45, Resident 2, Resident 29, Resident 38, Resident 23, Resident 229, Resident 128, Resident 39, Resident 227, Resident 231, Resident 6, Resident 34, Resident 16 & Resident 62) were served their prescribed diets without errors, by dietary staff when errors were noted prior to the trays being delivered to the residents. In addition, Licensed Nurses were observed checking only the trays of residents eating in the social dining room, but no Licensed Nurses were observed checking the trays of the residents eating in their rooms. These failures had the potential to result in nutritional problems and episodes of chocking for the residents involved, which could have resulted in death.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of four kitchen staff (Dietary Aid R, Dietary Aid S, Dietary Aid T, and Dietary Aid U) were knowledgeable of the cooling process for leftover food, thawing process for frozen food, and 3-step process to manually wash, rinse, and sanitize dishware correctly. These findings had the potential to result in foodborne illnesses and spread of infections to all residents of the facility except for Resident 64, who did not eat by mouth.

Inspectors wroteBased on food production observation, dietary staff interview and departmental document review the facility failed to ensure staff competency during food production activities when standardized recipes were not used. Failure to utilize and follow standardized recipes may result in compromised quality and altered nutritional content of prepared meals, potentially resulting in decreased meal satisfaction, and inability of the facility to meet the nutritional needs of residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to offer attractive and palatable meals to 80 of 81 residents (All residents of the facility except for Resident 68 who used formula feedings [liquid formula delivered directly into a person's stomach through medical equipment). The food was noted to be lacking flavor, and the vegetables were previously frozen and then overcooked, leading to loss of nutritive value. This failure had the potential to result in weight loss issues, malnutrition and low quality of life to the residents of the facility as food and drinks were attractive, palatable and served at appetixing temperature.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medical documentation was complete and accurate for 2 of 2 sampled residents (Resident 25 and Resident 29) when: 1. Resident 25, who had a significant weight loss of more than 20% in 6 months, did not have complete documentation of her meal consumption for the month of May, 2024. 2. Resident 29, who had severe weight loss of 15.86% in six months, meal intake was not being monitored closely from 3/19/24 -6/19/24. These findings had the potential to result in insufficient information for the interdisciplinary team to track the care being provided to the residents, and the ability of the residents to meet their healthcare goals which could have resulted in low quality of care and harm to the residents involved.

Inspectors wroteBased on interview and record review, the facility failed to establish, implement and maintain a QAPI/QAA program (Quality Assurance Performance Improvement/Quality Assessment and Assurance-A program that involves a systematic approach to quality assurance and performance improvement. It is designed to identify areas of improvement and develop strategies to improve the quality of care provided to the residents) that identified system-wide problems and reassessed the effectiveness of their interventions to correct quality deficiencies. The facility failed to maintain documentation of an effective, comprehensive and data driven QAPI program that involved the govening body and executive leadership when the person responsible for the QAPI program's development was the Director of Nursing (DON), and no QAPI meeting minutes and documentation were maintained and provided. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective facility wide Quality Assurance Performance Improvement (QAPI) program that included the required members for the QAPI meeting, responsible for identifying significant resident safety and care issues, and failed to ensure that performance improvement activities fully evaluated the depth and scope of the issues, developed a plan to correct identified issues, implement the plan and monitor the results of the facility plan and make changes if the plan was not effective. 1. Lack of Infection prevention input and data to monitor Hand Hygiene for staff and residents (Cross-Reference F8800. 2. Lack of monitoring of Activities of Daily Living (ADL) to ensure residents were receiving two showers a week, and the documentation appropriate and accurate (Cross-Reference F677). 3. [...]

Inspectors wroteBased on interview and administrative document review, the facility failed to ensure it had an effective Quality Assurance Performance Improvement (QAPI) program when the Medical Director or designee did not consistently attend meetings. This failure to have required committee members consistently attend meetings had the potential to result in lack of facility identification of significant resident safety issues, developing a plan to correct identified issues, implementing the plan, and monitoring the results which had the potential to affect the outcomes, dignity, and safety of facility residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff practiced hand hygiene and encouraged resident to wash or wipe their hands with wet washcloths before and after meals when: 1. Five residents (Resident 13, Resident 64, Resident 3, Resident 9, and Resident 63) were served their lunch trays without washing or wiping their hands clean before eating. 2. None of the residents in the social dining room were observed being reminded about hand sanitation prior to their meals, or provided hand sanitation supplies. 3. Staff used the same gloves while feeding three residents at the same time and staff helped various residents with their meals without hand sanitizing in between. This failure can result in the spread of infection or an outbreak among the already frail health of the residents and staff in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 23 sampled residents (Resident 51) clinical record included a physician discharge order, a completed signed Discharge Assessment and a physician Discharge Summary of Care. The lack of completed discharge documentation had the potential to result in the lack of communication between the facility, the physician, and Resident 51 and/or Resident 51's responsible party, and a potential to affect continuity of care, such as Resident 1's overall readiness for discharge, medication, activities, diet, and/or follow-up visits, which could have impacted Resident 51's continuity of care leading to an unsafe discharge to home. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper foot and toenail care was provided for one of 23 sampled residents (Resident 6) when Resident 6's toenails had grown long and thick, Resident 6 was complaining her feet hurt when she wore her shoes and Resident 6 needed a Podiatrist to cut her toenails because they had become too thick for the nurse to cut. In addition, Resident 6's feet looked severely dry and cracked preventing Resident 6 from maintaining the highest practical level of functioning and was at increased risk for foot complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor one of two sampled residents (Resident 6), who was on continuous oxygen (O2) therapy (supplement O2) at 2 liters (L), portable O2 tank to make sure Resident 6's O2 tank was changed before it ran out of oxygen. This failure resulted in Resident 6's O2 tank running out of oxygen while Resident 6 was in her wheelchair propelling herself in the hallway, which could have led to Resident 6 becoming short of breath, which could have led to respiratory distress, a decline in Resident 6's health and possible hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the temperatures of 2 of 2 medication refrigerators (Refrigerator A and Refrigerator B) in the medication room of the facility, were within normal range to store resident insulins (Injectable medication to lower blood sugar levels) and COVID-19 vaccinations, among other medications. In addition, two expired medications were found stored with active medications in the medication room and one of the medication carts of the facility. This finding had the potential to result in medications and immunizations that were no longer effective, causing harm to the residents involved.

Inspectors wroteBased on interview and record review the facility failed to provide dental services for one of 23 sampled residents (Resident 33) who needed to see an oral [NAME] for a revisit. This failure had the potential for Resident 33 to experience intermittent oral pain, problems with eating, speaking and infections of the mouth if Resident 33's oral surgeon appointment was missed and decrease Resident 33's optimal physical, social, mental and psychosocial well-being.

Inspectors wroteBased on general kitchen observation and maintenance staff interview the facility failed to maintain the physical environment of dietetic services as evidenced by standing water in one of the floor drains and missing tiles in the dry storage area.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain effective infection prevention and control practices when: a. A symptomatic COVID-negative resident (Resident 36) was cohorted with a confirmed COVID-positive roommate (Resident 15) in the Red Zone, b. Three resident visitors were wearing inappropriate PPE during their visits, c. Surgical masks were improperly worn by multiple staff, d. Staff were touching residents' face masks without performing hand hygiene, e. A staff did not doff his PPE before leaving an isolation room, f. A staff was wearing a cloth mask in the facility, g. A bearded staff was wearing an N95 respirator mask and working in an isolation room, h. PPE signs were not posted outside of an isolation room, i. Vaccination status of facility visitors were not verified, j. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an effective and inclusive call system. This failure led to delays for expressions of frustration and feelings of neglect by the delayed provision of care for residents, and increased the potential to negatively affect the psychosocial well-being of all 61 vulnerable residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment when: 1. A room housing two residents (Resident 15 and Resident 36), had overflowing bins of trash and soiled linens, from which strong, offensive, and fetid smells originated. In this same room dry, urine-appearing (yellow) stains were observed on the floor. 2. Hallway carpets were soiled, stained, and appeared unvacuumed, 3. Three resident rooms had sticky floors (Rooms 107, 113 and 136) and dirty fall mats (rooms [ROOM NUMBERS]), 4. The building's central linoleum flooring was cracked and dingy, and 5. The shower room had cracked, discolored tiles, and peeling paint. [...]

Inspectors wroteBased on interview and record review, facility failed to appropriately respond to resident abuse allegations for two of three residents sampled for abuse (Residents 207 and 12), when: a. Resident 207's abuse allegation was not promptly reported and investigated, and failed to suspend from duty the staff member who was the alleged perpetrator, and b. The facility failed to complete and maintain documentation of a thorough investigation of Resident 12's abuse allegation, with the alleged perpetrator reinstated back to work after 45 minutes of suspension. These failures had the potential to result in further abuse of Resident 207 and Resident 12, and other vulnerable residents from the staff member.

Inspectors wroteBased on interview and record review, the facility failed to address significant weight loss and provide nutritional and hydration services to one of six sampled residents (Resident 158), consistent with the resident's comprehensive assessment. This failure resulted in significant weight loss, and had the potential to result in further weight loss, malnutrition and dehydration for Resident 158. This finding also may have contributed to Resident 158's rapid decline in April of 2022, which lead to Resident 158's death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy in accordance with standards of practice for two of two sampled residents (Residents 34 and 54) for respiratory care when: a. Resident 34's oxygen was connected to an empty humidifier for two days, and b. Resident 54's oxygen tubing was unlabeled. This failure resulted in Resident 34 to experience dry and painful nostrils (nose) due to inadequately humidified oxygen, and the use of unlabeled oxygen tubing increased the risk for Resident 54 to develop respiratory infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six residents (Resident 158) sampled for pain, received adequate pain management consistent with nursing standards of practice, the resident's individualized care plan and facility policy. Licensed nurses did not implement interventions to reduce her pain, on several occasions when her pain was as high as 8/10 (Pain Scale: a tool health care professionals utilize to help assess a person's pain; the pain scale is from 0 to 10, where 0 is no pain, and 10 is the worst pain imaginable). This had the potential to result in feelings of helplessness, suffering, and extreme discomfort for Resident 158.

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient nursing staff to provide nursing services to ensure resident safety and meet the healthcare needs of the residents, when: a. the facility failed to provide sufficient Licensed Nurses and Certified Nursing Assistants (CNAs) to meet resident's needs; and b. the facility failed to ensure Licensed Staff B had the appropriate competencies and skills to provide care to the resident population. These failures placed residents at risk of not achieving their highest practicable physical, mental, and psychosocial well-being, and placed them at risk of serious harm or death.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Evaluate the competencies of the treatment nurse, and 2. Document medication administration assessments for six residents (Resident 13, Resident 21, Resident 22, Resident 38, Resident 56, and Resident 107) on paper medication administration records when the facility power went down. These failures potentially resulted in the treatment nurse misidentifying a pressure injury (also called pressure ulcers or decubitus ulcers; damage to skin and underlying tissues caused by prolonged pressure on the skin) for Resident 207, and had the potential to negatively affect all residents with skin treatments; and resulted in an incomplete medical record for residents.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure monthly medication regimen reviewsn (MRR) were conducted by the Medical Director (MD) and Director of Nursing (DON) addressing the follow-up recommendations from the pharmacist. These failures had the potential to place residents at risk for harm or adverse consequences from medications administered.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were stored and maintained using safe medication practices when: a. Expired COVID-19 PCR (transcription polymerase chain reaction) test vials were found in the medication refrigerator, b. Medication disposal container in the medication storage room was unsecured, c. Expired medications for one resident (Resident 21) were located on a medication cart, and d. Medications were not re-ordered timely to ensure one resident (Resident 12) received a prescribed dose of medication These failures had the potential to alter the integrity of stored medications and put residents at risk for adverse consequences of medications administered.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure meals were served at appropriate temperatures affecting their safety, attractiveness and palatability. This failure had the potential to result in food-borne illnesses, reduced caloric intake, malnutrition, and weight loss among the residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare meals in a sanitary manner, when: a. Spoiled and expired food was found in the kitchen refrigerator, b. Unlabeled food was found in the kitchen refrigerator, c. The floor in the kitchen and dry storage areas were dirty and sticky, d. Dented cans were found stored along with the canned foods in good condition, e. The facility's ice machine was soiled, f. The toaster in the kitchen was soiled, and g. Two Dietary Aids prepared and served food after contaminating their hands with the lid of a trash can. These failures had the potential to cause foodborne illness and spread of infections to the vulnerable resident population.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive action plans for identification, analysis, correction, and evaluation of systemic care issues, including repeat survey deficiencies. This failure had the potential to prevent timely recognition and improvement of care services that do not meet standards of quality for all 61 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to protect one of 27 sampled residents (Resident 35) from verbal abuse when the two facility staff witnessed a licensed staff (Licensed Staff E) swear at one sampled resident (Resident 35), hit the side of her helmet, and shove her back in her wheelchair. This failure placed Resident 35 at risk for further physical and/or mental health harm from verbal and physical abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to report an abuse allegation timely for one out of one sampled residents (Resident 35). This failure placed Resident 35 at risk for serious physical and/or mental health consequences and potential ongoing abuse for Resident 35 and all residents in the facility when not reported immediately.

Inspectors wroteBased on interview, and record review, the facility failed to provide discharge documentation for one resident (Resident 157). This failure had the potential for Resident 157 to leave the facility without proper care and services to maintain her health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide weekly showers and honor shower requests for two of three sampled residents (Residents 208 and 26) for ADLs (Activities of Daily Living). These failures resulted in residents, who were vulnerable and dependent on staff for ADL care, to be unkempt, feel neglected and unclean, and had the potential to negatively impact the resident's physical and psychosocial wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow-up with a cardiology referral for one of three residents (Resident 41) with an artificial cardiac pacemaker (A small device that's placed (implanted) in the chest to help control the heartbeat), for more than six months after the primary care physician ordered the referral. This failure had the potential to result in malfunction of the pacemaker, delay in care, and possible harm or death to Resident 41.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 24) for dietary services received the meal portions she required. This finding had the potential to result in unintended weight loss, malnutrition, and reduced caloric intake for Resident 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that fluid preferences were honored for one of six sampled residents (Resident 46) for food/fluid preferences. This had the potential to cause nutritional deficiencies, dehydration and weight loss for Resident 46.