Culver West Health Center

Inspectors wroteBased on interview, and record review, the facility failed to complete the Annual Minimum Data Set (MDS-a resident assessment tool) Assessment timely for one of four sampled residents (Resident 4 and Resident 12) according to the facility's policy and procedures (P&P) titled, Resident Assessment Instrument, revised 1/2/2026, This deficient practice had the potential to negatively affect the provision of necessary care and services needed for Resident 4 and Resident 12. Cross Reference F640Findings: During a concurrent interview and record review with Minimum Data Set Coordinator (MDSN) on 7/9/2026 at 3:19 PM, Resident 4 and Resident12's most recent annual MDS assessments were reviewed. MDSN stated Resident 4 and Resident12's MDS was not completed at that time. MDSN stated the annual assessments were started on 6/8/2026 and should have been completed within 14 days (6/22/2026). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one out of the four sampled residents (Resident 4, Resident12) according to the facility's policy and procedures (P&P) titled, Resident Assessment Instrument, revised 1/2/2026, i . This deficient practice had the potential to result in delayed services for Resident 4 and This deficient practice had the potential to result in delayed services for Resident 12. Cross Reference F636Findings: A review of the facility's Centers for Medicare and Medicaid Services (CMS) Submission (transmission) Report dated 7/9/2026, indicated Resident 12's Annual MDS was submitted on 7/9/2026 (31 days after the assessment reference date (ARD), 6/8/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to contact and verify with a physician if one of one sampled resident (Resident 17) can continue to take apixaban (a prescription anticoagulant (blood thinner) 2.5 (dose) milligrams (mg - unit of measure) Atrial Fibrillation (AFib-an irregular and often very rapid heart rhythm which can lead to blood clot formation in the heart increasing the risk of stroke, heart failure and other heart-related complications). This deficient practice resulted in Resident 17 not receiving apixaban after 2/2026 and substantially placing Resident 17 at increased to suffer cardiovascular event, hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the facility kitchen when: Refrigerator 1's internal temperature indicated 45 degrees Fahrenheit (F- unit to measure temperature - 41 degrees F or lower). Freezer 1's internal temperature indicated 10 degrees Celsius (C- unit to measure temperature - 17 degrees C or lower). These failures had the potential to result in cross contamination (transfer of harmful bacteria from one place to another) and an increased risk of foodborne illness (any illness resulting from eating contaminated or spoiled food) to the resident who consumed food from the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services and equipment to improve toileting and toilet transfer abilities for one of four sampled residents (Resident 5) who was continent (having voluntary control of urination and bowel movements) and able to walk and transfer (move from one surface to another) with assistance. [...]

Inspectors wroteBased on observation interview and record review, facility failed to provide a clear and concise policy and procedures (P&P) regarding storage of and accessibility to smoking materials (cigarettes, lighters, matches) for one out of one (1) sampled resident (Resident 17). This deficient practice had the potential to cause inconsistency and confusion for residents and staff by making it difficult to uniformly implement the policy and to ensure safety and compliance. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise the comprehensive care plan for one of four sampled residents (Resident 5) by failing to discontinue the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) plan of care when Resident 5 was discharged from OT services on 3/22/2026. This deficient practice resulted in staff confusion of services provided and had the potential to negatively affect the delivery of necessary care and services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services and equipment to improve toileting and toilet transfer abilities for one of four sampled residents (Resident 5) who was continent (having voluntary control of urination and bowel movements) and able to walk and transfer (move from one surface to another) with assistance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of one (1) sampled resident (Resident 17) with the opportunity to make choices about aspects of his (Resident 17's) care planning that is significant to the resident overall health and well-being according to the facility's policy and procedures (P&P) titled Resident Rights dated 1/12/2026. This deficient practice denied Resident 17 the right to be informed of and participate in his treatment plan with the potential to affect Resident 17's ability to attain or maintain his highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 6), who was assessed as at risk to develop pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) and was admitted without pressure ulcers, received the necessary care and services to prevent pressure ulcer from developing, by failing to:Prevent Resident 6 from developing a right heel pressure injury while residing in the facilityRevise the resident right heel skin impairment care plan interventions These deficient practices had the potential for Resident 6 not to receive the necessary care and services to prevent the development of pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for two of four sampled residents (Residents 9 and 10) with ROM and mobility (ability to move) concerns by failing to: Ensure Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) provided passive ROM (PROM, movement at a given joint with full assistance from another person) exercises to Resident 9's left elbow and left knee in accordance with physician's orders, dated 2/19/2027. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:A. Ensure the facility staff are provided with one clear policy and procedures regarding whether or not, residents who independently smoked cigarettes, could keep smoking materials, lighters, matches or any other smoking related items as evidenced by the following two conflicting and confusing facility policies and procedures titled:1. Smoking Policy dated 1/12/2026 indicated, Residents are not permitted to keep smoking materials, lighters, matches or any other related items in their possession. Cigarettes, matches, lighters, and other materials will be kept by the designated staff of the facility .2. Smoking Policy-Residents dated 1/12/2026 indicated, Residents who have independent smoking privileges are permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services and equipment to improve toileting and toilet transfer abilities for one of four sampled residents (Resident 5) who was continent (having voluntary control of urination and bowel movements) and able to walk and transfer (move from one surface to another) with assistance. [...]

Inspectors wroteBased on observation interview and record review, the facility failed to:1. Provide appropriate monitoring of insulin for one of five sampled residents (Resident 5).2. Initiate a comprehensive care plan that addressed Resident 5's diagnosis of diabetes or the administration of insulin. These deficient practices had the potential to result in complications from the use of insulin such as hypoglycemia and lethargy.

Inspectors wroteBased on interview and record review, for one of one sampled residents (Resident 99), the facility failed to ensure Certified Nursing Assistant (CNA) 1 followed/verified a physician's order for minced and moist diet (therapeutic diet-a personalized meal plan prescribed by a doctor or registered dietitian to treat a medical condition or manage symptoms) dated 4/8/2026. CNA 1 brought and gave Resident 99 protein bars (a convenient, ready-to-eat snack designed to deliver a concentrated dose of protein) to eat. Resident 99 has a diagnosis of dysphagia (difficulty swallowing). This failure resulted in Resident 99 eating the protein bar/s placing Resident 99 at increased risk for choking, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a garbage dumpster lid completely closed and covered for one of two garbage dumpsters. This failure had the potential to attract pests (any living thing that can spread disease) and spread infection (when harmful germs like bacteria or viruses can enter your body and make you sick) to facility residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 adhered to the facility's professional code of conduct (rules for how employees should behave at work) by not engaging in an inappropriate romantic relationship with one of one resident (Resident 99) according to the facility's Employee Handbook, dated 3/2025 and evidenced by:1. CNA 1 making arrangements with a private transportation company (PTC) to pick up Resident 99 from the facility, transported Resident 99 to a bank in Pasadena 20 miles away from the facility, and transported Resident 99 back to the facility unaccompanied and without supervised, and without the knowledge of Resident 99's family members, and facility staff. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility to ensure the medical record contained sufficient information for one of four sampled residents (Resident 10) was complete by failing to indicate the recommendations and plan of care on the Joint Mobility Assessment (JMA, a brief assessment of a resident's range of motion [ROM, full movement potential of a joint] in both arms and both legs), dated 4/2/2026, for Resident 10, who was identified as having a decline in ROM of both shoulders compared to the previous JMA, dated 9/9/2025. This deficient practice had the potential to delay and negatively affect the delivery of necessary care and services and result in ROM decline leading to contracture (loss of motion of a joint associated with stiffness and joint deformity) development and functional decline for Resident 10.

Inspectors wroteBased on observation, interview and record review the certified nursing assistant (CNA) 3 failed to put on personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before entering a room identified with signage as enhanced barrier precautions() to transfer Resident 3 from bed to chair for one of three sampled residents, Resident 3. This deficient practice placed other residents at risk of transmission of possible bacteria. [...]

Inspectors wroteBased on observations, interview and record review the facility failed to ensure the call light was accessible for one of three sampled residents, (Resident 1). This deficient practice caused Resident 1 to sit in wet diaper from 12:30 am to 6:30 am and further cause burning sensation to buttocks. [...]

Inspectors wroteBased on observation, interview, and record review the Licensed Vocational Nurse (LVN) failed to notify supervision of request for room change for one of four sampled residents, (Resident 2). This deficient practice left Resident 2 in a room across from Resident 4 while Resident 4 constantly yells and screams making it difficult for Resident 2 to sleep. [...]

Inspectors wroteBased on interview and record review the facility failed to document call system inspection monthly per the facility policy. This deficient practice placed the facility at risk for non-functioning call system. On 12/29/2025 The California Department of Public Health (CDPH) received a complaint alleging the call light was not working for 4 weeks. A review of the maintenance log for July, August and September 2025 indicated all the call lights were working. During an interview on 1/8/2025 at 2:00pm with the Maintenance Manager (MM). The MM stated the call lights and call system are checked monthly and should be documented. The MM stated there was no documentation for the months of November and December 2025. A review of the facility's policy and procedures titled, Building Systems Nurse's Call System reviewed 1/2025, the P&P indicated: Nurse's Call System Testing Procedure 1. Check weekly. [...]

Inspectors wroteBased on interview and record review for one of three sampled residents, Resident 1. The registered nurse (RN) 1 failed to review the new dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) transportation method prior to picking up Resident 2 for dialysis on 5/10/2025. This deficient practice caused Resident 1 to miss scheduled dialysis treatment on 5/10/2025 and be sent to the general acute care hospital (GACH) where Resident 1 did not receive dialysis because Resident 1 received it the day before at the GACH.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff consulted with a physician, the Interdisciplinary team (IDT - a group of professionals from different specialties working together to provide care) or the faciity Bioethics committee (a group of individuals, often including doctors, nurses, ethicists, and community members, who help navigate complex moral and ethical questions in healthcare and research) regarding vaccinations for one of five sampled residents (Resident 33) who did not have a resident presentative and did not have the mental ability to make decisions. This deficient practice violated Resident 33's right to be supported and represented supported in making decisions regarding vaccinations.

Inspectors wroteBased on observation, interview and record review, the facility's interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to ensure one out of four sampled residents (Resident 42) had a physician's order for self-administrations, was assessed determined capable to self-administer medications left at the bedside. This deficient practice had the potential for unintended for and unauthorized access to the medications which could result in adverse reactions (any unwanted, unpleasant, noxious, or potentially harmful effect of a drug or medication), unnecessary hospitalization and possible poor outcomes.

Inspectors wroteBased an observation, interview and record review, the facility failed to ensure one out of 25 sampled Residents (Resident 16) was cared for in a manner that promotes, maintains and/or enhances his (Resident 16s) quality of life and individuality by failing to ensure Resident 16 by received routine personal hygiene (nail hygiene) services that meet the needs of residents. This deficient practice and the potential to result in Resident 16's loss of dignity, selfrespect, and identity that allows the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, for two of five residents (Resident 29 and Resident 71), the facility failed to: 1. Label the indwelling catheter (a flexible tube that is used to drain urine in the bladder) bag (a device forcollecting urine) labeled with date and time the facility changed the indwelling catheter bag for Resident 71. 2. Immediately notify a physician of the abnormal lab values for urinalysis (a laboratory test that examines a person's urine to detect any abnormalities or health conditions) and record in the resident's medical record regarding the change in condition evaluation (COC -a noticeable alteration in someone's health or circumstances that could have a significant impact on their well-being or the situation they're in) on 4/21/2025 for Resident 29. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely administer Ertapenem (an antibiotic - medication used to treat severe infections) 1 gram (GM -unit of measure in weight) intramuscularly (IM - inject medication into a muscle) antibiotics (medicines that fight bacterial infections) leading to a nine-day delay of medication administration for Resident according to physician's order for urinary tract infection (UTI - an infection in the bladder/urinary tract) dated 4/24/2025. This deficient practice had the potential to result in hospitalization and/or death for Resident 29.

Inspectors wroteBased on interview and record review, for two of five sampled residents (Resident 26 and Resident 33), the facility failed to assess the individual needs and food preferences to ensure the menus and/or the resident's food plan met the nutritional needs and preferences for Resident 26. This deficient practice had the potential for insufficient food intake and weight loss for Resident 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 66) was served with the correct food portion per facility menu spreadsheet when serving meals to residents on 4/30/2025. This deficient practice had the potential for Resident 66 to suffer unintentional weight loss.

Inspectors wroteBased on observation, interview, and record review, for two of two sampled residents (Resident 19 and Resident 71) the facility staff failed to: 1. Observe infection control measures by failing ensure Certified Nurse Assistant (CNA) 2 put on and use (don) personal protective equipment (PPE- not limited to gowns, and gloves) while providing Activities of daily leaving (ADL- self-care tasks necessary for daily functioning and maintaining independence) to Resident 19 who was on enhanced barrier precaution (EBP- infection control measures that expand the use of PPE, during high-contact resident care activities to reduce the spread of multidrug-resistant organisms (MDROs - These are microorganisms, typically bacteria, that have become resistant to multiple classes of antibiotics). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff consulted with a physician, the Interdisciplinary team (IDT - a group of professionals from different specialties working together to provide care) or the faciity Bioethics committee (a group of individuals, often including doctors, nurses, ethicists, and community members, who help navigate complex moral and ethical questions in healthcare and research) regarding vaccinations for one of five sampled residents (Resident 33) who did not have a resident presentative and did not have the mental ability to make decisions. This deficient practice violated Resident 33's right to be supported and represented supported in making decisions regarding vaccinations and placed Resident 33 at increased risk for in infection and/or hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation for one out four sampled Resident (Resident 19) by failing to ensure the resident's call light was in working condition and within reach. This deficient practice had the potential to negatively impact on the psychosocial well-being of the residents or result in delayed provision of necessary and emergent services.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in multiple resident bedrooms for 37 resident rooms. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the health caregivers.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain essential lifesaving equipment, automated emergency defibrillator (AED, a portable device that can be used to treat a person whose heart has suddenly stopped working) machine at the designated nursing stations, Unit nursing stations and North and South Nursing stations. This deficient practice resulted in delayed life saving measures during Resident 1 ' s emergency resuscitation attempts by the facility staff on [DATE] at 7:34 PM.

Inspectors wroteBased on observation, interview and record review, facility failed to ensure that the Licensed nurse (LVN) notified Resident 1 ' s family member (FM) about a change of condition (COC -a sudden or acute deviation from a patient ' s baseline that may lead to complications or death if left untreated) for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedures (P&P) titled Change of condition management guideline revised 9/11/2023, by failing to notify Resident 1 ' s FM after a COC occurred on 8/6/2024. This deficient practice violated Resident 1 ' s FM ' s right to be notified of Resident 1 ' s care services provided and had the potential to result in lack of proper care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for one of three sampled residents (Resident 1) by failing to ensure Resident 1 ' s call light (a device with a button or touchpad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) was within reach as indicated in the facility ' s Policy and Procedures (P&P) titled Call Light Answering revised on 9/11/23. This deficient practice had the potential for Resident 1 not to receive emergency care or have a delay in care and services that could result in a fall or accident.

Inspectors wroteBased on interview and record review, the facility failed to investigate and report allegations physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one out of three sampled residents (Resident 1) to the Department of Public Health, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedures (P&P) titled Abuse and Crime Reporting effective 9/11/2023, by failing to report the unusual occurrence of a resident-to-resident altercation to the State Survey Agency (SSA) within 2 hours after the allegation occurred on 4/23/2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare and store food in safe and sanitary condition and/or manner to prevent growth of microorganisms when: 1. Hairnets were not worn in the kitchen according to the facility's policy and procedures. 2. Hand hygiene and apron change were not performed during dishwashing when transition from dirty dishes to clean dishes. 3. Drinks and other food items were left at bedside for Resident 33 without proper storage and/or refrigeration for over 14 hours. Those deficient practices had the potential to cause foodborne illness (infections or irritations of the gastrointestinal tract caused by food or beverages that contain harmful bacteria, parasites, viruses, or chemicals) among 75 of 85 residents, who received the food from kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate storage and conduct inventory for personal belongings for homelike environment for one of six sampled residents (Resident 38). This deficient practice resulted in Resident 38 storing personal belongings in several boxes on the floor and the resident complaining of having lost some personal belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide appropriate bed to accommodate one of six sampled residents (Resident 38). 2. Ensure call light was within reach for one of 28 sampled Residents (Resident 29). These deficient practices had the potential to result in Resident 38 developing new pressure injuries (Injury to skin and underlying tissue resulting from prolonged pressure on the skin), and for staff not to meet Resident 29's needs, which could place the resident at risk for incidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for one of six sampled residents (Resident 38). This deficient practice resulted in Resident 38 storing personal belongings in boxes on the floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and identify environmental hazards and risk factors for accidents for one of twenty-eight sampled Residents (Resident 35). This deficient practice had the potential to result in, harm through ingestion of hazardous liquid leading to poisoning and/or allergic reactions (A condition in which the immune system reacts abnormally to a foreign substance), unnecessary hospitalizations, and even death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 65) received continuous feeding of isosource 1.5 (Nutritional formula) as per physician's order, This deficient practice had the potential to cause inadequate nutrition for Resident 65.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that pain was managed in a timely manner for one of four sampled residents (Resident 33). This deficient practice resulted in Resident 33 experiencing unnecessary pain.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to: 1. Provide functioning call light to one of six sampled residents (Resident 37). 2. Ensure call light was within reach for one of 28 sampled Residents (Resident 29). This deficient practice had the potential for staff not to the needs for Residents 37 and 29, which could result in physical and emotional harm to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in multiple resident bedrooms for 38 out of the 38 resident rooms. 30 rooms consist of 2 beds each and 8 rooms consist of 3 beds in each room. This deficient practice had the potential to result in inadequate useable living space for the residents' safety and freedom and working space for the staff to provide resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functioning call light (the primary method of patient-nurse communication in a hospital setting, often used as a measure of nurse responsiveness) for two of five selected residents (Residents 1 and 3). This deficient practice had the potential to result in staff delay in meeting resident's needs for hydration, toileting, and activities of daily living as well as a delay in provision of assistance which may lead to falls and accidents.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report an alleged abuse related missing funds to the state agency (Department of Public Health) within 2hrs after the allegation was reported by Resident 1. This deficient resulted in a delay of an onsite inspection by the Department of Public Health and had potential to place all 77 residents in the facility at risk of elder abuse through misappropriation of funds.

Inspectors wroteBased on interview, and record review the facility failed to provide the care, assistance, and supervision needed to ensure an environment free of risks and hazards for one out of one sampled resident (Resident 1), by failing to safely transfer Resident 1 from the wheelchair to the bed with an ordered Hoyer lift (a patient lift used by caregivers to safely transfer patient) on 1/4/2024. This deficient practice resulted in Resident 1 falling on 1/4/2024 during the transfer sustaining a laceration (deep cut) on the right lateral (outer part) leg with bleeding severe enough to require transport to the hospital.

Inspectors wroteBased on interview and record review, the facility failed to provide reasonable accommodations for resident needs and preferences for one of four sampled residents (Resident 1) by not providing showers as Resident 1 preferred. This deficient practice had the potential to negatively affect Resident 1 ' s wellbeing, level of satisfaction with life, self-worth, and self-esteem due to lack of and/or delay in receiving sufficient services to maintain good grooming and personal hygiene.

Inspectors wroteBased on interview and record review, the facility failed to investigate and report allegations of either verbal abuse (mocking, insulting, ridiculing; yelling, with the intent to intimidate), neglect (failure to provide necessary care and services to avoid harm), or physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one out of four sampled residents (Resident 1) to the Department of Public Health, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedure within five (5) working days of the allegation. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report an allegation of abuse within 24 hours or in accordance with state or federal law for one of four sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect all 84 facility residents from abuse. Cross Reference F609.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident who is incontinent of bowel and bladder receives appropriate treatment and services to prevent reoccurrence of urinary tract infection (UTI - an infection that can occur in any area of the urinary tract, including the ureters, bladder, kidneys, or urethra) for one of four sampled residents (Resident 2) by failing to ensure Resident 2 ' s skin remained clean, dry and free of irritation. This deficient practice had the potential to negatively affect the resident's physical comfort and psychosocial well-being and had the potential for formation of pressure sores (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and a buildup of bacteria and a reoccurrence of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor two of two sampled residents (Residents 1 and 2) for specific target behaviors for the use of Risperdal and Zyprexa (antipsychotic medications used to treat psychosis, a mental disorder characterized by a disconnection from reality) respectively. This deficient practice had the potential to result in overuse of an antipsychotic medication, without adequate indication for use, nonpharmacological interventions, or monitoring for the effectiveness and/or ineffectiveness of the medication; and could increase Resident 1 and Resident 2 ' s risk of adverse drug reactions and potential to not recognize or address the residents ' underlying causes of behavior (e.g., pain, discomfort) or psychosocial stressors (e.g., loneliness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care consistent with professional standards to maintain skin integrity for one of 10 sampled residents (Resident 1) by failing to: 1. Implement the Comprehensive Care Plan for diabetic ulcer (a slow-healing wound that commonly appears on the feet) interventions on monitoring Resident 1 ' s blood sugar to help with wound healing. 2. Ensure that a recommendation of a vascular consult (a doctor who specializes in the treatment of arteries and veins) by the Wound Care Specialist/Nurse Practitioner (WCS) was followed up with the physician to obtain an order after Resident 1 ' s left heel wound size changed from 8/8/2023 with a measurement of 4.2 centimeters (cm, unit of measurement) length by 4.7 cm width and increased size of 4.4 cm length by 5 cm width on 8/15/2023. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the facility pest free (free of cockroaches and flies), maintain the facility clean, prevent pest harborage areas, and maintain an effective pest control program. As a result of the noncompliance, Resident 1 was transferred to the general acute care hospital 1 (GACH 1) on 8/23/2023, and reported maggots (small, wormlike fly larva [a worm-like creature, which emerges from an egg]) were found in Resident 1 ' s left heel wound upon admission in the Emergency Department (ED). Resident 1 needed intravenous (IV - administering fluid medication through a needle or tube inserted into a vein) antibiotics (medication that fight bacterial infection) and amputation (removal of the limb) below the knee (BKA) was performed.

Inspectors wroteBased on interview and record review, the facility failed to implement its incident reporting for residents and visitors ' policy for one of 10 sampled residents (Resident 1) by failing to report an unusual occurrence to the State Survey Agency and send a written report within 24 hours for Resident 1 after they were made aware by General Acute Care Hospital 1 (GACH 1) that maggots were found in Resident 1 ' s left heel wound. This deficient practice resulted in a delay of an onsite inspection by the Department of Public Health and had potential to place other residents at risk for neglect.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 10 sampled residents by failing to implement a comprehensive and resident-centered care plan regarding Resident 1 diagnosis and left heel wound. This deficiency findings placed Resident 1at risk of further delay of wound healing and treatment of the disease.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the appropriate setting of the low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was properly set up for three of 10 sampled residents (Resident 1) according to the residents' needs and professional standard of care. These deficient practices placed Resident 1 at risk to develop a pressure injury (bed sore-localized damage to the skin and or underlying soft tissue over bony prominence) or at risk of poor wound healing of the current pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 10 sampled residents, Resident 1 received the nutritional management for patient with diabetes by administering the ordered enteral tube feeding (TF - a method of supplying nutrients directly into the stomach) formula of Diabetisource (a unique carbohydrate blend includes pureed fruits and vegetables to help with the nutritional management of patients with diabetes or stress-induced hyperglycemia (high blood sugar), instead Resident 1 was observed receiving Fibersource TF (formulated with fiber to meet the nutritional needs for tube feeding patients with normal or elevated calorie and/or protein requirements and has higher carbohydrate content). [...]