Dreier's Nursing Care Center

Inspectors wroteBased on interview and record reviews, the facility failed to ensure the prescribers obtained informed consent (communication process where a healthcare provider explains the risks, benefits, and alternatives of a treatment so a resident can choose whether to agree) from the resident or the resident's representative before administering psychotropic medications (medications that affects mood and behavior) for two of the five sampled residents (Residents 3 and 5) in accordance with the facility's policy and procedures titled Informed Consent. This deficient practice had the potential for Resident 3 and 5 to receive psychotropic medications without proper consent, which could result in unwanted treatment and violation of resident rights. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmacy services that ensure non-controlled medication disposition log (log used for drugs that do not have a high risk of abuse or dependence and are not regulated by special government schedules) was completed with the date of disposition and with witnessing nurse's signature. The facility also failed to keep a separate record of emergency drug supplies emergency kit (E-kit- a targeted supply of prescription drugs or emergency gear used for urgent medical needs, severe acute symptoms, or home hospice care) usage. These deficient practices had the potential of misappropriation (misuse or unauthorized taking, use, or sharing of prescription drugs) of medications, and/or medication loss and errors.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute and serve food for 47 sampled residents in accordance with professional standards and the facility's policy and procedures for food service safety by ensuring the facility were properly labeled and dated with the product name, date product was opened or prepared and to be use by date for the following: 1. 17 cups of milk that were not labeled and dated 2. 30 cups of juice (including red and yellow-colored juices) not labeled and dated As a result of these deficient practices exposed residents to the risk of widespread foodborne illness (infections caused by consuming contaminated food, beverages, or water containing harmful microbes, pathogens [disease causing organism] or toxins).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information on their rights to formulate an advanced directive (AD-a written legal document that explains your choices for medical care if you become unable to speak or make decisions for yourself) for one out of eleven sampled residents (Resident 5) in accordance with the facility's policy and procedure (P&P) Advance Directives. This deficient practice had the potential for the facility not to honor the resident's preference and/wishes for their medical care and treatments when they can no longer have the capacity to make their own decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote a homelike environment for one out of five sampled residents (Resident 45) in accordance with the facility's policy and procedure titled Homelike Environment when the wall clock in Resident 45's room did not show the correct time. This deficient practice had a potential to disorient Resident 45, which could lead to agitation.

Inspectors wroteBased on interview and record review, the facility failed to ensure a psychotropic (chemical substances that alter brain function, affecting perception, mood, behavior, and consciousness) medication prescribed for as needed (PRN, not routine) usage had adequate indication for its use and treat specific behaviors, documented descriptions on significant episodes, and documented reasons to administer the as needed psychotropic for one (1) of 5 sampled residents (Resident 3). This deficient practice had the potential to use medications, and/or chemical restraints, unnecessarily.

Inspectors wroteBased on interview and record review the facility failed to report to the State agencies and police department and thoroughly investigate an abuse (intentional actions or practices that cause one's harm and distress) allegation as required for 1 out 1 sampled resident (Resident 59), who alleged that on 7/11/26, Certified Nursing Assistant (CNA) 1 struck Resident 59's right foot while stopping his wheelchair that rapidly rolled down a ramp towards his room in accordance with the facility's policy and procedure titled Abuse, Neglect, Exploitation (treating a person unfairly to gain an advantage) or Misappropriation (misuse of funds)- Reporting and Investigating. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a resident assessment and care-screening tool) assessment was completed and submitted timely to the Centers for Medicare and Medicaid Services (CMS) system for 1 of two sampled residents (Resident 36 and Resident 40) in accordance with the facility's policy and procedure titled Electronic Transmission of the MDS. This deficient practice had the potential to result in confusion regarding the care and services provided to the residents, and a potential to affect the facility's quality of care monitoring system that measures the effective, safe, efficient, patient's centered, equitable (fair), and timely care.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a comprehensive care plan for one out of five sampled residents (Resident 3) who had a diagnosis of cerebrovascular accident (CVA, also known as stroke) and who was also placed on enhanced barrier precautions (EBP, an infection control strategy used in nursing homes and skilled nursing facilities to prevent the spread of multidrug-resistant organisms) in accordance with the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered. This deficient practice placed Resident 3 at risk of receiving care that is not consistent with the resident's goals and health status. 1. [...]

Inspectors wroteBased on interviews and record reviews, the licensed nursing staff and physician failed to act upon the pharmacist's recommendations documented in the Medication Regimen Review (MRR)-a comprehensive evaluation of a resident's medication regimen intended to promote positive outcomes and minimize adverse effects-for one of five sampled residents (Residents 5) reviewed for MRR. The facility failed to follow the pharmacists' recommendation to clarify the diagnosis for Resident 5's aspirin EC (a form of aspirin with a special enteric coating designed to resist stomach acid) 81 mg (a unit of measurement). This deficient practice had the potential for delayed identification of clinical changes, ineffective medication administration, and adverse effects that could lead to acute medical events requiring emergency care or hospitalization.

Inspectors wroteBased on interview and record review the facility failed to accurately and document in the Dialysis (a medical procedure of removing toxins and excess fluid in the blood with the use of a specialized machine) Communication log (a form used by the facility to communicate the resident's condition to the dialysis center prior to receiving dialysis) for one of three residents (Resident 35) the blood glucose (sugar) levels on 7/4/2026, 7/8/2026, and 7/14/2026 in accordance with the facility's policy and procedure titled Care of a Resident with End-Stage Renal Disease. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the spread of multidrug-resistant organism (MDRO- infection-causing organisms that are resistant to one or more medications that treat infection) ) for one out of five sampled residents (Resident 3) who was placed on for enhanced barrier precautions (EBP, an infection control strategy used in nursing homes and skilled nursing facilities) in accordance with the facility's policy and procedure (P&P) titled Enhanced Barrier Precautions. The facility failed to ensure: 1. Two Certified Nursing Assistants (CNAs) don (put on) an isolation gown (or gown, a piece of clothing that is worn to protect both the wearer and the residents from the transfer of microorganisms and bodily fluids) while repositioning Resident 3 in bed. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was informed in writing of the findings of the investigations and the corrective actions needed after grievances (a formal, written or verbal expression of dissatisfaction regarding the quality of care, services, or treatment from a provider or health plan) were received in accordance with facility's Policy and Procedures (P&P) titled Filing Grievances/Complaints. This deficient practice violated Resident 1's right to be informed of the outcome and actions required from the facility after a grievance was filed to address Resident 1's concerns and had the potential for needs to be unresolved.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged resident to resident altercation within two (2) hours for one of three sampled residents (Resident 1 ) to the California Department of Public Health (CDPH) in accordance with the facility's Policy and Procedure (P&P) titled, Abuse Neglect, Exploitation or Misappropriation-reporting and Investigating. This deficient practice resulted in the facility underreporting alleged abuse and had the potential for the facility to not report future allegations of abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of five sampled residents ( Resident 4 ), whose preferred language was Farsi, was provided communication and interpretation services to accurately assess Resident 4. This deficient practice had the potential to result in emotional distress and prevent Resident 4 from being provided care and services based on Resident 4's specific care and needs. During a review of the admission record (AR), the AR indicated Resident 4 was originally admitted to the facility on [DATE], with a diagnosis of fracture of the right patella(small bone in front of knee) , acute respiratory failure(sudden condition where the lungs can't get enough oxygen into the blood or remove enough carbon dioxide) , and diabetes (high blood sugar). [...]

Inspectors wroteBased on interview and record review, the facility failed to treat one of three sampled residents (Resident 1) with respect and dignity by failing to get permission prior to entering Resident 1's room on 8/12/2025, in accordance with the facility's policy & procedure (P&P) on Dignity, and the resident's care plan that indicated facility staff is to knock and request permission before entering a residents' room. Furthermore, the facility failed to assist Resident 1 in maintaining dignity, well-being, manage emotional needs and monitor for further emotional distress, due to the anxiety and stress brought about by a facility staff (Housekeeper [HK] 1) when HK 1 entered Resident 1's room without permission on 8/12/2025, while the resident was dressing up, opened the privacy curtain and looked at Resident 1 while she was naked. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for five of 14 sampled residents (Resident 47, Resident 44, Resident 56, Resident 41, and Resident 14) by failing to: 1. Develop a resident specific care plan for Resident 47 ' s specific food preferences and dietary needs. 2. Develop a resident specific care plan for Resident 44, 56, and 41 oxygen therapy. 3. Develop a resident specific care plan for Resident 14's epilepsy medications: Lacosamide (medication used to control certain types of seizures in people with epilepsy), Keppra (medication used to treat seizures caused by epilepsy), and Lamictal (medication primarily used as an anticonvulsant, often prescribed for epilepsy). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to safely store, discard drugs and biologicals in accordance with the professional standard of practice and facility ' s policy and procedure for two of two sampled residents (Resident 2 and 25) by failing to: 1. Medication Cart (MC) 1 was found to have one insulin pen (a device used to inject insulin, a medication that is used to control the blood sugar), belonging to Resident 25, that was not labeled with the opened date. 2. MC 2 was found to have 2 bottles of over-the-counter medications, Naproxen Sodium (an over-the-counter pain medication) 220 mg (unit of measuring weight) and Vitamin B1 (a supplement) 100 mg, that were not labeled with the opened dates. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards of practice for food service safety by failing to: 1. Monitor and document in the temperature log the refrigerator and dry storage room temperatures to ensure temperatures were within the federal guidelines. 2. Ensure that refrigerated prune juice in the jar was discarded after five days after opening in accordance with the facility ' s policy and procedure titled, Dry Goods Storage Guidelines. These deficient practices placed the facility ' s residents at risk for foodborne illness (an illness that comes from eating contaminated food) by serving expired fruit juice and due to inconsistent refrigerator temperature monitoring and documentation.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain appropriate infection prevention and control practices for two of six sampled residents (Resident 35 and 109) by failing to: 1. Ensure Resident 35 who was on contact precautions for a multidrug - resistant organism (MDRO) had alcohol- based hand sanitizer that was readily available and accessible at the point of care. 2. Ensure Resident 109 ' s peripheral IV (Intravenous- a tube inserted into a needle used to infuse medication into the vein) line port that inserted into the IV was uncapped (not covered) after the administration of intravenous antibiotics (medication used to treat infection) and was touching the bedside curtain. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident and/or responsible party (RP) were informed in advance, of the risks and benefits of hypnotic medications (a type of drug specifically designed to help you fall asleep and stay asleep) and an informed consent was reviewed and completed for psychotropic medications (medication that affects mood and behavior) for one of six sampled residents (Resident 44). This deficient practice violated the resident's right to make an informed decision and consent to receive hypnotic medications.

Inspectors wroteBased on interview and record review the facility failed to provide one of six sampled residents (Resident 12) with information regarding the right to formulate an Advance Directive (AD, a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual was incapacitated). This deficient practice had the potential for the facility to not honor Resident 12 ' s wishes and for the resident to receive inaccurate or unnecessary care and/or treatment services regarding life-sustaining treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 17) received Restorative Nursing Services (RNA, an exercise program to maintain or prevent decline in the resident's joint mobility) as indicated in the care plan and the facility ' s policy and procedure to prevent decrease in range of motion (ROM- how far you can move or stretch a part of your body). This deficient practice had the potential to place Resident 17 at increased risk for ROM decline and development of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of eight sampled residents (Resident 47) with weight loss received a comprehensive nutritional assessment and provided the resident ' s food preferences. This deficient practice had the potential to result in unmet nutritional need, poor meal acceptance, and increased risk for further weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary respiratory care services for two of six sampled residents (Resident 44 and Resident 41) reviewed receiving oxygen therapy by failing to: 1. Ensure Resident 44 received three liters (L, unit of volume used to measure how much oxygen gas was being delivered) of oxygen routinely according to physician ' s orders, and displayed a No Smoking/Oxygen in Use sign for Resident 44. 2. Follow the facility' s P&P for displaying a No Smoking/Oxygen in Use sign for Resident 41. This deficient practice had the potential to cause complications associated with oxygen therapy and result in respiratory distress and place residents at risk of injury due to a fire hazard.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 3 had sufficient skills sets and competency to accurately aspirate (removal of fluid from the body part) and check the gastric residual volume (GRV, the amount of fluid remaining in the stomach at a specific time) of one out of one sampled resident (Resident 15) who had a gastrostomy tube (G-tube, a feeding tube inserted through the abdominal wall directly into the stomach) when: 1. LVN 3 was observed only aspirating 20 mL (milliliters, unit of measurement) of gastric contents from Resident 15 ' s G-tube. 2. LVN 3 verbally stated he only aspirates up to 20 mL of gastric contents when measuring the resident ' s GRV. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three Certified Nursing Assistant (CNA) 3 ' s certificate was not expired and not permitted to perform resident care when CNA 3 ' s CNA certification expired on [DATE]. As a result of this deficient practice, the residents were at risk to receive substandard quality of care from CNA 3 with incompetent nursing skills.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent or (5%) or less during medication pass in accordance with the professional standard of practice and facility ' s policy and procedure on medication administration for two of four observed residents (Residents 17 and 31) in which three (3) medication errors were identified out of 29 opportunities which yielded a cumulative error rate of 10.3 %. The facility failed to ensure: 1. Licensed Vocational Nurse (LVN) 1 did not flush Resident 17 ' s gastrostomy tube (G-tube, a feeding tube inserted through the abdominal wall directly into the stomach) after administering the medication methimazole (medication to treat hyperthyroidism, a condition where the thyroid gland produces too much thyroid hormone). 2. [...]

Inspectors wroteBased on observations, interviews, and records reviews, the facility failed to ensure one of three sampled residents (Resident 1), who had a diagnoses of shortness of breath (SOB), was administered oxygen (O2) via nasal cannula (device used to deliver supplemental oxygen), as ordered by the physician when Resident 1 initially verbalized feeling unwell and having SOB with wheezing (a high-pitched, whistling sound heard during breathing, often indicating a narrowing or obstruction in the airways heard) on 5/06/25 at approximately 8 AM. This deficient practice resulted in Resident 1 not receiving O2 from 8 AM to 4:30 PM, a total of 8.5 hours, and Resident 1 stating she was panicking and struggling to breath, and leading to Resident 1 being transferred to the general acute care hospital (GACH) for respiratory distress.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 2) had appropriate measures taken to ensure the privacy and confidentiality of medical records by mistakenly sending Resident 2 ' s medical records to a general acute care hospital (GACH) with Resident 1, in accordance with the facility ' s policy and procedure titled Confidentiality of information. This failure violated Resident 2 ' s rights to personal privacy and confidentiality of personal and medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure that appropriate information and documentation is communicated to the receiving health care institution for one of four sampled residents (Resident 1), who was transferred to the General Acute Care Hospital (GACH) emergency room (ER) due to a change in condition (COC) on 2/16/2025. The facility transferred Resident 1 to the GACH for a COC, with the incorrect resident ' s records meant for another resident (Resident 2), that included another resident ' s Advance Directive (a legal document that provides guidance on a person ' s preferences for medical treatment), history and physical [H&P], medication orders, and laboratory results. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was transferred in the General Acute Care Hospital for a change in codition, in a safe and orderly manner on 2/16/2025. The Facility failed to ensure proper transfer procedures and preparation necessary were carried out, such as providing the resident ' s correct medical history and medication to ensure the resident ' s medical status and condition was clearly communicated to the receiving facility (GACH). Furthermore, Resident 1 did not have any form of identification with him such as an identification wrist band for proper identification after being sent out to a GACH on 2/16/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment in two of two resident ' s rooms (Residents 1 and 2), residents ' shared bathroom, facility kitchen, and resident ' s activity room. This had the potential for residents to be placed at risk for injury.

Inspectors wroteThe facility failed to provide a safe environment from rain damage to resident ' s rooms for three of five sampled residents (Resident 1, Resident 2 and Resident 3). This deficient practice had caused Resident 1, 2, and 3 to experience anxiety that resulted in the residents ' psychosocial well-being not to feel safe at the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan to address Resident 1's use of the knee immobilizer and/or abduction pillow ordered by the physician on 1/15/2025 s/p right hip reduction (a procedure that involves physically moving a dislocated hip back into place) surgery for one of three sampled residents (Resident 1). This deficient practice had the potential to result in post-surgical complications for Resident 1's recent right hip reduction surgery that included but not limited to increased pain, delayed recovery, and recurrent hip dislocation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 2) was treated with dignity and respect during a routine diaper change by failing to: 1. Ensure Resident 2 was treated with kindness, respect, and dignity as indicated in the Facility Policy titled Dignity dated February 2021. 2. Ensure the facility's staff spoke respectfully, without the use of demeaning practices and standards of care that compromised dignity as indicated in the Facility Policy titled Dignity dated February 2021. These deficient practices had the potential to negatively impact the resident, leading to decreased self-worth, fear, vulnerability and depression.

Inspectors wroteBased on observation, interview and record review, the facility (Skilled Nursing Facility [SNF] 1) failed to allow one of two sampled residents (Resident 1) to remain in the facility and does not initiate a facility-initiated discharge (a discharge which the resident objects to or did not originate through a resident ' s verbal or written request, and/or is not in alignment with the resident ' s stated goals for care and preferences) to another facility (SNF 2) based on SNF 1 ' s inability to meet the resident ' s need for supervision due to wandering (residents who aimlessly move about within the building or grounds unaware of their personal safety) and risk for elopement (a resident who is incapable of adequately protecting himself, and who departs a health care facility unsupervised and undetected). [...]

Inspectors wroteBased on interview and record review the facility (SNF 1) failed to follow its Policies and Procedures (P&P) titled, Transfer or Discharge, Facility-Initiated, dated October 2022, to provide the resident (Resident 1), who has a diagnosis of dementia and wandering behavior and Resident 1 ' s responsible party (RP 1) a written notice and send a copy of the notice to the Ombudsman prior to discharging Resident 1 to another Skilled Nursing Facility (SNF 2). This deficient practice had the potential to result in an unsafe discharge and or denying the resident of the right to appeal the discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a personal centered comprehensive care plan (a detailed plan for an individual's healthcare that is entirely focused on their unique needs, preferences, and goals) to address the care of Resident 2 ' s left eye after he was hit by Resident 1. This deficient practice led to Resident 2 ' s left eye not appropriately cared for by facility staff which had the potential for complications.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of one of three sampled residents (Resident 1) with the significant change in condition when the resident ' s blood sugar level (the amount of glucose in the blood) was consistently elevated from 12/12/2023 - 12/14/2023. This deficient practice can cause the resident to be in a state of hyperglycemia (a condition where there is too much glucose in the blood) that could result to a serious health problem requiring emergency care, including a diabetic coma (a life-threatening medical emergency that occurs when a person with diabetes has dangerously high or low blood sugar levels) that could lead to death.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure for the care of a resident with urinary catheter (a thin, flexible tube that drains urine from the bladder into a collection bag outside the body) for one of three sampled residents (Resident 1) by failing to maintain an accurate record of the resident ' s daily urine output to prevent a urinary catheter-associated urinary tract infection (UTI-infection of the urinary tract, the bladder, ureters, urethra and the kidney). This deficient practice resulted Resident 1 to be hospitalized in an acute care hospital (GACH), transfered via 911 (an emergency service) due to a UTI, sepsis (severe infection in the blood) and a sudden decline in health condition.

Inspectors wroteBased on interview and record review, the facility failed to implement its own policy and procedure by failing to provide necessary respiratory care to one of three sampled residents (Resident 1) by failing to: 1. Assess the respiratory status and report to the physician immediately when Resident 1 ' s oxygen saturation decreased to 92% (a measurement of how much oxygen the blood is carrying as a percentage, normal range 90-100%). 2. Obtain a physician ' s order to safely administer oxygen. 3. Reassess the effectiveness of the oxygen intervention. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy for one of five sample residents (Resident 1) by failing to report allegation of abuse to law enforcement according to the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-centered care plan and monitor Resident 1 after the allegation of abuse for one of five sampled Residents (Resident 1). Resident 1 did not have a care plan developed for allegation of abuse. This deficient practice had the potential to negatively affect Resident 1 psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to protect resident rights for privacy and dignity for eight of eight sampled residents (Resident 1,2,3,5,6,7,8, and 9) by failing to: 1) Ensure other male residents does not shower in Resident 1 and 2 ' s shower room (SR12) located in room [ROOM NUMBER] (RM 12). 2) Ensure Resident 3 does not shower in RM12/SR12 without privacy. 3) Ensure other female residents does not shower in shower room (SR2) located inside the residents (Resident ' s 5, 8 and 9) room, room [ROOM NUMBER] (R2) without privacy. 4) Ensure Resident 6 does not shower in RM2/SR2 without privacy. 5) Ensure Resident 7 does not shower in RM2/SR2 without privacy. These deficient practices violated resident rights for privacy and dignity for Resident ' s 1,2,3,5,6,7,8, and 9 that could affet the pdychosocial being of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a reasonable accommodation of needs for two of three sampled resident (Resident 1 and 3) who preferred to take a shower in a shower room with privacy by failing to: 1) Accommodate Resident 1 ' s preference to not have other residents use his bathroom to shower. 2. Accommodate Resident 3 ' s preference not to shower in Resident 1 ' s bathroom. This deficient practice had negatively affected Resident 1 and 3 rights for privacy and dignity and feeling embarrassed which affects the resident ' s psychosocial well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan to place a low mattress post fall for one of one sampled resident (Resident 4) who was a high risk for fall and had an actual fall from bed with injury on 8/11/24 during a seizure (a sudden, uncontrolled burst of electrical activity in the brain, it can cause changes in behavior, movements, feelings, and levels of consciousness). This deficient practice had the potential for the resident to sustain a severe injury or death from a fall.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one of four sampled residents (Resident 1), who had severely impaired cognition (thought process), severe contractures (a permanent tightening of the muscle, tendon, skin, and nearby tissues that cause the joints to shorten and become very stiff) to the upper and lower extremities, was free from accidents and hazards by failing to: 1. Ensure Licensed Vocational Nurse [LVN] 1 and Registered Nurse (RN) 1 provided report and informed Certified Nurse Assistant (CNA) 1 on potential accident hazards concerning Resident 1's activities of daily living [ADL- fundamental skills that people need to do every day to care for themselves independently], including transfers from bed to chair and bathing, in accordance with the facility's policies and procedures [P&P] titled, Activity of Daily Living. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy and procedure titled Change in a Resident's Condition or Status, and Pain Assessment and Management, by ensuring the physician was immediately notified for one of three sampled residents (Resident 53), who had a significant change of condition when noted with decreased blood pressure (BP) from baseline, increased heart rate (HR), new pain, moaning, fidgeting and agitated by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to reassess, monitor for the signs and symptoms of Cerebral Vascular Accident (CVA or stroke also called ischemic stroke, occurs when the blood supply to part of the brain is blocked or reduced) and Transient Ischemic Attack ([TIA] a short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain),) and exhibited new pain for one of three sampled residents (Resident 53) who was recently hospitalized for change in mental status and was diagnosed with TIA and CVA, in accordance to the facility's policy and procedures, and professional standard of practice the facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) and LVN 2 assessed and monitored Resident 53 for signs and symptoms of TIA and Stroke such as change in mental status, baseline BP, HR, RR and mental status such 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to designate a physician to serve as the medical director responsible for implementation of resident care policies and coordinating medical care, help to implement and evaluate resident care policies or overall goals, directives, and governing statements that direct the delivery of care and services to residents consistent with current professional standards of practice. The facility did not have a designated medical director since June 2023 a total of 6 months to serve the 46 residents of 46 residents in the facility that included Resident 53. The facility failed to: 1. Ensure Resident 53 ' s death was thoroughly evaluated to ensure the resident received healthcare services according to the facility ' s policy and procedure and standard of practice. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the privacy for one of 12 sampled residents (Resident 35), by ensuring the resident's personal information was disposed in a secure manner in accordance with the facility's policy and procedure titled HIPPA (Health Insurance Portability Act- a law that protects the residents privacy) Privacy- Basic Do's and Dont's to Remember, This deficient practice caused Resident 35's personal information readily observable by others not authorized to view information and could be a risk for identify theft (a form of fraud in which the person's personal information is used without the person's permission)

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a resident assessment and care-screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for three of three sampled residents (Resident 41, 45 and 26). This deficient practice had the potential to result in confusion regarding the care and services provided to Resident 41,45,26 and other potentially affected residents. In addition, the deficient practice could affect the quality-of-care monitoring system to ensure safe, efficient, resident centered care in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that two of three sampled residents (Residents 1 and 44) were not receiving any medications without an indication for use, in excessive dose or duration, and with inadequate monitoring by failing to: 1. Ensure that Resident 1 ' s behavior monitoring for auditory hallucinations was specific to the resident ' s behavioral issues for the use of Olanzepine oral tablets (antipsychotic medication). 2. Ensure that Resident 1 ' s behavior monitoring was specific to the resident ' s behavioral issues for the use of Divalproex Sodium Capsule Delayed Release Sprinkle (anticonvulsant medication). 3. Ensure that Resident 44 ' s behavior monitoring was specific to the resident ' s behavioral issues for the use of Risperdal (psychotropic medication). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop a system to systemically identify adverse events (a harmful and negative outcome that happens due to improper medical care), monitor, investigate, analyze root cause, implement and evaluate its Quality Assurance and Performance Improvement Program (QAPI, a program that is focused on action plan to correct identified quality deficiencies [a deviation in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement]) to 46 of 46 sampled residents including Resident 53. [...]

Inspectors wroteBased on interview and record review and observation the facility failed to ensure prompt efforts were made to resolve grievances verbalized by Resident 32 one of two sampled residents and keep Resident 32 apprised of progress towards resolution This deficient practice increased the risk for negative psychosocial impact on Resident 32's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive and resident-centered care plans for three of three sampled residents (Residents 1, 44 and 48) by failing to: 1. Ensure to develop a comprehensive resident centered care plan for Resident 48 that included what side effects to monitor for the use of Lexapro (a medication used to treat depression (a constant feeling of sadness and loss interest, which affects your daily normal activities). 2. Ensure to develop a comprehensive resident centered care plan for Resident 48 ' s use of Vistaril (a medication used to treat anxiety) that included what side effects and specific behaviors to monitor. 3. Ensure to develop a comprehensive resident centered care plan for Resident 1 that included specific interventions for the use of Apixaban, Olanzapine and Divalproex. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote resident safety in administering oxygen in accordance with the facility ' s policy and procedure for one (1) of 1 sampled residents (Resident 44) who was receiving oxygen therapy, by failing to ensure the oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient ' s ears) was not touching the floor. This deficient practice had the potential for Resident 44 to contract infection when receiving oxygen therapy which could increase the risk of the spread of infection to the residents, staff, and other visitors in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two (Licensed Vocational Nurse (LVN 1 and LVN 2) had the specific competency and skill sets necessary to assess, monitor, intervene and notify the physician of a change Resident 53 ' s vital signs (measurement of the blood pressure, heart rate, respiration and body temperature). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was posted and updated on a daily basis. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents` (Resident 53) medications were received and transcribed correctly by failing to: Ensure Resident 53 ' s Ativan tablet orders was transcribed correctly to indicate via g-tube instead of by mouth. These deficient practices increased the risk that Residents 1 and 53 and other residents could experience serious medical complications resulting in fall with injury, coma, or death.

Inspectors wroteBased on interviews and record reviews, the facility failed to assess and monitor continued angry outbursts for one of two sampled residents (Resident 1 and Resident 2): 1. The facility did not initiate a care plan for Resident 1 ' s initial aggression and outburst on 11/3/2023. 2. The facility did not conduct an Interdisciplinary Team (IDT) meeting addressing Resident 1 ' s continued behaviors and aggression. 3. The facility did not monitor Resident 1 ' s aggression after continued incidence of angry outburst. These failures resulted in Resident 1 ' s increased aggression, resulting in Resident 1 physically assaulting certified nurse assistant (CNA) 2, and Resident 1 being arrested at the facility on 2/14/2024.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain infection control (methods used to prevent, control, or stop the spread of infections) precautions by having expired alcohol hand sanitizer available and used throughout the facility. This failure had the potential to result in the spread of bacteria, viruses, and pathogens (harmful microorganisms) to residents, visitors and staff while increasing the risk of infections.

Inspectors wroteBased on interview and record review, the facility failed to decrease the risk of preventable falls for two of three sampled by failing to: 1. Complete the post fall monitoring for Residents 1 and 2, every shift for 72 hours per the facility protocol. 2. Ensure facility staff are aware of Resident 1's fall history, fall status, fall prevention interventions and injury from a previous fall during assigned shift. These failures placed Residents 1 and 2 at an increased risk for preventable falls with possible injury.