Desert Springs Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed appropriate interventions to prevent injuries from repeat fall incidents were implemented, for one of three sample residents (Resident 1). This failure placed Resident 1 at increased risk for serious injury related to falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was free from sexual abuse when there were no interventions developed to protect Resident 1 after Resident 2 subjected the resident to sexual abuse on May 19, 2026. Resident 1 was witnessed by facility staff being kissed and inappropriately touched on the breast by Resident 2. In addition, the facility staff did not immediately intervene when Resident 1 was witnessed being kissed and sexually inappropriately touched by Resident 2. Resident 1 has dementia (a decline in mental abilities which affects memory, thinking, and social abilities), has severe cognitive impairment, and has history of wandering (act of walking, moving and traveling without a specific destination or fixed route, often in an aimless manner). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a referral was sent in a timely manner, to Resident 4's insurance company, for authorization to schedule an oncology appointment for thrombocytopenia (Low platelet count - fragments in the blood that form clots to prevent bleeding). This failure resulted in the delay of Resident 4 from seeing an Oncologist sooner to evaluate his diagnosis of thrombocytopenia.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a homelike environment was provided, for three of three residents reviewed (Residents 52, 53, and 20) when:1. Resident 52 consistently heard yelling or screaming from a confused resident in another room throughout the shift. This failure resulted in Resident 52 experiencing sleep disruption and increased noise levels affecting his immediate environment.2. Resident 53 was not assisted by staff to put away her personal belongings such as clothes and blanket found on the floor of the resident's room. This failure resulted in Resident 53's clothes and blanket left on the floor, creating clutter and making her room less comfortable and homelike; and3. Resident 20's personal credit card was not kept safe and accounted for. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed for 21 out of 21 sampled residents (Resident 176, 164, 12, and 18 residents in 800 hallway), when: 1. For Resident 176, medications scheduled at 9 a.m. were administered outside the facility's medication administration timeframe. This failure had the potential for the medications to be ineffective;2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) services where consistent with professional standards of practice and facility's policy and procedure, for two of five residents reviewed for dialysis (Residents 16 and 137), when:1a. For Resident 16, the dialysis access site was not assessed and maintained. This failure had the potential to result in infection, including bloodstream infection, increased pain, and further decline in the president's health condition.1b. For Resident 16, received more than his physician prescribed 1500 milliliters (ml- a unit of measurement) of fluids per day. This failure placed Resident 16's care needs to go unmet and had the potential to result in fluid overload. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents when the facility did not meet the required minimum of actual total Certified Nurse Assistant (CNA) Direct Care Hours Per Patient Day (DHPPD - measure the numbers of hours of direct care given to residents in skilled nursing facility) of 2.4 hours for the months of November 2025, December 2025, January 2026, February 2026, March 2026, and April 2026. The failure to maintain the required minimum CNA DHPPD hours had the potential to place residents at risk for unmet needs, compromised safety, and decreased quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services were provided to meet the needs of the residents, for four of 13 residents reviewed (Residents 16, 17, 88, and 146), when:1. For Resident 16, the staff did not follow the physician's order when calcium acetate (medication to treat hyperphosphatemia [high phosphate levels] in patients with end-stage kidney disease) was not given with meals. This failure had the potential to reduce its effectiveness as a phosphate binder, placing the resident at risk for elevated phosphorus levels and related complications.2. For Resident 17, a blood pressure medication with holding parameters was not administered in accordance with the physician's order. This failure had the potential to significantly lower blood pressure and could cause dizziness, confusion, fainting, and a fall.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with physician orders and the facility's policies and procedures, when a medication error rate of 16.13% (five medication errors out of 31 opportunities) was identified during medication pass observations, for two of five residents (Residents 17 and 176), when:1. For Resident 176, medications ordered to administer with food were not followed according to the physician's order and manufacturer's guidelines for administration. In addition, medications were administered outside of administration timeframe; and2. For Resident 17, Vitamin D was not administered according to the physician's order. In addition, Resident 17 was not instructed to rinse mouth after administration of an inhalation medication, according to the physician's order and manufacturer's guideline. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in accordance with the facility policy and procedures and the manufacturer's specifications when:1. An opened and uncapped ophthalmic (eye) medication for Resident 103 was stored without an opened date, with the dropper tip covered by tissue, in one of two reviewed medication rooms (Oasis Medication Room);2. Discontinued medications, including controlled substances (CS - medications with potential for abuse and dependence), for Residents 63 and 153 were stored in two of four reviewed medication carts (Dunes and Oasis Medication Carts); and3. Expired house supply medication and inhalers for Residents 140 and 145 were stored with active medications in two of four reviewed medication carts (Oasis and MedBridge Medication Carts). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician-prescribed fortified diet (diet with added extra nutrients to increase the calories and/or protein density to promote improvement in residents' nutrition status) was provided, for four of four sampled residents (Residents 26, 84, 64, and 114) during lunch on April 20, 2026. This failure had the potential to have a negative impact on the residents' nutritional status and further compromise residents' medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy on Meal Service to provide appetizing food at appropriate temperatures according to residents' preferences, for five of 163 sampled residents (Residents 5, 17, 21, 52, and 54). In addition, meal trays were not served timely. These failures placed residents at potential risk for decrease nutritional intake which may affect the residents' overall nutrition status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen, for 163 out of 163 sampled residents who received foods from the kitchen, when:1. A Dietary Aide did not clean dirty meal carts per facility policy and procedure;2. Calcium buildup found on hot waterspouts in the kitchen;3. Two expired sandwiches found stored inside the nourishment refrigerator;4. Dust observed on several pieces of equipment and area in the kitchen; and5. Chipped paint was observed on the water drain found under the 3-compartment sinks. These failures had the potential to result in cross contamination (bacteria are unintentionally transferred from one substance or object to another with harmful effect) and foodborne illnesses (are illnesses that result from ingesting contaminated foods).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment and/or an evaluation for self-administration of medication was completed, for one of 173 residents reviewed for self-administration assessment (Resident 141), when eye drop medications were found at bedside, readily available for use. This failure places Resident 141 at risk for unsafe self-administration of medications and not monitored for potential side effects and drug interactions.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behaviors) medications, for one of five resident reviewed for unnecessary medications (Resident 18), when there was no documented evidence non-pharmacological interventions (NPIs) were attempted, implemented, monitored, or documented as clinically contraindicated. These failures had the potential to place the resident at risk of unnecessary psychotropic medication use and adverse side effects, including sedation and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services needed to perform ADLs ( Assisted Daily Living - fundamental self-care task required for a person to live independently, such as bathing, dressing, eating, and using the toilet) for one of eight sampled residents reviewed (Resident 36), when Resident 36 was not offered supervision and/or assistance on her upper and lower body dressing. This failure resulted in Resident 36 wearing the same clothing outfit from April 20, 2026, to April 26, 2026. In addition, this failure placed Resident 36 at risk of reduced abilities in activities of daily living (ADLs) due to the lack of appropriate assistance needed to prevent such decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment were provided, for two of five residents reviewed for skin management (Resident 95 and 66), when:1. For Resident 95, right anterior wrist skin redness with elevation was identified in a timely manner and was referred to the physician for treatment orders; and2. For Resident 66, the itching with redness on his neck, was identified in a timely manner and was referred to the physician for treatment orders. These failures caused discomfort for Residents 95 and 66 in the affected areas, and had the potential to increase their risk for complications due to delayed treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are free from accidents, for two of three residents reviewed for accidents (Residents 177 and 140), when:1. For Resident 177, 1:1 monitoring ( staff who provides continuous, direct observation for a single patient to ensure safety) was implemented as ordered by the physician. This failure had the potential to place Resident 177 at high risk for harm and accidents; and2. For Resident 140, was not allowed to keep the cigarette and lighter by bedside according to the facility's policy and procedure. This failure had the potential to place Resident 140 at high risk of accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of one sample resident reviewed for nutrition (Resident 12) when:1. The facility failed to monitor the effectiveness of nutrition interventions for Resident 12. This failure had the potential to result in delay in identifying and evaluating the necessity of an alternative nutrition approach; and2. The facility Registered Dietitians failed to follow its policy, WEIGHT CHANGE PROTOCOL to determine if meal intake of Resident 12 would be sufficient to meet Resident 12's nutritional needs. This failure had the potential to result in delay in identifying and evaluating the necessity of an alternative nutrition approach. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's nasal cannula (a medical device used to deliver supplemental oxygen) was changed on a weekly basis according to the facility's policy and procedure, for one of six residents reviewed (Resident 62). This failure had the potential to result in increased risk of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain was assessed and managed, for one of three residents reviewed for pain management (Resident 20) when the licensed nurse did not assess, intervene, and obtain physician orders after the resident verbalized pain. This failure had the potential to result in unrelieved pain, discomfort, decreased quality of life, and decline in physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure laboratory service was provided as ordered by the physician, for one of one residents reviewed (Resident 8), when the urinalysis (a small sample of your urine for signs of infection, kidney disease, or diabetes)/C&S (culture and sensitivity - a laboratory procedure that identifies infectious germs [culture] and determines the most effective antibiotic [sensitivity] to treat the infection) was not obtained as ordered by the physician. This failure had the potential for delayed care and treatment and could affect Resident 8's overall health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dental care services and follow up treatment were provided, for one of three residents reviewed for dental (Resident 128), when there was no follow up dental consult for denture impressions after tooth extractions completed by the dentist on July 31, 2025. This failure had the potential to result in poor nutrition, and further decline in overall health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure special adaptive equipment was provided to be used during meals as ordered by physician, for one of three sampled residents (Resident 62). This failure had the potential to slow down Resident 62's progress to eat independently.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe and sanitary storage, and consumption of food items brought to the residents by family and visitors was implemented according to the facility's policy and procedure. This failure had the potential to lead to food-borne illness in medically compromised population of residents who can consume food.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's rights to privacy was provided, for two of four residents reviewed (Residents 2 and 3), when Resident 1, who was identified with wandering behavior, entered other residents' bedrooms without permission. The failure resulted in Resident 2 and 3's right to privacy being violated and had the potential to affect psychosocial well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment was provided, for two of 20 residents reviewed (Residents A and F), when:1. For Resident A, the blood sugar levels were not evaluated to address control of diabetes mellitus (abnormal blood sugar). This failure had the potential for Resident A to experience complications of uncontrolled diabetes mellitus; and2. For Resident F, episodes of diarrhea (loose, watery and possibly more-frequent passage of stool) were not addressed timely. This failure resulted in a delay in the care and treatment to address illness related to diarrhea.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control measures were implemented according to the facility's policy and procedure and CDC (Centers for Disease Control and Prevention) guidelines, for five of 20 residents reviewed, when: 1. The facility staff did not wear the appropriate PPE (Personal Protective Equipment - specialized clothing or gear such as gloves, gowns, masks, respirators, and eye protection designed to protect healthcare personnel and patients from infectious materials, blood, and body fluids) when providing care to residents with C-Diff infection (Clostridioides difficile - a bacterium that causes severe, often hospital-acquired, diarrhea and colon inflammation (colitis) by producing toxins) (Resident B). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacy consultant recommendation to check blood levels was not referred to the physician for implementation, for one of eight residents (Resident A). This failure had the potential for Resident A's overall medical condition to be affected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control precautions were implemented in accordance with the policies and procedures for two of six sampled residents (Residents 4 and 3), when: 1. Certified Nurse Assistant (CNA) 1 was observed at Resident 4's bedside wearing a face mask, and not wearing gown, gloves, and face shield. The resident requires a droplet precaution; and 2. CNA 2 was observed with Resident 3 at bedside wearing a face mask, and not wearing gown, gloves, and face shield. The resident requires a droplet precaution. These failures had the potential to increase the spread of influenza (a contagious viral infection of the respiratory tract) and cause serious illness in high-risk individuals.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was thoroughly investigated and results of the investigation were reported to the state survey agency (CDPH - California department of Public Health) within five (5) calendar days of the incident, in accordance with the facility's policy and procedure, for two of three residents reviewed (Resident A and B). This failure had the potential for further abuse or mistreatment to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment were provided, for one resident of six residents reviewed (Resident E), when the resident had a critical low hemoglobin (an iron containing protein in red blood cells-transports oxygen from the lungs to the body). In addition, there was no care plan developed to address Resident E's low hemoglobin levels. This failure resulted in Resident E not receiving appropriate monitoring, care and services to address critically low blood levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an orthotic (an external brace or support used to align, support, prevent, or correct the function of the musculoskeletal system, like custom shoe inserts, ankle braces, or spinal supports, while orthotics refers to the science or practice of creating and applying these devices) consultation as recommended by the physical therapy (PT) was ordered timely, for one of five residents (Resident C). This failure had the potential to result in a delay in the rehabilitation progress of Resident C.

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were answered as soon as possible, for one of five residents (Resident 2). This failure had the potential to cause delay of care, and to cause Resident 2's needs to not be met in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the plan of care was implemented to have another staff present while care was being provided, for one of three residents (Resident 3). This resulted in Resident 3's care plan to not be followed.

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective antibiotic surveillance program (program to help monitor the effectiveness of antibiotics, identify emerging resistance patterns, and inform strategies for infection prevention and control) was conducted, for 11 out of 12 residents (Residents 2, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17), according to the facility's policy and procedure. This failure resulted to the residents' use of antibiotic not to be evaluated for the appropriateness of its use, which could lead to development of complications related to use of the antibiotics.

Inspectors wroteBased on interview and record review, the facility failed to ensure TB (tuberculosis - a serious lung infection) test was completed according to the facility's policy and procedure, for two of three residents (Residents 2 and 3). This failure had the potential for TB to be undetected and could result to the transmission of the disease to the vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy and procedure on abuse on investigating an allegation of abuse, for one of seven residents reviewed (Resident 2) when Resident 2 reported an allegation of abuse by Physical Therapy Assistant (PTA). In addition, the facility did not suspend the PTA after Resident 2 reported an allegation of abuse. This failure had the potential to result in further abuse to Resident 2 and other vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse to California Department of Public Health (CDPH), immediately or within two hours after an allegation of abuse was reported, for one of seven residents (Resident 2), when Resident 2 reported an allegation of abuse by the Physical Therapy Assistant (PTA). This failure had the potential to result in delayed investigation of abuse and further exposed Resident 2 and other vulnerable residents to abuse by the PTA.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment was provided, for one of seven residents (Resident 2), when Resident 2 sustained a skin tear on the right wrist. This failure had the potential for a delay in the care and treatment of Resident 2 skin tear on the right wrist.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary environment, for one out of seven residents (Resident 7), when black mold was observed in Resident 7's shower. This failure had the potential to result in physical and psychosocial effect to Resident 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's policy and procedure on accounting for narcotic controlled substances was followed when: 1. The liquid Ativan (anti-anxiety medication) for one of one resident (Resident 1) was not appropriately verified against the Narcotics and Controlled Substances Count Sheet (a sheet used to monitor the administration of a medication); and 2. The off-going (end of shift) and on-coming (beginning of shift) nurses did not sign the Narcotic and Controlled Substance (Shift-to-Shift) Count Sheet, after completion of the end of shift resident narcotic medications count. These failures could have led to an inaccurate medication count, and a discrepancy in medication count records, and has the potential for drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure preferences were honored, for one of four residents (Resident 1), when the facility staff used bleach to clean her room despite Resident 1's request not to use bleach when disinfecting her room while she was inside the room. This failure resulted to Resident 1's preference not honored and could affect the resident's overall psychosocial well being.

Inspectors wroteBased on interview and record review, the facility failed to notify the police and Adult Protective Services (APS - social services program that helps adults who are abused, neglected, or financially exploited), of an allegation of financial abuse, by an acquaintance, towards a resident, for one of three residents (Resident 1), according to the facility's policy and procedure. This failure had the potential for Resident 1 to be a victim of financial abuse without investigation from the police or APS.

Inspectors wroteBased on interview and record review, the facility failed to ensure human immunodeficiency virus (HIV - a virus that attacks the body's immune system) medications was administered, for one of three residents (Resident 2), according to the physician's orders. The failure had the potential to put Resident 2 at risk for an increased HIV viral load (amount of virus present in the blood), a weakened immune system & increased risk of opportunistic infections.

Inspectors wroteBased on interview and record review, the facility failed to provide Restorative Nursing Services (RNA - services provided to help increase/and or prevent a decrease in range of motion {ROM -Full flexion and extension of a joint}), as ordered by the physician, for one of five residents (Resident 2). This failure has the potential for the resident to develop muscle contractures (permanent shortening of the muscle due to lack of use), and decreased ROM and/or mobility for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effectiveness of interventions to address multiple falls were evaluated and provide new interventions to prevent further falls, for one of three residents (Resident 1). This failure had the potential for Resident 1 to experience further falls and sustain serious injury from repeated unwitnessed falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse by the Restorative Nursing Assistant (RNA) towards a resident, for one of six residents (Resident 3), was reported to the California Department of Health (CDPH - State Agency) immediately or within two hours after the facility was made aware of the alleged abuse. This failure resulted in a delayed investigation by CDPH and had the potential to expose the patient to further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage bins were not overflowing and properly closed, for two of five garbage bins. In addition, trash was found on the ground beneath the dumpsters. This failure had the potential to attract pests and rodents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment for safe self-administration of medication was conducted, for three of 165 residents (Residents 101, 265, and 19) when: 1. One opened Ventolin HFA (albuterol sulfate inhalation aerosol- medication used to prevent and treat wheezing and shortness of breath) 90 mcg (micrograms- unit of measurement) per actuation (ACT- allows the patient to operate the inhaler and directs the medicine into the patient's lungs) inhaler was found inside Resident 101's desk drawer; 2. Three opened medications were found on top of Resident 265's bedside drawer, as follows: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were answered within a reasonable time, for three of 34 residents, (Resident 95, 5, and 464). Thes failures resulted in a delay of care and had the potential for the residents' needs to not be met. (Cross Reference F725)

Inspectors wroteBased on interview and record review, the facility failed to uphold resident's rights when: 1. Formulation of an Advance Directive (AD - a written instruction, such as a living will, relating to the provision of treatment and services when the individual becomes unable to decide) was not offered to the resident and/or their resident representative , for seven of 13 residents reviewed for Advance Directives (Residents 514, 463, 116, 123, 263, 95, 38, and 81); and 2. Copies of the AD were not available in the medical records, for one of 13 residents reviewed for AD (Residents 13). These failures had the potential to result in the residents' wishes related to the provision of medical treatment and services, to not be followed if the residents became unable to make decisions for themselves.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable homelike environment, for five of 165 resdients (Residents 63, 265, 28, 73, and 27), when peeled and damaged wall paper were observed inside the resident rooms 808, 212, 213, 113, and 609. These failures had the potential to affect the comfort and psychosocial well being of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quarterly Minimum Data Set (MDS - a resident assessment tool) assessments were submitted to the Centers for Medicare and Medicaid Services (CMS - provides health coverage) in a timely manner, for five of 10 residents reviewed fro Resident Assessment (Residents 20, 31, 33, 72, and 81),: These failures resulted in the facility being out of compliance with federal regulations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's preferred activity was consistently provided, for three of three residents for activities (Resident 10, 48, and 128). This failure had the potential to result in residents to have an inactive life while in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents, when: 1. For 15 of 165 residents (Residents 45, 101, 85, 88, 124, 91, 138, 20, 2, 139, 318, 265, 23, 104, and 123) complained of staff failing to aid with activities of daily living (ADLs- daily care activities) in a timely manner; and 2. Seven of eight confidentially interviewed residents from the Resident Council meeting complained of call lights not being answered timely, lost personal belongings, and meals not being delivered on time. These deficient practices caused feelings of frustration amoung the residents, and negatively affected the quality of care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when: 1. An unopened container of Controlled II (CII, Schedule II drugs with a high potential for abuse) Emergency Kit (E-kit, a sealed container of various medications for use in emergencies) contained a small, opened E-kit medication box with no medications inside and no documentation of missing medications on the outside of the E-kit container. This failure had the potential to significantly delay treatment for pain; and 2. Three different medications lowering blood pressure were administered to Resident 103 when Systolic Blood Pressure (SBP, the top number in blood pressure reading which measures how hard the heart pumps blood into arteries) levels were below the holding parameter orders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store and label medications in accordance with the manufacturer's instructions and the facility policy and procedures when: 1. Total of three expired medications were identified in the medication refrigerator, IV/IM (intravenous/intramuscular, routes of administrations, methods of injecting medication into body) E-kit (Emergency Kit, a sealed container of various medications for use in emergencies) and the oral E-kit; 2. Total of six different medications without the open dates were stored in the medication room, the medication refrigerator, and the medication carts; 3. A discontinued order of controlled medication was stored in the medication cart; and 4. A box of ointment was stored in the treatment cart with no pharmacy-applied labels. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Food service staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. [NAME] 1 and Food Service Director (FSD) did not follow the recipes to prepare pureed foods items (bread, chicken, and vegetable) during dinner meal on January 6, 2025; (Cross reference 803) 2. [NAME] 1 and Diet Aide 3 used water as sanitizer to clean used kitchen equipment; 3. [NAME] 1, [NAME] 2, and Diet Aide 3 did not follow manufacturer guideline instruction time length for submerging washed kitchenware in sanitizer sink; and 4. [NAME] 1, [NAME] 2, and Diet Aide 4 did not follow facility's sanitization policy and procedure to clean the used prep counter and equipment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Recipes were followed to prepare pureed food items (bread, chicken, and vegetables) during dinner meal on January 6, 2025. This failure had the potential for 15 out of 15 residents receiving pureed food prepared in the kitchen to not meet their nutritional needs which may lead to nutritional related health complications; and 2. Recipes for seasoning broccoli was followed during lunch meal on January 7, 2025 (Cross reference F804). This failure had the potential for 161 out of 165 residents receiving food prepared in the kitchen to not meet their nutritional needs which may lead to nutritional related health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure to provide appetizing and palatable (refers to the taste and/or flavor of the food) food at appropriate temperatures according to residents' preferences, for nine out of 161 sample residents, Residents 2, 3, 20, 34, 45, 87, 103, 145, and 264. This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutrition status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pureed bread was prepared following the recipe, for 12 of 12 residents (Residents 18, 38, 44, 58, 96, 126, 109, 463, 513, 663, 664 and 665) who had physician prescribed order for pureed diet texture. This failure had the potential to place the residents at risk of aspiration (accidentally inhaling food or liquid into the lungs), choking and decreased meal intake.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure evening snacks were offered to eight of nine residents (Residents 3, 124, 464, 50, 67, 76, 11, and 13). This failure had the potential to affect the nutritional and wellbeing of the residents.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Thawed, uncooked meat (chicken and bacon) was stored in the walk-in refrigerator past their use-by dates; 2. A coffee cart was stored next to an uncovered trash bin; 3. Trash was found on the kitchen floor in multiple areas; 4. Worn-out cutting boards were still in use by dietary staff; 5. Buildup was found on different kitchen equipment; 6. Moldy, bruised, wilted, and wrinkled produce (tomatoes, cucumber, zucchini, red bell peppers and strawberries) were found in the walk-in refrigerator; 7. A rolling cart used to store soup bowls and dessert cups had chipping white coating; 8. Food residue was on the condiment tray underneath the prep area; 9. Dust accumulation in several areas of the kitchen was found; 10. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary and comfortable environment, for two of seven residents reviewed for environment (Residents 22 and 63), when: 1. For Resident 22, appropriate window covering to block the light per resident's preference was not provided; and 2. For Resident 63, multiple black stained patches of bathroom floors were observed inside the resident's room. In addition, rooms [ROOM NUMBERS] were also observed to have black stained patches on the bathroom floors. These failures resulted in the resident feeling uncomfortable and disrupted the resident's daily living needs and environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat resident with respect and dignity when the facility staff failed to cover the urinary bag, for one of four residents reviewed for dignity (Resident 516). This failure increased the potential to negatively affect Resident 516's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care and services to achieve and maintain the highest practicable physical, mental, and psychosocial well-being were provided, for two of two residents reviewed (Residents 515 and 414), when: 1. For Resident 515, treatment orders were not initiated upon identification of a blister on the right heel. This failure had the potential to result in worsening of the wound, which could negatively affect the health status of Resident 515; and 2. For Resident 414, the following medications were not administered as ordered by the physician: - Eliquis (medication to reduce formation of blood clots) 5 (five) mg (milligram- a unit of measuerement); - Atorvastatin (medication used to lower cholesterol) 40 mg ; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a scheduled eye appointment was followed up, for one of one resident (Resident 50) reviewed for vision. This failure had the potential for Resident 50 to not receive the necessary treatment timely to maintain effective vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nutrition, monitor the effectiveness of nutritional intervention, and recommend interventions to maintain an acceptable parameters of nutritional status, for one of five sampled residents (Resident 116, when: 1. Resident 116 did not receive the requested juices on his meal tray according to the diet order and resident's food preferences; 2. Resident 116 did not receive a protein substitute in the meal tray to honor the resident's preference for a vegetarian diet. In addition, the facility did not have a menu spreadsheet for a vegetarian diet; 3. There was no alternative measures implemented for resident's refusal to be weighed; 4. There was no monitoring of Resident 116's consumption of the protein shake ordered; 5. [...]

Inspectors wroteBased on observation, interiew, and record review, the facility failed to provide pain management according to the physician's order, for one of two residents reviewed for pain (Resident 267), when the resident was not given the pain medication Norco (a narcotic pain medication) according to the physician's order. This failure resulted in Resident 267 experiencing inadequate pain relief.

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist (CP)'s Medication Regimen Review (MRR) recommendation for one of five residents reviewed for unnecessary medications (Resident 50) was carried out in a timely manner. In addition, the facility's MRR policies did not include the time frames for the physician to act upon the CP's MRR recommendation. These failures resulted in inadequate monitoring and had the potential to result in ineffective medication management and to compromise the Resident 50's health.

Inspectors wroteBased on interview and record review, the facility failed to ensure antipsychotic medications (medications to treat psychotic disorders with symptoms of altered sense of reality) were ordered and used for residents with proper diagnoses and evaluations to meet residents' needs, for one of five residents reviewed for unnecessary medications (Resident 157). An antipsychotic medication for sleep received while Resident 157 was admitted in the hospital was ordered to continue with a new indication of psychosis (symptoms of psychotic disorders) without prior history of psychotic disorders and thorough psychiatric evaluation by a qualified medical professional. This failure had the potential for residents to receive an unnecessary medication with serious long term adverse effects including permanent movement disorder, seizure, and uneven heart rate.

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 7.14% when two medication errors occurred out of 28 opportunities during the medication administration, for two out of six residents (Resident 465 and 314). The deficient practice resulted in medications not given in accordance with the prescriber's orders and had the potential for residents not receiving the full therapeutic effects of medications with the potential for worsening of residents' medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, refer, and follow up the dental needs for the resident, for one of one resident reviewed for dental (Resident 22). These failures have the potential to place the resident at high risk for complications related to dental and psychosocial needs due to the possible delay in providing dental devices.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Food Service Director (FSD - the position responsible for the day-to-day operation of the dietary department), met the educational requirements as outlined in the facility's policy, Federal Regulation, and California Health and Safety Code.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's beverage preference was honored on January 6, 2025 lunch and protein substitution was given on January 9, 2025 breakfast for one of one sampled resident (Resident 116). This failure resulted in Resident 116 not to receive sufficient calories and protein which could contribute to the unplanned weight loss, further compromising Resident 116's nutritional and medical status.

Inspectors wroteBased on observation, interview and record review, facility failed to ensure infection control practices were implemented when Certified Nursing Assistants (CNA) did not wear personal protective equipment (PPE - equipment used to protect against infection or illness) when providing care to a resident with enhanced barrier precautions (EBP- infection control intervention to reduce transmission of multi-drug resistant organism [MDRO- bacteria that have become resistant to multiple antibiotics]). This failure had the potential spread infections throughout the facility, which is transferred through direct close contact of skin to skin or sharing of bedding or clothing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed equipment in the residents' rooms were maintained in a safe operating condition, when the bed controls were observed to have damaged and exposed wirings, for two of seven residents reviewed (Residents 8 and 318). This failure to maintain a functional environment had the potential to compromise resident safety. 1. On January 6, 2025, at 9:38 a.m., a concurrent observation and interview was conducted with Resident 8 inside her room. The bed control to the left of Resident 8's bed was observed damaged, and the inner wire was exposed. Resident 8 stated she reported it a long time ago, but was never repaired. Resident 8 further stated every time she used the bed control, It makes me nervous. On January 7, 2025, at 3:08 p.m., an interview was conducted with the Maintenance Supervisor (MS). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Certified Nursing Assistant (CNA) 1 did not use Personal Protective Equipment (PPE - equipment use to protect against infection or illness) when providing care to a resident requiring contact isolation precaution (an infection control intervention to prevent the spread of harmful germs that can be transmitted through touch); 2. Three direct care staff did not perform proper handwashing before and after proving care to a resident; and 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to transfer a resident via ambulance, on an emergent basis (unstable health condition), to the General Acute Care Hospital (GACH) for further evaluation, for one of three residents (Resident 1). This failure had the potential to delay management of symptoms of respiratory distress during transport to GACH for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to reevaluate the risks and effectiveness of interventions to address incident of falls, for one of three residents reviewed (Resident 1). This failure had the potential to result in further falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse involving Residents 1 and 2 to the California Department of Public Health (CDPH) within a 2-hour time frame. This failure had the potential to put residents at further risk of abuse and compromise their safety.

Inspectors wroteBased on interview and record review, the facility failed to provide residents and/or their representatives, the right to participate in the development of an individualized plan of care (an outlined care plan, including, goals and interventions, developed in collaboration with the resident and/or their representative) for three of three sampled residents (Residents 1, 2, and 5). This failure has the potential for the resident and or resident's representative not to be aware of the care plan developed for them to obtain their health goals.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Ensure (Dietary nutritional supplement drinks) to four of four sampled residents (Residents 1, 2, 3, and 4) with their meals, in accordance with the physician order. This failure has the potential for the residents not to receive their nutritional needs.

Inspectors wroteThe facility failed to ensure the authorized resident representative was provided the opportunity to be notified of the changes in the resident's medical condition and was provided with opportunities to participate in planning the resident's care. Resident 5's representative who has the durable power of attorney (DPOA) was not listed as the resident's emergency contact. This failure has the potential for the resident's authorized representative to be unaware of the changes in the resident's condition which could result in the representative not to be able to exercise her rights to advocate for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician's orders for Life Sustaining Treatment (POLST-a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) was consistent with the Advance directive (a living will that outlines personal, medical, end of life decisions, including an assigned decision maker) for one of three sampled residents (Resident 5). This failure placed the resident at risk of not receiving the treatment or care in accordance to their choice.

Inspectors wroteBased on interview and record review, the facility failed to notify the representative of missed dialysis (A medical treatment that removes waste and excess fluids from blood due to kidney failure) treatment due to hypotension (low blood pressure) for one of three sampled residents (Resident 5). This failure resulted in Resident 5 ' s Representative not to be aware of the resident ' s missed dialysis treatment, which prevented the representative to exercise rights to be involve in the care for Resident 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure a grievance related to a lost denture was addressed in accordance to the facility policy and procedure for one of three sampled residents (Resident 1). This failure has the potential for the resident's concerns not to be investigated and resolved.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a two person assist and use a gait belt during transfer from a regular chair to a wheelchair for one of three sampled residents (Resident A). In addition, the facility failed to ensure the wheelchair's brake was functioning well during the transfer. These failures had resulted in a fall for Resident A, which led to the development of genu valgum (knock-knee - the knees angle in and touch each other when the legs are straightened) deformity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a consistent skin assessment which would include accurate measurement of wounds, were conducted on a weekly basis for three of three sampled residents (Residents 1, 2, and 3). This failure has the potential to result in the facility not to be aware of the changes in the condition of the pressure injuries subsequently delaying the provision of appropriate treatment.

Inspectors wroteBased on interview and record review, the facility failed to obtain treatment consent for a prescribed psychotropic medication (Seroquel- medication to treat mental or mood disorders) from the resident's responsible party prior to use, for one of three sampled residents (Resident 1). This failure has the potential for the responsible party not to be involved in the planning of care for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's representative was informed of the changes in one of three sampled residents' (Resident 1) skin condition. This failure has the potential for the resident or the resident's representative not to be aware of the changes which could result in the representatives not to be able to exercise their rights to be involved in planning the care for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to notify law enforcement when reporting allegations of financial abuse involving one of three sampled residents (Resident 1). This failure had the potential for allegations of financial abuse reported by Resident 1, not to be investigated which increased the risk for further abuse on Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure a dedicated 1:1 sitter (caregiver assigned to monitor one resident), was provided for two of two residents (Residents 1 and 2). In addition, the facility failed to get a physician order for a 1:1 monitoring for one of two residents (Resident 2). These failures had the potential for the two residents to be involved in another altercation which could result in serious physical injury.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of financial abuse within two hours to California Department of Public Health (CDPH) after the facility was made aware of the allegation, for one of five residents (Resident 1). This failure had the potential to result in further financial abuse for Resident 1, affecting the resident's emotional, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident was monitored after the resident reported an allegation of financial abuse, for one of five residents (Resident 1). This failure had the potential for the staff to be unaware of the effect on the resident's emotional and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided, for one of three residents (Resident 2) who required close monitoring and supervision, when Resident 2 was left unsupervised during care. This failure had the potential to put other residents in the facility at risk for further aggressive behaviors by Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse within 2 hours to California Department of Public Health (CDPH) after the allegation was made, for one of 3 residents (Resident 1). This failure had the potential to result in further abuse for Resident 1, affecting the resident's physical, emotional, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to perform a background check for a direct care employee prior to employment. This failure had the potential to expose residents to abuse and exploitation.

Inspectors wroteBased on interview and record review the facility failed to develop a care plan with interventions for one of three sampled residents (Resident 1) receiving psychotropic medications. This failure has the potential to result in Resident 1 not receiving interventions to promote the resident's optimal level of function.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician or designee visited one of three sampled residents (Resident 1) every 30 days. This failure had the potential to result in Resident 1 not maintaining or achieving their highest practical level of function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of three sampled residents (Resident 1), the physician order to provide Resident 1 with a trapeze (a device to assist patients in transferring from one surface to another, reducing the risk of injury) was followed. This failure had the potential for the resident to have limited mobility, and being unable to transfer from one surface to another.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the written notice of transfer or discharge was provided to the long-term care Ombudsman for 30 of 50 patients, who were transferred and discharged from the facility in between [DATE], and [DATE], in accordance with the facility policy and procedure. This failure had the potential to result in the discharged residents experiencing an inappropriate transfer or discharge and to not have the opportunity to speak with the Ombudsman to advocate in protecting the resident's rights from being inappropriately transferred or discharged .

Inspectors wroteBased on observation, interview, and record review the facility failed to provide repositioning for one of three sampled residents (Resident 1) when Resident 1 was not offered repositioning. This failure had the potential to result in Resident 1 sustaining a pressure-related skin injury.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services in preventing development of pressure injury (skin or soft tissue injuries that form due to prolonged pressure exerted over specific areas of the body), for one of three sampled residents (Resident 1), as evidenced by the following: 1. There was no skin evaluation conducted when Resident 1 was admitted on [DATE], in accordance with the policy and procedure titled, Skin Management Guidelines, dated March 2022. 2. There was no interventions developed to address Resident 1's risk for pressure ulcer on admission. The resident was assessed to be at risk for developing pressure injury. 3. Treatments for Resident 1's pressure injury on the right and left heel; sacrococcygeal; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure skin evaluation was conducted on admission for one of three sampled residents (Resident 1). In addition, the facility failed to ensure monitoring and treatment for non-pressure skin injuries were provided to Resident 1. These failures had the potential to result in delayed provision of care and treatment for the resident's skin condition, which placed the resident at risk for infection and complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure nutritional assessment were completed on admission for one of three sampled residents (Resident 1). In addition, weekly weights were not completed in accordance with the policy and procedure. These failures placed Resident 1 at risk for compromised nutrition, a delay in necessary treatment and services, which has the potential to result in further decline of the resident's health status.

Inspectors wroteBased on interview and record review, for one (Resident 1) of three sampled residents, the facility failed to complete the quarterly Minimum Data Set assessment (MDS - Resident Assessment and care guide tool) according to the regulation. This failure had the potential to result in the delayed assessment of residents' needs, goals of care and inability to monitor each residents' progress over time.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse within two hours to the California Department of Public Health (CDPH) after the allegation was made for one of three residents (Resident A). This failure had the potential to result in further harm to Resident A ' s physical, emotional, and psychosocial (social factors and individual thoughts and behaviors) wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of three residents (Resident A), receiving hospice care (focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life), was assessed on a regular basis for constipation and received medications as ordered. This failure resulted in Resident A, experiencing constipation, as well as impact her physical, mental, and psychosocial (interrelation of social factors, individual thought, and behavior) well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to report an outbreak of COVID-19 (An infectious disease, which affects the respiratory system, accompanied by symptoms of fever, cough and shortness of breath, caused by the SARS-CoV-2 virus) to California Department of Public Health (CDPH). This failure resulted in CDPH to be unaware of the outbreak which caused a delay in investigation of the communicable disease outbreak.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse within 2 hours to California Department of Public Health (CDPH) after the allegation was made, for two of two residents (Residents 1 and 2). This failure had the potential to result in further abuse for Residents 1 and 2 affecting the residents physical, emotional, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the volume of the call light was audible enough to alert staff when residents call for assistance. This failure had the potential for the staff not to be aware of the needs of residents thereby delaying provision of needed care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide consistent range of motion exercises for five of eight residents reviewed for limited range of motion (ROM - the full movement potential of a joint) (Residents 9, 36, 42, 45, and 52). The facility did not have a restorative nursing program (a program that promotes and maintains resident's function which would include passive range of motion exercises [stretching muscles, moving body part around the joint] and active range of motion exercises [performed solely by the resident, who moves the joint without assistance]) for the residents at the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD - a written statement of an individual's wishes regarding his/her medical treatment) was available in the resident's records, for three of 10 residents reviewed for AD (Residents 11, 41, and 55). This failure had the potential for Residents 11, 41, and 55's AD to not be readily available to the staff and the physician, making them unaware of, and unable to honor the resident's wishes regarding their medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the following: 1. Resident 1's splint (a rigid device to help with range of motion and to prevent or maintain range of motion) to the hand was applied daily for resident as ordered by the physician; and 2. Resident 52's skin lesion to the right forearm was assessed, monitored, and referred to the physician for further evaluation and treatment; These failures had the potential to compromise the health of Residents 1 and 52 and to lead to the development of complications in their overall health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) were not administered without adequate monitoring for the targeted behaviors for which the medications were used for the residents. This failure had the potential to inadequately track progress toward improvement of the resident's status and for the facility to not able to measure the effectiveness of psychotropic medications.

Inspectors wroteBased on interview and record review the facility failed for one of one resident reviewed for dialysis (Resident 26), to ensure Sevelamer- (phosphate binder-it binds phosphates in the stomach and prevents them from being absorbed into the body) was administered according to physician order. This failure had the potential to reult for Resident 26 to have elevated phophorus [mineral that causes body changes that pull calcium out of the bones] level.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed during the tray line on June 21, 2023 when: 1. Resident 1 on regular CCHO (consistent carbohydrate) diet (a diet used in the treatment for diabetes) received a wheat roll, and a grilled cheese on white bread; 2. Resident 4 on regular CCHO diet received three (3) small plastic cups of brown sugar: and 3. Resident 214 on regular mechanical soft (easy chew) diet received fresh pineapples. These failures had a potential to result in compromising the medical and nutritional status for Residents, 1,4, and 214.

Inspectors wroteBased on observations, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. Expired foods and open foods without date were discarded and readily available for use. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food in the facility. 2. Metal sheet pans and plastic storage containers were stacked and stored wet; and 3. Dietary staff personal belongings were observed in the food preparation station. These failures had the potential to contaminate the food and cause foodborne illnesses in a medically vulnerable resident population who consumed food in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that plan of care for repositioning was implemented for one of 18 residents reviewed (Resident 60). This failure had the potential to result in skin breakdown for Resident 60.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the plan of care (POC) was reviewed and revised, for one of 18 residents reviewed (Resident 36), when Resident 36 had a decline in range of motion (ROM - the extent to which a part of the body can be moved around a joint). This failure had the potential to result in further decline of Resident 36's range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed for one of one resident reviewed for accidents (Resident 11), to ensure: 1. An assessment was conducted and a care plan was developed for Resident 11's wandering behavior; and 2. The physician was notified for Resident 11's wandering behavior. These failures had the potential to result in injuries for Resident 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards for quality of care were followed for hemodialysis (HD- process of removing waste from the blood with the use of a machine) for one of one resident reviewed for dialysis (Resident 26), when: 1. The licensed nurse did not assess Resident 26 before and after hemodialysis on mulitple occasions. This failure increased the potential for delayed detection, reporting, and/or management of complications from the hemodialysis access sites; and 2. The licensed nurse did not communicate with the physician regarding Resident 26's missed dialysis treatment. This failure had the potential for Resident 26's physician to be unaware of the resident's medical condition after missing dialysis treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provision of pharmacy met the needs of the residents when expired, discontinued, discharged resident's medications were not removed and stored in the medication storage areas along with active medications. This failure had the potential for residents to receive inaccurate, ineffective medications.

Inspectors wroteBased on interview and document and record review, the facility failed to ensure medication irregularities were identified during monthly medication regimen review (MRR) by the Consultant Pharmacist (CP) and recommendations were made to ensure appropriate use of medications for one of five residents reviewed. Resident 40 received a medication not recommended for use in the adults 65 years or older by the American Geriatric Society's Beers Criteria. This failure had the potential to expose the resident to adverse effects such as increased risk of falls, delirium, and dementia.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications when one of five residents reviewed (Resident 49) was receiving four different pain medications as needed without specific parameters indicating which pain medication to be given ahead of others based on the level of pain perceived by the resident. This failure had the potential for the resident to unnecessarily receive stronger narcotic pain medication for minimal pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of three residents reviewed for choices (Resident 8), resident's food preference was honored. This failure had the potential for Resident 8 not being able to enjoy her preferred food, resulting in decrease oral intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection control practices were implemented when: 1. A staff member (CNA - Certified Nursing Assistant) did not perform hand hygiene after picking up a finished meal tray from the resident's room; and 2. An uncovered urinal (receptacle used for urinating) with half-filled urine in the resident's room was hanging on the side of the trash can next to the resident's bed. These failures had the potential to spread infection and comprise the overall health status of the residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure in-services provided was sufficient when one certified nursing assistant (CNA) did not complete twelve hours of in-service trainings for the year 2022. This failure had the potential to affect the quality of care and services provided to the residents.