Cupertino Healthcare & Wellness Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards for five out of five residents (Residents 1, 2, 3, 4, and 5) when social services did not follow up with the psychologist (a mental health professional with a doctoral degree in psychology who focuses on behavior, emotions, and though patterns)/psychiatrist (a medical doctor that focuses on physical and biological causes of mental health) consultation (psych consult - mental health consultation or initial intake meeting) and treatment as ordered by their physician. These failures had the potential to affect Residents 1, 2, 3, 4, and 5's psychosocial needs and behavioral well-being.

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of three residents (Resident 1) when Resident 1's diclofenac sodium (Brand name is Voltaren, a drug used to treat mild to moderate pain, and helps to relieve symptoms of arthritis such as inflammation, swelling, stiffness, and joint pain) was not available for administration on 2/9/2026 at 5:00 p.m. and 2/10/2026 at 9:00 a.m. This failure had the potential for unrelieved pain, inflammation, and stiffness.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 1) out of 6 sampled residents was free from physical abuse when a staff physically hit Resident 1 on the face. This failure resulted in a slap on the right side of the face of Resident 1 by CNA A which was witnessed by CNA B. This failure had the potential to put Resident 1 in psychosocial distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the kitchen when:1. A peeled/sliced peaches was beside the red and green bucket at the three-compartment sink tap;2. Two kitchen staff did not perform handwashing/ hand hygiene before and after gloving; and 3. An open box of Almond nondairy beverage was inside the residents' refrigerator with an open date of 12/18/25 and use by date of 12/21/25 and still there on 12/22/25. These failures had the potential to cause food contamination and spread food-borne illnesses to residents who received their food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure refuse materials (any disposable materials, which include recyclable and non-recyclable materials) were disposed properly when One of two garbage dumpsters were found to be overflowing, and garbage bags were found on the floor outside the containers. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on interview and record review, the facility failed to have a valid copy of a resident's Physician Orders for Life-Sustaining Treatment (POLST, a written medical order that assists people in making decisions about medical treatment and life saving measures during end-of-life care or medical crisis) when one of 31 sampled residents (Resident 3) had a POLST with no signature and identity of the person who discussed it. This failure had the potential to result in a resident's end-of-life choices not being honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Residents 151) had the baseline care plan completed within 48 hours of admission. This failure had the potential for the facility staff not to meet the residents' immediate care needs and safety against adverse events that are most likely to occur right after admission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized, resident-centered care plan for two of two residents (Residents 20 and 3) with a sitter (a caregiver who provides companionship and supervision to patients who need constant observation or assistance, often due to medical conditions or behavioral issues that could pose a risk). This failure had the potential not to meet care needs appropriately for Residents 20 and 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure enteral feeding (the delivery of nutrients through a feeding tube directly into the stomach) was provided with appropriate care and services when an enteral feeding was found to be running for more than 24 hours for one (Resident 13) out of 31 sampled residents. This failure had the potential to put Resident 13 at risk for enteral feeding complications such as tube clogging/displacement, fluid overload, abdominal distention and infections. During an observation on 12/16/25 at 9:22 a.m. at Resident 13's bedside, Resident 13 was on the bed with eyes closed and noted rise and fall of the chest. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the daily staffing information was posted in a clear and readable format and in a prominent place readily accessible to residents, staff, and visitors. This failure had the potential to result in staffing misinformation for residents, families, and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate account of controlled drugs was maintained and periodically reconciled when Clonazepam (medication used to prevent and treat anxiety disorders, and seizures) was dispensed but was not recorded in the Narcotics Record book for one (Resident 65) out of 31 sampled residents. This failure had the potential for diversion of controlled medications. During a concurrent observation and record review of Station 2 medication cart on 12/16/25 at 11:29 a.m. with Registered Nurse (RN) B, RN B verified Narcotics Record book indicated Resident 65 had 16 remaining Clonazepam pills dated 12/15/25 at 5:20 p.m. RN B also verified Clonazepam blister pack for Resident 65 had 15 pills. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure irregularities were identified during drug regimen review for the medication Lurasidone (an antipsychotic medication, works by rebalancing important natural substances in the brain called dopamine and serotonin to improve thinking, mood, and behavior) for one (Resident 17) out of 31 sampled residents when adequate monitoring for the medication was not done. This failure had the potential to compromise the physical, social, and mental well-being of Resident 17. A review of Resident 17's medical records indicated an admission date of 4/28/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when:1. Opened eyedrop medications without open and discard date labels, an eyedrop medication past discard date, and an opened Phenytoin Oral Suspension (a medication used for seizures) without open date label were found.2. Insulin pen without opened date label and an expired inhalation solution (medication used to keep airways open and to control and prevent symptoms like wheezing, shortness of breath, coughing and chest tightness) were found.3. Insulin pen without open and discard date was found. These failures had the potential for residents to receive medications with reduced efficacy.1. During a concurrent observation and interview regarding Station 5 Medication Cart on [DATE] at 10:04 a.m. [...]

Inspectors wroteBased on observations, resident and staff interviews, and facility document review, the facility failed to provide food that was palatable. This failure places all residents who eats food from the facility's kitchen at risk for poor food intake which may compromise their nutritional status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were implemented when:1. Housekeeper J (HK J ) did not wear the proper personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when mopping inside a the room of cohorted (joined together) residents (Resident 62 and Resident 1) who were on contact precautions (extra steps, like wearing of gloves and gown, needed to stop the spread of germs by touch) and enhanced barrier precautions (EBP, an infection control measures in nursing homes to stop the spread of multidrug-resistant organisms [MDROs]), and did not perform hand hygiene upon exit of the room. Resident 62 was on contact precautions for C. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to provide services according to professional standards for one of two sampled residents (Resident 1) when: 1. Licensed vocational nurse A (LVN A) crushed all of Resident 1's morning medications, mixed them with oatmeal, and left them at Resident 1's bedside; and 2. Certified nursing assistant B (CNA B) administered crushed medications, mixed with oatmeal to Resident 1. These failures had the potential to affect Resident 1's care, health, and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident 1) out of three sampled residents was provided needed care and services in accordance with professional standards of practice when Resident 1 did not receive urology (a medical specialty that focuses on the diagnosis and treatment of disorders related to the urinary and reproductive systems) consultation as ordered by the physician. This failure resulted in Resident 1's prolonged use of indwelling urinary catheter [thin, flexible tube inserted into the bladder through the urethra to collect and drain urine] and placed Resident 1 at risk for urinary tract infection and delayed urology evaluation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure treatment and care provided were in accordance with professional standards of practice when one (Resident 1) out of three sampled residents was left with their oral medication to be taken unsupervised at bedside and was documented as given without confirmation. This failure resulted in inaccurate documentation of correct time of medication administration and had the potential for a missed dose.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient and appropriate social services were provided for two (Resident 7 and Resident 10) out of 12 sampled residents when psychosocial and emotional assessments were not done following a resident-to-resident altercation. This failure had the potential for psychosocial decline of the residents that can affect their overall health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff honored one of two residents (1) preferences when the social services assistant (SSA) did not assist Resident 1 to choose another physician. This failure had the potential to compromise resident rights. Review of Resident 1's admission Record (part of the medical record that documents patient information) indicated he was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of Ankylosing Spondylitis of the Spine (an inflammatory arthritis affecting the spine and large joints). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/12/24, indicated the resident was cognitively intact (mental process used to think, learn, remember, reason, pay attention, and ultimately, comprehend information and turn it into knowledge). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to obtain prescription eyeglasses for one of four sampled residents (Resident 1). This failure resulted in Resident 1's impaired vision and had the potential to result in decreased participation in activities requiring visual acuity.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their elopement care plan for one of three sampled residents (Resident 1). This failure had the potential to result in another incident of Resident 1's elopement to unsafe place.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from abuse when the two residents were not separated after the incident. This failure resulted in Resident 1 was feeling terrified and was not able to sleep after the incident.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement strategies to prevent the spread of coronavirus 2019 (COVID-19, a strain of virus that can cause mild to severe respiratory illness) when one of one resident (Resident 3) was not isolated after testing positive for COVID-19. This failure had the potential to result in the spread of COVID-19 in the facility.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to date open food items and properly store dry food in sealed containers. These deficient practices affected all residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 3 (Residents #50, #65, and #159) of 33 sampled residents.

Inspectors wroteBased on observation, interview, record review, facility policy review, the facility failed to develop a care plan to address the yelling behavior for 1 (Resident #17) of 1 sampled resident reviewed for behavior emotional.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure nail care was provided for 2 (Resident #20 and Resident #93) of 5 sampled residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a root cause was determined for a fall for 1 (Resident #62) of 3 sampled residents reviewed for accidents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure an enteral gastrostomy tube feeding was administered as ordered for 1 (Resident #113) of 1 sampled resident reviewed for tube feeding.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a therapeutic diet were served to 1 (Resident #71) of 33 sampled residents as ordered by the physician.

Inspectors wroteBased on observation, interview, record review, document review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented during indwelling catheter care for 1 (Resident #12) of 1 sampled resident reviewed for urinary catheter.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's drug regimen was free from unnecessary medications when nursing staff did not accurately transcribe (transfer or copy information) from the physician's order to the medication administration record (MAR) for one of two sampled residents (Resident 1). For Resident 1, an order for milk of magnesia (MOM, a laxative used to treat constipation) was incorrectly transcribed onto the MAR and was administered daily instead of every third day. This failure resulted in Resident 1 receiving unnecessary doses of MOM and had the potential to compromise Resident 1's health and safety due to overuse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure routine medication was available for one of two sampled resident (Resident 1). This failure resulted in Resident 1 not receiving the medication which could lead to adverse effects on the health and well being of Resident 1.

Inspectors wroteBased on interview and record review the facility failed to follow professional standards of care when a Braden Scale assessment for pressure ulcer/injury (localized damaged to the skin and/or underlying soft tissue usually over a bony prominence) was not performed until after a resident developed a pressure ulcer for one of two sampled residents (Resident 1) This failure had the potential of not thoroughly assessing the resident ' s risks and in not developing pertinent preventative measures.

Inspectors wroteBased on interview and record review, the facility failed to follow their policies regarding protecting resident's personal property for two of three residents (Resident 1 and 2) when: 1. Resident 1's personal property was not stored securely when the resident was transferred to the hospital. Resident 1's missing personal property was reported and the facility did not take corrective action in a timely manner. 2. Resident 2's Inventory of Personal Effects was not signed when the resident was discharged . These failures resulted in Resident 1's missing cell phone and had the potential to result in personal belongings not accounted for.

Inspectors wroteBased on interview and record review the facility failed to provide necessary treatment for one of three residents (Resident 1) when wound dressing changes (treatments) for Resident 1 was not done for three days and wound dressing changes were not ordered by the physician. This failure had the potential to result in infection, delayed wound healing, and other health complications for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure transportation services was provided to scheduled dialysis (a treatment to remove extra fluid and waste in the blood) appointments for one of three sampled residents (Resident 1), when Resident 1 missed two dialysis treatments for lack of transportation. This failure resulted Resident 1's transfer to emergency room (ER) for dialysis.

Inspectors wroteBased on interview, record review, the facility failed to notify the responsible party (RP, person designated to make decisions on behalf of a resident) of a resident about a change in medication for one of three sampled residents (Resident 1). This failure affected the ability of Resident 1's RP to participate in Resident 1's treatment.

Inspectors wrote4. Review of Resident 117's medical record indicated she had diagnoses including a history of falling, cerebrovascular accidents (CVA/stroke, a condition resulting from a lack of oxygen in the brain potentially causing a loss of sensory and motor function), right hand, right shoulder, right hip contractures (hardening of muscles and other tissues causing rigidity to the joints) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning). Review of Resident 117's MDS, dated [DATE], indicated she was cognitively intact. The MDS also indicated her balance was not steady when moving from seated to standing position and she needed staff assistance during surface-to-surface transfers, such as toileting. [...]

Inspectors wrote3. During the medication pass observation on 7/19/21 at 4:10 p.m. with LVN D, she entered Residents 26 and 69's shared room with a small cup of medications and a 6-ounce cup of water in each hand (two cups in each hand). She was asked to stop and explain the medication administration process. She said she prepared the medications for both residents and was about to give each of them their medications at the same time. She acknowledged preparing and administering medications for two residents at the same time had the potential for medication errors due to resident mix-up. LVN D said she normally prepared medications for one resident at a time. During an interview on 7/20/21 at 12:45 p.m., with the ADON, she said nurses were supposed to prepare and administer medications for one resident at a time to avoid medication errors. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain order and cleanliness in the kitchen area and to ensure that food was stored, prepared, and served under sanitary conditions when: 1. The kitchen environment was not cleaned and orderly; dry food containers and storage were dirty; 2. There were opened, undated and expired food and drinks in the freezer and walk-in refrigerator; unlabeled and undated food in the residents' refrigerator; 3. Kitchen utensils (7 water pitchers and 2 measuring cups) were not air-dried properly; 4. Proper cooling procedures were not observed for the tuna and egg salad; and 5. Med pass supplement was held in room temperature for an extended period of time. These failures had the potential to cause foodborne illness to 130 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain residents' privacy and dignity for eight out of 26 residents (Residents 36, 39, 41, 46, 92, 109, 124, and 327) when: 1. For Resident 92, privacy curtains were not provided by the restorative nurse assistant DD (RNA DD) during care, which resulted in exposing the resident from the waist down to the public view in the hallway; 2. For Resident 46, certified nursing assistant EE (CNA EE) was standing while assisting Resident 46 with her meal and calling her mama; 3. For Resident 109, licensed vocational nurse FF (LVN FF) called Resident 109 love and Resident 109 became upset; 4. For Resident 41, CNA GG called Resident 41 mama and honey when assisting with her meal; 5. For Resident 39, LVN Q called Resident 39 mama during wound treatment; 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, safe, orderly, and sanitary homelike environment for three of five facility shower rooms. This failure had the potential to place residents at risk for injuries and prevent their rights to a comfortable environment. 1. During a concurrent observation and interview with the Maintenance Director (MD), on 7/21/21, at 3:09 p.m. in station 2, the shower room walls had irregularly shaped gray spots and open holes. The MD stated the building was old and the wall was damaged by constant splashing of water during showers. He acknowledged the wall needed to be replaced and repaired immediately. The MD confirmed the wall did not look good and it may possibly cause accidents because the open holes were located at the lower corner of the wall. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their abuse policy and procedure for five out of seven residents (Residents 7, 57,64,78, and 118) reviewed when: 1. Corrective action to not assign male caregivers and care plan for Resident 7 were not implemented; 2. For Resident 57, social services did not conduct three daily visits following an abuse allegation as indicated in the care plan; 3. For Residents 64 and 118, social services did not do psycho-social follow-up after the incident; 4. For Resident 78, licensed nurses did not implement Resident 78's care plan following an abuse allegation These failures had the potential to affect the resident's psychosocial well-being, safety and protection from harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for five of 26 sampled residents (Residents 22, 120, 11, 98 , and 57) when: 1. For Resident 22, facility staff failed to ensure oxygen (a colorless and odorless gas that people need to breath) was administered as specified in the physician's order; 2. For Resident 120, facility staff continued to provide restorative nursing treatment without a physician order and did not follow a physician order to monitor Resident 120's left hand swelling; 3. For Resident 11, facility staff failed to address nail care; 4. For Resident 98, facility staff failed to check the functioning of his low air loss mattress (LAL mattress, special mattress filled with air that reduces pressure) as indicated in the physician's order; and 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving dialysis (removal of waste and excess fluid from the body) treatment received care consistent with professional standards for three out of four residents (Residents 6,7 and 81) reviewed when: 1. For Resident 6, his dialysis communication records (DCR) were incomplete and his physician order, treatment administration record (TAR) did not reflect his current dialysis access site; 2. For Resident 7, her DCR's were incomplete and her care plan did not reflect the dialysis access site and necessary precautions and; 3. For Resident 81, his DCR's were incomplete. These deficient practices had the potential for the residents to be inadequately assessed and be at risk for complications.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 29.03% when nine medication errors occurred out of 31 opportunities during medication administration for five out of seven residents (Residents 29, 40, 57, 117, and 123). The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which resulted in residents not receiving the full therapeutic effect of the medications, and may cause preventable side effects for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 26 sampled residents (Residents 29 and 82) and one resident (Resident 123) were free of significant medication errors. Resident 123 did not receive his pain medication when needed. Resident 29 did not receive his daily sevelamer (a phosphate binder, medication to control high blood level of phosphorus, a mineral found in food, in people with kidney disease who are on dialysis) for more than two months. Resident 82 did not receive his inhalers (to treat breathing problems), Xifaxan (medication to help prevent recurrence of certain liver problems), and gabapentin (nerve pain medication) as ordered. The failures resulted in medications not available to meet the residents' therapeutic needs, and the potential for unnecessary pain and worsening of their medical conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Temperature monitoring was not documented consistently on the temperature log sheets, in July 2021, for four out of four medication refrigerators; 2. Four inhalers were not dated after being opened; 3. Three insulin vials were identified in the active stock, being used beyond the discard (expiration) date; and 4. A non-prescription medication was not properly labeled. The deficient practices had the potential for unsafe and ineffective use of medications due to being unmonitored or used past the expiration date.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient staff to safely and effectively perform the meal preparation and other food and nutrition services for two of 26 sampled residents (Residents 31 and 74) and three residents (Residents 427, 327, and 27). This failure affect the residents' scheduled meal times and had the potential to affect the resident's intake.

Inspectors wroteBased on interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to implement and evaluate systemic measures to ensure oversight of the following: 1. Pharmacy Services (Refer to F760 Residents Are Free of Significant Med Errors and F755 Pharmacy Services) 2 Dialysis (Refer to F698) This failure had the potential to negatively affect the improvement of the residents' quality of care, quality of life and safety in a highly susceptible population of 130 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Staff did not properly wear N95 (a high filtering mask); 2. Rehab staff wore cloth mask as source control; 3. Licensed vocational nurse J (LVN J) wore two pairs of gloves (double gloving) and did not perform hand hygiene in between tasks; 4. Medication and treatment carts' sharps containers were full; 5. LVN BB went in and out of the room wearing a gown in the yellow zone (quarantine unit), applied wound treatment gel using her gloved index finger and did not perform hand hygiene in between tasks; 6. LVN G was wearing KN95 (a respirator that does not meet the US standard) in the yellow zone; 7. LVN Q did not perform hand hygiene in between tasks, and did not wear N95 properly; 8. Rehabilitation staff (RS CC) used hand wipes to clean medical equipment; 9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain two clothes dryer lint traps, power generator, resident refrigerator, and kitchen equipment in safe operating condition. These failures could affect the health, safety, and comfort of all residents, staff, and visitors in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment when cracks and crevices where identified in the kitchen area, and a bed mattress was in the hallway for four days. These failures could affect the health and safety of the residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen was free of pests (flies and fruit flies), and the use of an open bait mouse traps in the kitchen area. These failures has the potential to spread infectious disease to the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to inform Family Member I (FM 1) for one of 26 sampled residents (Resident 124) when he tested positive for Coronavirus disease (COVID-19, a disease caused by a new strain of coronavirus). This deficient practice resulted in FM 1 being unaware of Resident 124's health condition and was not able to participate in his care and treatment. During a telephone interview with Resident 124's FM 1 on 7/23/21 at 9:31 a.m., she stated the facility did not inform her when Resident 124 tested positive for COVID-19 December, 2020. She only came to know the COVID-19 test result information after Resident 124 was hospitalized the following month. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notification to the Long-Term Care Ombudsman (person who routinely visits the facility and advocates for the residents) for two of four sampled residents (Residents 75 and 33) when Residents 75 and 33 were transferred to the acute care hospital. This failure had the potential to result in the residents not having an advocate who could inform them of their admission, transfer and discharge rights and options.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold (written documentation specifying the duration the facility will hold a resident's bed) for two residents (117 and 125). This failure had the potential to result in residents not being able to exercise their rights.

Inspectors wroteBased on an observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) in minimum data set (MDS, an assessment tool) for two of 26 sampled residents (Residents 117 and 125). This was when Resident 125 had significant weight loss, had declined in activities of daily living (ADL, daily self-care tasks, e.g., bathing, toileting, and transferring); and Resident 117 had declined in activities of daily living and new onset of diagnosis. These failures had the potential to result in Residents 117 and 125 to be unable to achieve or maintain optimal status of health, function and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and accurately assess the preadmission screening and resident review report (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI) requires specialized services such as referral to a mental health authority) for two of 26 sampled residents (Residents 71 and 125). This failure had the potential to put the residents at risk for not receiving appropriate care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing activity program to meet the needs and interests for two of 26 sampled residents (Residents 47 and 124). This deficient practice had the potential to affect the resident's psychosocial well-being and self-worth. 1. During an observation on 7/19/21 at 8:38 a.m. in station 5, Resident 47 was sitting on her wheelchair in her room in front of an overhead table. She was alert and verbally responsive and able to engage in simple conversation. She stated she had nothing to do but just to sit in her wheelchair for most of the time. On 7/19/21 at 2:45 p.m., Resident 47 was lying in bed but awake. The television was off and no radio was available. She stated she would prefer to be up and doing something rather than lying in bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to prevent decline in range of motion (ROM, full movement potential of a joint) for one of 26 sampled residents (Resident 34) when staff did not implement Resident 34's care plan to address contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and the facility failed to develop restorative nursing assistant (RNA) services (a program intended to maintain or improve physical function of the body) care plan (it provides direction on the type of nursing care the individual may need) for Residents 31 and 113. These failures had the potential to result in worsening of Resident 34 contractures and had the potential to result in not meeting Residents 31 and 113's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the consultant pharmacist (CP) identified irregularities and make recommendations to the facility during the monthly drug regimen review (DRR); and the CP's recommendations were carried out or had the clinical rationale for not attempting the gradual dose reduction (GDR), for five of 26 sampled residents (Residents 29,31, 57, 82 and 98). This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 26 sampled residents (Resident 29) was free from unnecessary medications. Resident 29 received two medications, vitamin C (a dietary supplement) and zinc sulfate (dietary supplement to treat zinc deficiency) 30 days longer than ordered by the physician. This deficient practice resulted in unnecessary medications for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 26 sampled residents (Resident 82) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors). Resident 82 received Seroquel (an antipsychotic medication) without an adequate indication for use. The failure resulted in unnecessary medication for the resident, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility menus for three residents (Residents 60, 73, 328). This failure could affect the nutritional status of the residents.

Inspectors wroteBased on observation and record review, the facility failed to ensure the dumpster lid was kept closed and the garbage was properly disposed in the trash area. This failure had the potential to attract pests in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate use of antibiotic (medication for infection) for two of three residents reviewed (Residents 25 and 123) when the surveillance data collection form was incomplete and/or not done. This failure had the potential for the resident to take unnecessary antibiotics which could lead to resistance to the antibiotic.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five residents (36 and 81) were offered and/or received pneumococcal vaccinations. This failure had the potential to expose residents to pneumococcal infections (caused by common bacteria [streptococcus pneumonia] that can affect different parts of the body).