Devonshire Care Center

Inspectors wroteBased on interview, and record review, the facility failed to implement their policy and procedure on abuse for one of three residents, Resident 1, when:1. Resident 1's allegation of physical abuse by the Certified Nursing Assistant (CNA) towards Resident 1 on July 4, 2026, was not investigated timely; and2. The alleged CNA was not suspended pending investigation of an allegation of abuse and continued to have provide care and services to the residents. These failures resulted in the delay of providing safety and protection for Resident 1 and other vulnerable residents and placed them at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse to California Department of Public Health (CDPH) immediately or within two (2) hours after the allegation was made, for one of three 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 observation, interview, and record review, the facility failed to ensure infection control measures were being implemented, when:1. The sit to stand lift (a mechanical aid designed to help individuals with limited mobility move from a seated to a standing position, reducing physical strain on caregivers) was dirty and dusty. In addition, the sit to stand sling/pad was dirty; and2. The shower rooms were observed to have dirty linen and trash bins filled with linens with urine and stool smell. These failures had the potential for infections to be transferred among residents and staff. In addition, the strong urine and stool smell has the potential for residents and staff to experience uncomfortable and unsanitary conditions with potential for spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physical environment is safe and sanitary, for 92 residents who could use the shower rooms, when:1. There were missing tiles and peeled off base boards on the shower wall of shower room [ROOM NUMBER];2. The shower walls in shower room [ROOM NUMBER] were dirty with brown/blackish substance on the grout and tiles; and3. There were used razors in the trash bin in shower room [ROOM NUMBER] and overflowing sharps container with used razors in shower room [ROOM NUMBER]. These failures had the potential for accidents and infection to residents and staff who uses the shower rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain medications were administered according to the physician's orders, for one of three residents reviewed (Resident A). In addition, the facility failed to ensure an accurate pain assessment was conducted on Resident A when a PRN (as needed) pain medication was administered to the resident. These failures could have resulted in unmanaged pain for Resident A and impacted their activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident A) of three residents sampled, was receiving food and drink prepared in a form to meet the resident's needs. This failure had the potential to result in coughing and choking for Resident A.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 was adequately assessed for pain during the evening and night shifts on July 12, 2025, and provide appropriate pain medication to manage pain. This failure resulted to Resident 1 calling emergency services to be transferred out of the facility on July 13, 2025, due to worsening pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional and comfortable environment, when the ceiling of room [ROOM NUMBER] was observed damaged, and the television cable outlet was exposed and did not have a plate cover. This failure to maintain a functional environment had the potential to compromise resident safety. On July 9, 2025, at 1:28 p.m., an unannounced visit was conducted at the facility for several complaints including a complaint regarding a resident room. On July 9, 2025, at 4:20 p.m. room [ROOM NUMBER] was observed. room [ROOM NUMBER] was observed to have two beds occupied by two residents in bed A and bed B, respectively. The ceiling above bed B was observed to have an irregular, circular, warped protrusion, with paint peeling, and the center cracked exposing the board underneath. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an IV (intravenous - administered into a vein) antibiotic (medication to treat infection) for septic arthritis (a serious joint infection, often caused by bacteria, that can lead to significant joint damage and even sepsis if left untreated) was administered in accordance with the physician's order and the orthopedic surgeon's (OS - a medical doctor specializing in the diagnosis, treatment, and prevention of musculoskeletal system injuries and diseases) recommendation, for one of three residents reviewed (Resident 1), when the orthopedic physician ordered for Resident 1 to start on Rocephin (medication to treat infection) on May 23, 2025, for septic arthritis. The IV Rocephin was not administered to Resident 1 from May 23, 2025, to June 27, 2025 (35 days). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate nursing services were provided to carry out the physician and orthopedic surgeon (OS - a medical doctor specializing in the diagnosis, treatment, and prevention of musculoskeletal system injuries and diseases) orders to administer IV antibiotic, for one of four residents reviewed (Resident 1), when:1. Registered Nurse (RN) 1 did not clarify with the physician or the OS regarding the IV orders after Resident 1's follow up appointment on May 23, 2025. In addition RN 1 did not endorse to the following RN the need to clarify the IV order, and there was no documentation other licensed nurses (RNs and Licensed Vocational Nurses), followed up or clarified the IV order with the OS from May 23, 2025, to June 11, 2025; 2. [...]

Inspectors wroteBased on interview and facility record review, the facility failed to have a written Quality Assurance Performance Improved (QAPI - a systematic, interdisciplinary, comprehensive, and data - driven approach to maintain and improve safety, quality of care, and quality of life of the residents) plan in place to address issue on carrying out physician's order for IV antibiotics, when the facility identified the resident did not receive the IV antibiotic the orthopedic surgeon (OS - a medical director specializing in the diagnosis, treatment, and prevention of musculoskeletal system injuries and diseases) ordered. This failure resulted to the resident not to receive the appropriate care and treatment after a surgical procedure and had the potential for the resident to develop complications such as pain or discomfort, infection, joint stiffness, and affect overall health condition.

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 four of four residents (Residents 1, 2, 3, and 4) according to the facility's policy and procedure, when:1. For Resident 1, there was no appropriate indication for the use of Levaquin (medication to treat infection). In addition, there was no antibiotic surveillance assessment completed for the use of Levaquin;2. For Resident 2, the physician was not notified the use of Cipro (medication to treat infection) did not meet the criteria of the symptoms of urinary tract infection;3. For Resident3, there was no appropriate indication for the use of Macrobid (medication to treat infection). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient number of nursing staff was provided to attend to the resident's needs and assure resident safety, when the nursing staff had an extended lunch break with no staff coverage. This failure had the potential to result in several residents to not have their needs met safely nor in a way to promote their rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards, when two nursing staff members were observed using their personal cell phones in the patient care areas. This failure had the potential to affect the quality of care the residents would receive in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure follow-up appointments and laboratory work were completed according to the discharge instructions from the acute hospital, for one of six residents (Resident A). This failure resulted in a delay in care and treatment for Resident A and had a potential to affect the resident's overall health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the California Department of Health (CDPH - a state agency) was notified timely or within two hours after an abuse allegation against a Certified Nursing Assistant (CNA) was reported to the facility staff according to the facility's policy and procedure, for one of three residents reviewed (Resident A). This failure had the potential for a delay in the investigation and implementation of the abuse protocol and exposed the vulnerable residents to further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation of the residents' wishes regarding their care were maintained for 12 of 18 residents reviewed for Advance Directives (AD - a written instruction relating to the provision of health care when the individual is incapacitated) (Residents 14, 21, 32, 40, 41, 50, 55, 59, 61, 71, 78, and 138), when: 1. For Resident 14, the signing doctor was different from the physician's name on the Physician Orders for Life-Sustaining Treatment (POLST - documents a patient's preferences for end-of-life care in the face of serious illness or irreversible conditions); 2. For Resident 32, the POLST did not have the physician's information or license number on the form; 3. For Resident 41, the POLST was not signed by the physician since January 28, 2025; 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans were initiated and/or updated when: 1. No discharge care plans were developed and/or updated for Residents 33, 71, 78 and 139. This failure had the potential for the residents' pre and post-discharge needs to not be anticipated and addressed by the facility staff; 2. No care plan was developed for the use of a indwelling catheter (a flexible tube inserted into the bladder to drain urine) for Resident 13. This failure had the potential to result in Resident 13's indwelling catheter care issues to not be addressed and monitored by the facility staff; and 3. No care plan was developed regarding the change in condition on April 3, 2025, regarding a urinary tract infection (UTI) for Resident 138. This failure had the potential for Resident 138's UTI to not be addressed and monitored by the facility staff.

Inspectors wroteBased on observation, interview, and record review, for four of four residents, (Residents 14, 18, 49, and 8), the facility failed to ensure the residents were not left soiled, wet, and unchanged by staff. These failures resulted in Resident 8, 14, 18, and 49, being left soiled in their urine, feces, and wet linen for hours and feeling ignored and not cared for. In addition, the failure has the potential for the residents to develop skin conditions and infection which could affect the resident's overall health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents, 1. For four of 88 residents (Residents 14,18, 46, and 51) complained that staff failed to assist with activities of daily living (ADL- daily care activities) in a timely manner; and 2. The facility did not meet the required minimum of Actual Total Direct Care Service Hours (Actual DCSH) of 3.5 and the actual CNA DCSH of 2.4 hours for the month of March 2025. These deficient practices caused feelings of frustrations and anger, among the residents, and negatively affected the quality of care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food of the temperature, flavor, consistency, and appearance preferred by residents, when: 1) Residents 14, 19, 41, 32, 50, 61, 71, and 289 complained of the food being tasteless, poor appearance, and temperatures were either too hot or too cold; and 2) Resident 67 complained snacks were not available for most of the residents. These failures could potentially lead to weight loss and a general lack of enjoyment in daily living, which could lead to potentially negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in the kitchen when: 1. One open box of breakfast patties was exposed and open to air in the walk-in freezer; and 2. Black wet debris was observed where the metal walls met the flooring on all four sides of the walk-in refrigerator. These failures had the potential to cause food-borne illness in a highly susceptible resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were upheld when: 1. One staff was observed placing the ice scoop on top of the transport cart instead of the designated container, while refilling the residents' water pitchers with ice; 2. Resident 236's peripheral (away from the center) intravenous line (IV- into the vein) was not labeled with a date and licensed nurse initials; This had the potential for the IV site to not be changed timely, resulting in infiltration or infection of the IV site; and 3. During medication administration observation, Licensed Vocational Nurse (LVN) 1 was observed not disinfecting the blood pressure cuff in between patient use. In addition, LVN 1 did not follow infection control practices when administering medications to Resident 16. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light was within reach for use, for one of one resident reviewed for accommodations of needs (Resident 17). This failure had the potential to cause delay of care and to cause resident's needs to not be met in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to exercise reasonable care for the protection of the resident's property from theft or loss to occur, for one of one resident reviewed for personal property (Resident 27), when the resident's lower dentures were lost. This failure resulted in Resident 27 feeling distressed about the loss of her bottom dentures.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a clinical assessment tool) was accurately coded, for one of three residents reviewed for dialysis (Resident 52). This failure resulted in an inaccurate MDS assessment to be submitted to CMS (Centers for Medicare and Medicaid Services).

Inspectors wroteBased on observation, interview, and record review, for one of 21 residents reviewed (Resident 138), the facility failed to ensure the physician was notified timely of Resident 138's urine culture and sensitivity result. This failure resulted in Resident 138 not receiving prompt treatment for the urinary tract infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate optometry services when the resident requested it for one of one Residents, (Resident 40), reviewed for vision/hearing. In addition, Resident 40 was admitted on [DATE], with a pair of glasses that was missing the right lens. This failure could have caused Resident 40 sensory deprivation and had the potential to result in physical discomfort.

Inspectors wroteBased on observation, interview, and record review, for two of three residents reviewed for urinary catheter (used to drain urine from the bladder) (Residents 13 and 59), the facility failed to identify, assess, and address signs and symptoms related to urinary catheter complications, when: 1. Resident 13's suprapubic catheter (a tube placed through the abdominal wall directly into the bladder) tubing was found to have an excessive amount of sediment. In addition, the follow up appointment with the urologist was not done timely; and 2. Resident 59's indwelling foley catheter (urinary catheter used for continuous drainage of the bladder) tubing was found to have an excessive amount of sediment. In addition, the follow up urology appointment scheduled on November 19, 2024, was not done accordingly. These failures had increased the risk of urinary tract infection for Residents 13 and 59.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow Resident 289's physician order to provide a regular textured, thin liquid consistency diet. This deficit practice had the potential for Resident 289's needs to not be met and placed the resident at risk for weight loss.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the performance evaluation was completed annually, for one of eight direct care staff reviewed (DCS 5).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure storage of medical supplies and medication conformed to national standards and the facility policy and procedure when: 1. Four Biopatch IV (intravenous- into the vein) dressings (used to absorb exudate and to cover a wound caused by IV lines) were found outdated inside the Station 1 IV cart, readily available for use; and 2. Fluocinonide 0.05% (percent- unit of measurement) topical solution (used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions) with an open date of [DATE], with the label torn and faded, was found in the treatment cart, readily available for use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment when loose wires were observed hanging at the base of the back wall in the room, for one of one resident reviewed for environment (Resident 67). This failure had the potential to affect the safety and wellbeing of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure scheduled hemodialysis (a treatment using a machine and special filter to clean the blood of a kidney failure person) treatments were received, for one of three residents reviewed (Resident 4), when transportation to the dialysis center was not arranged. This failure resulted in Resident 4 to missed dialysis treatments while at the facility. In addition, this failure had the potential for Resident 4 to increased risk of medical complications including fluid overload (excess fluid in the blood), edema (swelling), shortness of breath, and high blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate monitoring was conducted according to the facility's policy and procedure, for three of six residents (Residents A, B, and C), when the residents sustained a fall. This failure had the potential for a delay in the care and treatment to address possible neurological complications related to fall incident for Residents A, B, and C.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided according to the physician's order and plan of care, for two of six residents (Residents B and D). This failure had the potential to result in Residents B and D's pain to not be managed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an injury of unknown origin (the cause of injury was not observed by any person or could not be explained by the resident) to California Department of Public Health (CDPH), for one of three residents (Resident 1), when Resident 1 had discoloration on the both upper extremities, lower abdomen, and left lateral trunk on March 10, 2025. This failure had the potential to result into a delayed investigation to rule out abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was developed to address the rashes, for five of the six residents (Residents 2, 6, 7, 8 and 10). This failure had the potential to result in unmet needs and a potential for the rashes to worsen.

Inspectors wroteBased on interview and record review the facility failed to ensure resident's money are protected from theft and loss, for one of four sampled residents (Resident 1), when the residents money was missing and not accounted for after the resident was admitted to the facility. This failure had the potential for a misappropriation of resident's funds to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented according to the facility policies and procedures and Centers for Disease and Prevention Control (CDC) guidelines, when the facility had COVID -19 (respiratory infection caused by the SARS-CoV virus) outbreak with 33 residents and 12 staff tested positive for COVID-19, when: 1. The Director of Nursing (DON) was observed wearing an N95 respirator mask (a type of respiratory protective device or personal protective equipment [PPE] designed to achieve a very close facial fit and very efficient filtration of airborne [suspended in air] particles) which was not fit-tested (a procedure that verifies that a respirator fits a person's face and provides the expected level of protection). In addition, the DON had a beard while wearing an N95 mask; 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of physical abuse involving Resident 1 was reported to the California Department of Public Health (CDPH - a state agency), Omdubsman, and law enforcement immediately, or not later than two hours after the allegation was made according to the facility's policy and procedure, for one of three residents (Resident 1). This failure had the potential to place Resident 1 at risk for harm from further abuse.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation of an allegation of abuse, for one of three residents (Resident 1), when Resident 1 reported to the facility staff on December 20, 2024, that someone pulled her hair. This failure resulted in Resident 1 to not be provided sufficient protection, and potentially exposed the resident to further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician ' s treatment orders for skin conditions, for two of three residents (Residents 3 and 4). This failure had the potential to result in the worsening of Resident 3 and 4 ' s skin conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure the physician ' s orders for treatment of pressure injuries (a localized area of skin and/or underlying tissue damage caused by prolonged pressure, shear, and/or friction) was conducted, for two of three residents reviewed (Residents 3 and 4). This failure had the potential to result in the worsening of Resident 3 and 4 ' s pressure injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure consults were arranged for four of the seven sampled residents (Residents 3, 4, 6 and 7) in accordance with the physician order. This failure had the potential to result in delayed provision of care and treatment for the residents to reach the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure list of home medications were obtained timely to ensure routine medications were made available and administered for one of the four sampled residents (Resident 2) on admission to the facility. This failure to make the medications readily available had the potential to cause an adverse effect on the health of the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate infection control practices, when one visitor and one staff failed to wear personal protective equipment (PPE) before entering a room with a signage for contact isolation precaution (required to protect against either direct or indirect transmission). This failure had the potential to result in the spread of infection, cross-contamination and spread of disease that could affect other residents in the facility, visitors, and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary services to maintain appropriate hygiene was provided, for one of eight residents reviewed (Resident 1), when Resident 1 did not receive fingernail care. This failure had the potential to negatively impact the physiological and psychological well-being for Resident 1. In addition, this failure had the potential for Resident 1 to acquire food borne illness and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary services to prevent skin breakdown was provided, for one of eight residents reviewed (Resident 1), when Resident 1 developed skin irritation on the neck. This failure had the potential for Resident 1 to develop worsening skin irritation and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner, for one of nine residents (Resident 5), when Resident 5 waited 15 minutes for the call light to be answered. This failure had the potential for Resident 5 to have needs unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate care and treatment services for pressure injuries (PIs - localized damage to the skin and underlying soft tissue over a bony prominence or from a medical device) were provided, for two of seven residents reviewed (Residents 1 and 5), when: 1. The facility failed to assess Resident 1's intergluteal cleft linear (the deep [NAME] or groove that lies between the two gluteal regions), and the right buttock linear excoriations, (raw wearing of the skin), weekly. This failure had the potential for the facility not to be able to determine if the wound was healing or worsening; and 2. The facility failed to place an air mattress on the bed at admission according to the physician's order for Resident 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of nine residents (Resident 7), had floor mats on both sides of the bed. This failure increased the risk of Resident 7 to have an injury if she fell out of bed on the right side.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure 2 (Resident #56 and Resident #296) of 2 sampled residents reviewed for privacy, did not share a bathroom with residents of the opposite sex.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure a Level II mental health evaluation was completed for 2 (Resident #17 and Resident #41) of 4 sampled residents reviewed for preadmission screening and resident review (PASARR).

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure all medications were available to be administered during medication administration for 1 (Resident #68) of 5 residents observed for medication administration.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure staff changed their gloves during the provision of incontinence care between dirty and clean tasks for 1 (Resident #17) of 1 sampled resident reviewed for bladder and bowel incontinence.

Inspectors wroteBased on interview and record review, the facility failed to develop a plan of care (POC) with specific goals and objectives to address the resident's condition, for one of four sampled residents (Resident 1) when Resident 1 complained of painful urination on September 7, 2023. These failures increased the potential to result in inconsistent and inadequate provision of care for Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to ensure laboratory (lab) tests were completed as ordered by the physician, for one of four residents reviewed (Resident 1) when the physician ordered urinalysis (UA-test to determine if a urinary tract infection [UTI] is present) was not completed. This failure had the potential to result in the delay of diagnoses and necessary treatments for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide physician ordered consultation services for two of three residents (Resident 1 and 2) when: 1. A follow up dental appointment was not scheduled for Resident 1, and; 2. An ophthalmologist appointment was not scheduled for Resident 2. These failures had the possibility to delay treatment and care for the residents.

Inspectors wroteBased on observation, interview, and record review, for three of three sampled residents (Residents 23, 44, and 7), the facility failed to ensure: 1a. Resident 23's new skin injury (left upper arm bruise) identified by the licensed nurses in their nursing weekly summaries from the period of March 1 to May 15, 2021, was addressed and referred to the physician for appropriate care and treatment. In addition, the facility's licensed nurses failed to create a care plan, conduct an ongoing assessment and evaluation of the skin injury, and monitor the resident for complications after it had been identified; 1b. Resident 23's redness to the right lower leg, edema (swelling) of the right foot, and blackish discoloration on the right big toe and fourth toe were identified, addressed, and referred to the physician for appropriate and timely care and treatment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses implemented the facility's policy and procedure on narcotic drug reconciliation and proper documentation in the narcotic count sheets for 14 of 15 residents reviewed (Residents 10, 37, 53, 313, 314, 315, 316, 317, 318, 319, 321, 322, 323, and 324). This failure had the potential for narcotic drug diversion (transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Expired and outdated medications were not stored and readily available for use. This failure had the potential for residents to receive medications with less efficacy; 2. Medication requiring refrigeration was stored appropriately. This failure had the potential for the residents to receive medications with decreased efficacy; and 3. Discontinued medications were immediately removed and not readily available for use. This failure had the potential for the residents to receive unnecessary medications or for medication error to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services when four food items in the walk-in refrigerator were not labeled with open dates or use-by-dates. This failure had the potential for the growth of harmful microorganisms which may result in food-borne illnesses in a medically vulnerable population.

Inspectors wrote2a. On May 17, 2021, at 11:49 a.m., Resident 1 was observed lying in bed. Resident 1 was alert and able to verbalize her needs. The oxygen tubing was observed laying on top of her bed. The nasal cannula prongs (a device used to deliver oxygen consists of a lightweight tube with pointed parts placed in the nostrils) was discolored. The oxygen tubing was dated April 29, 2021. Resident 1 was observed putting on the nasal cannula in her nose and taking it off several times. On May 17, 2021, at 11:55 a.m., a concurrent observation and interview was conducted with LVN 2. LVN 2 stated the oxygen was off and the oxygen tubing was dated April 29, 2021. LVN 2 stated the oxygen tubing was being changed every Thursday during day shift. 2b. On May 17, 2021, at 11:43 a.m., Resident 18 was observed sitting at the edge of the bed with oxygen on at five liters per minute through nasal cannula. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident was evaluated for the safe self-administration of medications, for one of one resident reviewed (Resident 23). This failure had the potential for the resident to administer the medication in an unsafe manner and to experience adverse (harmful) effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure information regarding formulating an Advance Directive (AD - a written instruction, such as a living will, relating to the provision of treatment and services when the individual is rendered unable to make decisions) was provided to the resident's representative (RR), for three of 15 residents reviewed for AD (Residents 53, 4, and 33). This failure had the potential to result in not determining and/or following the residents' wishes related to the provision of medical treatment and health care services when the residents become unable to make decisions for themselves.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and secured environment was provided for the resident's belongings when the resident representative (RR) reported missing personal items and belongings upon the resident's discharge from the facility on May 2, 2021, for one of three residents reviewed for personal property (Resident 63). In addition, the facility failed to promptly respond to the RR's report of missing belongings. These failures had the potential to negatively impact the well-being of Resident 63.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from verbal abuse, when Resident 2 was heard yelling while using foul language towards Resident 20. This failure had the potential for Resident 20 to be subjected to verbal abuse which could negatively affect the resident's emotional and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of five residents reviewed (Resident 27), metformin (medication used to treat high blood sugar levels in the blood) was administered with food as ordered by the physician and according to current professional standards of practice. This failure had the potential for the resident to experience medication adverse effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure a complete discharge summary was provided to the resident or resident representative upon the resident's discharge from the facility, for one of four closed record sampled residents reviewed (Resident 63). This failure had the potential to cause confusion to the resident, the resident representative, and/or caregivers involved with the resident's care and could increase the risk for an unsafe discharge transition to the community.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's fingernails were kept clean and well-trimmed, for one of two residents reviewed for activities of daily living (ADLs) (Resident 4). This failure had the potential to result in injury and/or the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment to manage pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure to the skin) was provided, for one of one residents reviewed for pressure ulcers (Resident 53) when: 1. The wound dressing on the right hip wound was not replaced immediately after being dislodged; and 2. The Registered Dietitian's (RD) recommendation for Vitamin C (supplement) was not referred to the physician for appropriate action. In addition, the RD's recommendation for Proheal (protein liquid supplement) was not evaluated after the order was completed in 30 days. These failures had the potential for Resident 53 to experience delayed wound healing or worsening of multiple pressure ulcers.

Inspectors wrote2. On May 18, 2021, at 11:30 a.m., Resident 6 was observed awake, lying in bed. The bed was observed to have u shape grab bar on each side of the bed. The bed was observed to be on a high position. In a concurrent interview with Resident 6, she stated she fell from bed reaching for something from the night stand. On May 19, 2021, the record of Resident 6 was reviewed. Resident 6 was admitted to the facility on [DATE], with diagnosis of muscle weakness. The plan of care for falls, dated June 22, 2015, indicated, 1/2 side rails to bed for bed mobility . The Order Summary Report, dated May 16, 2017, indicated 1/2 (one half) SIDE RAILS AS AN ENABLER FOR TURNING AND REPOSITIONING IN BED . The FALL RISK EVALUATION, dated May 8, 2021, indicated a score of 14 (score of 12 or above indicates high risk of for falls). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order was obtained for oxygen use, for one of four sampled residents (Resident 27). This failure resulted in Resident 27's continuous oxygen use without a specific physician's order. In addition this failure had the potential for Resident 27 to receive unnecessary oxygen treatment without proper physician's evaluation.

Inspectors wroteBased on observation and interview, the facility failed to ensure two of 66 residents (Residents 2 and 20) had a functioning call light (a device used by a patient to signal his or her needs for assistance) in their room. This failure resulted for residents not to have a means of directly contacting the staff for assistance.