Downey Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 3 residents (Residents 2, 3, and 4) received care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence). The facility failed to ensure:Resident 2 was turned and repositioned every two hours to prevent skin breakdown. [...]

Inspectors wroteBased on interview, and record review, the facility failed ensure belongings of one of four residents (Resident 1) who was discharged from and readmitted to the facility were created and itemized (list per item) in the resident's inventory list (a detailed record of items). This failure had the potential for the resident's belongings to be lost or stolen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents' (Resident 1) missing dentures were followed up with the dental consultant timely. This failure resulted in Resident 1 not having dentures while eating for more than a month and placed the resident at risk for poor food intake.

Inspectors wroteBased on interview and record review, the facility failed to ensure the safe discharge planning of one of four sampled residents (Resident 3), who had an unstageable (a full-thickness pressure ulcer whose depth and severity cannot be determined because the wound bed is obscured [covered] by dead tissue, slough, or eschar [dead tissues]) sacral (tailbone) wound, and had home health services (are skilled, physician-directed medical care and related support provided in a patient's home to help them recover from illness, injury, or surgery, manage chronic conditions, or maintain their current health status) ordered prior to the discharge on [DATE]. These failures had the potential that Resident 3's needs will not be met at the receiving facility and had the potential for recurrent hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and food preparation practices was observed for all 95 residents. The facility failed to:1. Maintain cold food items at safe temperatures when glasses of milk and flan measured 50 to 61 degrees Fahrenheit ( F, a scale of temperature).2. Ensure staff did not wear a beaded bracelet during trayline service.3. Ensure one bottle of Martinelli's Sparkling Cider was labeled with the date received. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control measures for four of eight sampled residents by failing to: 1. Ensure Resident 10's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) collection bag did not touch the floor.2. Ensure Licensed Vocational Nurse (LVN) 1 performed hand hygiene (cleaning hands to remove dirt and bacteria) after preparing Resident 86's medications and before administering Resident 86's medications.3. Ensure LVN 1 sanitized the blood pressure cuff before using on Resident 101 after using on Resident 86.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely notification to the responsible party (RP) and physician for one of six sampled residents (Resident 58) by failing to:Ensure the licensed nursing staff notified the Responsible Party (RP) that Resident 58 exhibited increased confusion and had partially slid off the bed on 4/20/2026. Ensure the licensed nursing staff notified the physician that Resident 58:Exhibited increased confusion during the early morning hours of 4/20/2026. Partially slid off the bed between approximately 2:30 am to 3:00 a.m. on 4/20/2026. Developed bruising to the left arm on 4/22/2026. These deficient practices had the potential to place Resident 58 at risk for delayed diagnosis, delayed treatment, worsening injury, unmanaged pain, and further decline. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was initiated for a resident's development of a bruise for one out of six sampled residents (Resident 58). These deficient practice had the potential to place Resident 58 at risk for delayed treatment, delayed assessment, and further injury. Resident 58 was later hospitalized and diagnosed with a left elbow fracture (broken bone). Cross Reference F580, F689, and F842. During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was initially admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise two of two sampled residents' (Residents 52 and 10) care plans to reflect their need for the Hoyer Lift (a mechanical device used to lift and/or transfer a person) during transfers. This deficient practice had the potential to result in the miscommunication of the transfer needs for Residents 52 and 10, which could lead to unsafe transfers. Cross Reference F689.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 52 and 58) were free of accidents and hazards by failing to:1. Use a Hoyer Lift (a mechanical device used to lift and/or transfer a person) when Resident 52 was transferred from the shower chair to the bed on 4/29/2026.2. Conduct an Interdisciplinary Team (IDT- a coordinated group of experts from several different fields) meeting after Resident 52 sustained two injuries to the lower left leg from a shower chair-to-bed transfer on 4/29/2026.3. Ensure adequate supervision and timely physician notification occurred after Resident 58 exhibited acute confusion and displayed urgent desire to leave her bed. These deficient practices resulted in Resident 52 sustaining two wounds on her lower left leg and had the potential for additional accidents to occur. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received the volume of oxygen ordered by the physician for one of six sampled residents (Resident 61). This deficient practice resulted in Resident 61 receiving less oxygen than required and had the potential to negatively impact Resident 61's well-being. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 61's diagnoses included hypoxia (when the body does not get enough oxygen) and cerebral infarction (a stroke caused by blocked blood flow to the brain). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate and complete documentation on the Controlled Record for one of one sampled resident (Resident 110). This deficient practice resulted in the inaccurate count of medications remaining in the medication bubble pack (a card used to store medications for the resident) and had the potential to result in the administration of additional doses, drug diversion (the theft or misuse of prescription medications by health care providers for personal use), and/or medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate clinical records for two out of twelve sampled residents (Resident 52 and Resident 58) by failing to: 1. Ensure nursing interventions and pertinent clinical details were documented after Resident 58 exhibited acute confusion and experienced an episode of partially sliding off the bed on 4/20/2026. 2. Ensure a skin assessment included bruising (occurs when small blood vessels near the skin's surface break from an injury) or discoloration to Resident 58's left arm on 4/22/2026. 2. Ensure a skin assessment was documented after Resident 52 sustained two wounds on her left lower leg on 4/29/2026. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that Resident 65's bedroom was equipped with a privacy curtain to ensure full visual privacy for one of six sampled residents (Resident 65). This deficient practice had the potential to violate the resident's right to visual privacy and dignity during personal care and activities of daily living.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality, for one of three residents (Resident 2), by failing to:1). Ensure timely documentation was performed when Resident 2 was assessed and administered pain medication on 3/11/2026. 2). Ensure Resident 2, who had a foley catheter (catheter that drains urine from bladder into a bag outside the body), was provided a securing device (to keep the catheter from being pulled away), as indicated in the resident's care plan titled Resident with an episode of blood in the urine. These failures had the potential for poor quality care and placed Resident 2 at risk for unintentional drug overdose (taking more than what is safely prescribed) and further catheter-associated trauma (like bleeding), pain and discomforts, leading to complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident-centered care plan, for one of three residents (Resident 1), who was incontinent (no control) of bowel and bladder functions and who developed a Moisture-Associated Skin Damage (moisture associated skin damage caused from prolonged exposure to moisture) on 11/3/2025, was created, with interventions, to keep the resident's skin clean and dry. This failure resulted in delayed interventions and had resulted in the development of further MASDs, placing the resident at risk for wound complications and further skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision during toilet use to one of six sampled Residents (Resident 1), who was assessed as high risk for falls. This failure resulted in Resident 1 falling from the toilet and sustaining a forehead laceration (a deep cut in the skin), which required five sutures (used to close wounds and hold tissues together) at a general acute care hospital (GACH).

Inspectors wroteDuring an observation, interview, and record review the facility failed to practice pressure related injury preventive practices for three out of seven residents (Resident 1, 2, and Resident 3): 1. Nursing staff did not follow doctor's order for a low air loss mattress ([LALM], a mattress that provides airflow to help keep skin dry, as well as to relieve pressure, treat pressure sores and prevents pressure sores) for Resident 1, 2, and 3. 2. Nursing staff did not follow up on LALM order status. 3. Nursing staff did not ensure Resident 1, 2, and 3 had LALM to prevent pressure injuries (localized area of tissue damage that develops when prolonged pressure or shear forces are applied to the skin and underlying tissues). These deficient practices placed Resident 1,2, and 3 at risk for further skin damage and it placed residents at risk for developing pressure injuries.

Inspectors wroteBased on interview and record review, the facility did not ensure Braden scale assessment (tool used in Skilled Nursing Facilities to assess a patient's risk of developing pressure injuries [localized area of tissue damage that develops when prolonged pressure] or shear forces [horizontal force that causes the bony prominence to move across the tissue as the skin is held in place] are applied to the skin and underlying tissues) was accurately performed for one resident (Resident 1) out of 4 sampled residents. 1. Facility did not ensure Resident 1 was correctly assessed during Braden Scale assessment. 2. Facility did not ensure Nursing staff had the knowledge of scoring resident during the Braden Scale assessment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan (a document that outlines a person's health needs and the care they required) for four out of four sampled residents (Resident 27, 71, 78, and 62) by failing to: 1. Ensure Resident 27 received a magic cup (a nutritious frozen supplement designed to enhance nutritional intake for individuals experiencing involuntary weight loss) on his lunch meal tray as indicated in Resident 27's physician orders and in his nutritional care plan. 2. Ensure a resident centered care plan was developed for Resident 71's vision impairment. 3. Ensure a care plan was developed for Resident 78's vision impairment. 4. Ensure the facility developed a care plan for Resident 62's medication refusal. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of care for two of two sampled residents (Resident 62 and 142) by failing to: 1. Ensure the nurse documented Resident 62's medications refusal on the Progress Notes. 2. Ensure the nurse did not educate Resident 62 on risk and benefit of refusing medications. 3. Ensure Resident 142's doctor was informed of a change in condition to Resident 142's urine. This deficient practice had the potential to result in delayed necessary medical care for Resident 62 and Resident 142.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 78) was seen by an Ophthalmologist (a doctor trained in diagnosing and treating eye problems, including injury and disease) by failing to: 1. Ensure Resident 78 was referred to an ophthalmologist per the optometrist (healthcare provider that examine, diagnose, and treat diseases and disorders that affect eyes and vision) recommendation. This deficient practice had the potential to result in a delay in treatment for Resident 78.

Inspectors wroteBased on interview and record review, the facility failed to ensure weekly skin interdisciplinary (IDT) meetings were conducted between the dates of 1/9/2025 through 2/27/2027 after a resident had developed redness on his left hip and left anterior iliac crest (a bony prominence located on the anterior (front) portion of the left iliac bone, which is part of the pelvis) for one of six sampled residents (Resident 27). This had the potential to result in additional pain-inducing, pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for Resident 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who required dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) had failed) received services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of one resident (Resident 62), when the facility failed to remove Resident 62's pressure dressing (a bandage designed to apply pressure to a dialysis access site, to help control bleeding and promote clotting after a needle was removed) on the arteriovenous shunt (AV shunt, a surgically created connection in the arm to facilitate blood flow for dialysis) site as ordered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately account for and document the administration of one out of three doses of lorazepam (a controlled medication [had a high potential for abuse] to treat anxiety [a feeling of fear, dread, and uneasiness]) for one of one resident (Resident 77) on East Station, Medication Cart East. This deficient practice increased the risk for unsafe medication administration with the potential for diversion (situation when a medication was taken for use by someone other than whom it was prescribed) and medication errors due to lack of documentation, possibly resulting in serious health complications that could lead to hospitalization or death for Resident 77.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one resident (Resident 25) was free from a significant medication error (one which caused the resident discomfort or jeopardizes his health and safety) when Licensed Vocational Nurse (LVN) 3 administered a chewable aspirin tablet to Resident 25 without a physician's order on 3/26/2025 at 9:01 a.m. This deficient practice had the potential to result in an adverse drug reaction (unwanted undesirable effects that were possibly related to a drug) which could lead to ulceration and/or bleeding to the gastrointestinal ([GI] organ system in the human body that included mouth, throat, esophagus, stomach, small intestine, large intestine, rectum, and anus) tract, hospitalization, or death for Resident 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection (the invasion and multiplication of microorganisms [like bacteria, viruses, etc.] in body tissues, potentially causing illness or harm) control practices for two of two residents (Resident 33 and 62) by failing to: 1. Ensure Resident 33's opened nebulizer mask (a plastic cup that fit over the mouth and nose to deliver liquid medication as a mist into the lungs) was placed directly on the surface of the nightstand at bedside on 3/25/2025. 2. Resident 66's dirty clothes and linen were observed on Resident 66's bed unattended on 3/26/2025 This deficient practice had the potential to place Resident 33 and Resident 62 at risk for infection which could increase the morbidity (the amount of disease in a population) and mortality (the state of being subject to death) among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required room size measurement of 80 square feet ([sq. ft.]- a unit of measurement) of room space per resident in rooms with multiple residents. This deficient practice had the potential to result in not providing residents privacy and could potentially affect residents' health and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Report an injury of unknown source within 2 hours, to the California Department of Public Health (CDPH), for 1 of 4 residents (Resident 1), who had a fractured (broken bone) right wrist on 3/3/2025. 2. Ensure the result of all investigations were reported to CDPH within five (5) working days of the incident. These failures resulted in the delayed investigation by CDPH and placed the resident at risk for further injuries.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Develop a care plan for for 1 of 4 residents, Resident 1, who had behavior of thrashing (swinging) arms and with erratic (unpredictable) behaviors. 2. Implement its policy and procedure (P&P), titled Significant Change of Condition, Response, for Resident 1, who was guarding (protecting) his right wrist and had complained of pain. These failures resulted in the lack of safe interventions and poor-quality care, resulting in the resident ' s transfer to a general acute care hospital (GACH) on 3/3/2025.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were placed within residents ' reach for two of six sampled residents, (Resident 3 and Resident 4. This deficient practice could result in residents not able to call nurses for assistance in case of medical emergency (change in medical condition) and when in need of care and assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records requested by one of four sampled residents (Resident 1), were released within 24 hours as indicated in the facility ' s policy and procedure (P&P) titled Residents Rights, Release of Information. This deficient practice resulted in the violation of a residents ' rights and had the potential to affect Resident 1 ' s quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent a fall for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA 1) provided a two-person physical assist (help from two persons) when using a Hoyer Lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from a wheelchair to the bed. This deficient practice caused Resident 1 to fall, sustain a right distal femur fracture (thigh broken bone), was admitted to a general acute care hospital (GACH), and had an open reduction internal fixation ([ORIF]-surgical procedure to stabilize and heal a broken bone).

Inspectors wroteBased on interview and record review, the facility failed to transfer one of three sampled residents (Resident 1) immediately to the general acute care hospital (GACH), on 8/2/2024, when Resident 1 had an unavoidable fall that caused Resident 1 to sustain a right distal femur fracture (thigh broken bone) and required admission to a GACH for evaluation and treatment. This deficient practice resulted Resident 1 ' s delayed transferred to the GACH on 8/3/2024, 10 hours after an X-ray (a photographic image of a part of the body) result indicated acute (sudden) comminuted supracondylar (broken bone into more than two pieces) fracture of the right distal femur, and had the potential for Resident 1 to experience severe pain, and risk for delayed care, and treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide Restorative Nursing ([RNA] nursing aid that helps residents maintain their function and joint mobility) exercises according to the physician ' s order for three of five residents (Residents 1, 2 and 5). This deficient practice placed Residents 1, 2, 3 and 5 at risk for contractures (permanent or temporary shortening of muscles, tendons, skin, and other tissues that causes joints to stiffen and prevent normal movement) and a decline in range of motion ([ROM] how far you can move or stretch a part of the body, such as a joint or a muscle).

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement an individualized person-centered care plan with measurable objectives, timeframes, and interventions for two of three sampled residents (Resident 1 and Resident 3), who had moisture associated skin damage ([MASD] skin damage caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection). This deficient practice had the potential to negatively affect the delivery of skin treatments and skin breakdown prevention for Resident 1 and Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written or verbal authorization was obtained from one of three residents' (Resident 1), responsible party, prior to resident's discharge to another facility. This failure resulted in resident's primary responsible person not aware of the discharge.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized person-centered care plan (document helps nurses and other team care members organize aspect of resident care) addressing a Stage III pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin which extends through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) for one of five sampled residents (Resident 1). The care plan was developed a month after Resident 1 was diagnosed with a Stage III pressure injury. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to securely store discontinued controlled medications (medications regulated under federal law) in a locked drawer that was inaccessible by residents, visitors, and staff for one of one resident (Resident 46). This deficient practice had the potential to result in the unsafe access of medications by residents, staff, and visitors that could lead to adverse reactions due to accidental ingestion of unnecessary medication and the increased risk of drug diversion (when medications are obtained or used illegally).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignified care for one out of six sampled residents (Resident 240) when Resident 240 had thick, yellow-white-ish residue and plaque buildup on his teeth, gums, and tongue, and was not provided oral care before he was fed breakfast and lunch. These deficient practices had the potential to cause Resident 240 to exhibit feelings of self-worthlessness and sadness related to inability to eat or communicate effectively.

Inspectors wroteBased on interview and record review, the licensed nurses failed to review, update, and/or revise a care plan addressing residents' new hemodialysis (the process of removing waste products and excess fluid from the body) access site for one resident out of two sampled residents (Resident 52) by failing to: 1. Update the dialysis care plan after Resident 52 had surgery (7/26/2023) for an arteriovenous fistula ([AVF] surgical connection made between an artery and a vein, typically located in the arm, and used for hemodialysis). 2. Revising the dialysis care plan interventions to address Resident 52's left arm hemodialysis access site. These deficient practices resulted in the lack of plan of care for Resident 52's hemodialysis access site care, and placed Resident 52 at risk for an unidentified complications to the hemodialysis access site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, quality care was provided for one out of six sampled residents (Resident 204) when the facility failed to ensure the following: 1. Resident 240's oral care was performed before the first meal of the day. 2. Resident 240's blood sugar was taken, as ordered by the Physician. 3. Resident 240's lab results were relayed to the physician in a timely manner. 4. A Stat (an order to be performed within one hour) urine culture (a urine collection for testing) was collected in a timely manner. 5. A safe swallowing strategies sign was posted for Resident 240 before he was fed. These deficient practices led Resident 240 to exhibit hunger and a delay in care and treatment for Resident 240's possible leukocytosis (infection). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were repositioned to aid in the prevention of the development of pressure ulcers or the worsening of existing pressure ulcers for two out of two sampled residents (Resident 16 and 61). These deficient practices led to Resident 16 to acquire a Stage III pressure ulcer (full thickness tissue loss) and had the potential for Resident 61's existing Stage IV pressure ulcer (severe tissue damage in which muscle or bone may be exposed) to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Resident 87, 77, and 67) with limited mobility (ability to move) and range of motion [ROM, full movement potential of a joint (where two bones meet)] received services to maintain mobility and ROM. a. For Resident 87, the facility did not provide assistance with ambulation (the act of walking) in accordance with the physician orders, dated 3/13/2024. b. For Resident 77, the facility did not provide active range of motion (AROM, performance of ROM of a joint without any assistance or effort of another person) to both arms, three times per week, in accordance with the physician orders for 1/2024 and 3/2024. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to change the intravenous line (IV, a soft flexible tube placed inside a vein to administer medications or fluids) dressing in accordance with the physician's order for one of five sampled residents (Resident 190). This deficient practice had the potential to result in a delay of the assessment of the IV insertion site and development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for three of three sampled residents (Resident 39, 55, and 190) by failing to: 1. Provide two (2) liters (L, unit of volume) of oxygen in accordance with Resident 39's physician orders and care plan. 2. Label Resident 55 and Resident 190's nasal cannula (device used to deliver supplemental oxygen or increased airflow through the nose) with the open date. These deficient practices resulted in excessive levels of oxygen to Resident 39's body and had the potential to weaken Resident 39's lungs. These failures also had the potential to increase the risk for a respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was accurately assessed before and after hemodialysis (process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do own their own) treatment for one resident out of two sampled residents (Resident 74) by failing to: 1. Ensure licensed staff accurately assessed Resident 74's perma catheter (catheter placed inside a blood vessel in the neck or under collarbone and then threaded into the right side of heart, used for hemodialysis) before leaving to hemodialysis and when returning from hemodialysis. 2. Ensure licensed staff accurately documented the assessment of Resident 74's hemodialysis access site. These deficient practices had the potential for an unidentified complication after dialysis treatment such as swelling, pain, bleeding, and bruising.

Inspectors wroteBased on interview and record review, the facility failed to ensure the following: 1. The Director of Nursing (DON) did not separately work to perform duties as a Registered Nurse (RN) Supervisor. 2. An RN supervisor worked for at least 8 consecutive hours. 3. The number of RN hours worked were accurately accounted for. 4. Intravenous (IV, into the vein) medications were administered for three of three residents receiving IV medications (Resident 25, Resident 90, and Resident 240). These deficient practices had the potential for assessments and IV medications to be missed, and the potential for an overall decrease in the quality of care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe administration of medications for two out of six sampled residents (Resident 73 and Resident 2) when the following occurred: 1. One white pill was found on top of Resident 73's night stand. 2. Two yellow pills, one beige capsule, one white powdered medication was found spread across Resident 2's blanket while Resident 2 laid in bed. Two orange pills, one red capsule, and one crushed yellow pill was also found on Resident 2's meal tray. These deficient practices could have led to Resident 73 and Resident 2 to double dose on medications, exhibit a hypotensive (low blood pressure) or hypertensive (high blood pressure) episode, and medically related issues associated with the missed doses of the medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to reevaluate the medication indication of use for one of five residents (Resident 190) who received mirtazapine (an antidepressant, a medication to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest in life]). This deficient practice had the potential for Resident 190 to receive mirtazapine for the incorrect indication and be subjected to unnecessary side effects such as dizziness, constipation, and sleepiness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe and sanitary food storage practice in the kitchen that affected 88 out of 88 sampled residents when the facility failed to: 1. Ensure the refrigerator did not have spoiled vegetables and fruit. 2. Ensure refrigerated food items were properly labeled with a use by date or an open date. 3. Ensure the refrigerator did not have expired food. 4. Ensure lettuce was placed in a bag or a sealed container. 5. Ensure the dry storage room did not have items that were not accurately labeled. These deficient practices had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illness in residents that are medically compromised residents.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide accurate documentation for two of five sampled residents (Resident 77 and 67) with limited mobility (ability to move) and range of motion [ROM, full movement potential of a joint (where two bones meet)]. a. For Resident 77, the facility did not remove the Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) task to perform passive range of motion (PROM, movement of joint through the ROM with no effort from the person) to Resident 77's legs in accordance with the physician order, dated 2/22/2024, discontinuing RNA for PROM to both legs. b. For Resident 67, the facility did not accurately indicate the facility staff providing the RNA treatment on 3/19/2024 in the clinical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility nursing staff failed to ensure infection prevention practices were implemented for intravenous ([IV]- in the vein) medication therapy for three out of four sampled residents (Resident 25, Resident 91, and Resident 241) when the following occurred: 1. Resident 91's and 241's IV tubing (tubing used to administer medications directly into the vein) was not labeled with the time and date of when the IV tubing set was changed and when the tubing set expired. 2. Resident 25's IV site (a catheter than is placed in the resident's vein to administer medication) was not labeled with the date and time of when the IV was started. These deficient practices had the potential to cause sepsis (blood infection) or an infection for Residents 25, 91 and 241.

Inspectors wroteBased on interview and record review, the facility failed to administer the pneumococcal vaccine (medication that trains the body's immune system so that it can fight pneumonia [an infection that inflames the air sacs in one or both lungs]) to two of five sample residents (Resident 27 and 48), who were eligible and had consented to receive the vaccine. This deficient practice had the potential to result in the development and spread of pneumonia.

Inspectors wroteDuring an observation, interview, and record review the facility failed to provide 80 square feet of room space per resident for 4 rooms out of 35 rooms. This deficient practice could potentially not provide residents privacy and could potentially affect residents' health and safety.

Inspectors wroteBased on interview, and record review, the facility failed to maintain accountability of 30 doses of Norco (a medication used to treat pain) 5/325 milligrams ([mg] a unit of measurement) between 1/15/2 and 1/16/24 for one of three sampled residents (Resident 1). The deficient practice had the potential to result in diversion of medication (used for any purpose other than the one intended by the prescriber) and unrelieved pain due to pain medication not being available for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control and prevention practices by failing to: 1. Ensure facility staff wear a face mask (a personal protective equipment worn covering mouth and nose to serve as a barrier to interfere direct airflow in and out of nose and mouth) when in the facility. 2. Ensure the mouth and nose were covered when face mask was worn by facility staff during direct residents ' care. This failure placed all the residents and staff at higher risk for infection, and the transmission of communicable diseases in the facility and the community. During an entrance to the facility on [DATE] at 8:30 a.m., the Director of Nursing (DON) was observed walking on the hallway and talking to staff and residents and had no mask on. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection prevention and control policy and procedures (P&P) by failing to: 1. Notify the Department of Public Health (DPH) of an outbreak of coronavirus disease ([COVID-19], a highly contagious respiratory infection caused by a virus that can easily spread from person to person) in a timely manner. 2. Ensure facility Housekeeper (HSK) performed hand hygiene (cleaning hands by handwashing or using an alcohol-based hand sanitizer) after entering the covid-19 isolation room (designated area to keep residents confirmed with covid-19 separate from other residents to prevent the spread of infection) and prior to touching other clean surfaces, areas and resident rooms. [...]