Driftwood Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 2's Responsible Party (RP) choices were upheld regarding medication consent and dosing for one of three sampled Residents (Resident 2) who was prescribed Trazodone (medication used to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest] 50 milligrams ([mg] unit of measurement) at bedtime for insomnia. This deficient practice resulted in the Resident 2 receiving treatment inconsistent with the RPs directive. Resident 2 continued to receive Trazadone 50 mg on 7/2/2026, 7/3/2026, 7/4/2026 and 7/5/2026 despite the RP consenting to decrease the Trazodone to 25 mg. This failure resulted in Resident 2 experiencing increased lethargy on 7/2/2026 and had the potential to result in excessive sedation, increased fall risk, and cognitive impairment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) whose Responsible Party (RP) verbalized quality of care concerns to facility staff, was informed of and helped in completing a Grievance/Complaint Investigation Report. This failure resulted in Resident 2 and RP 2 not receiving timely or formal communication regarding the outcome or resolution of the complaint, which led to distrust toward the facility. This failure had the potential to delay necessary care and services to Resident 2 and could negatively impact Resident 2's mental health and emotional well being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (Resident 2) who had insomnia (trouble falling asleep or staying asleep) staff implemented Care Plan interventions which included behavioral monitoring to determine changes in sleep patterns and received resident-directed care and treatment consistent with the residents Care Plan prior to the initiation of Trazadone (a medication used to treat prescription medication prescribed to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest]) for one of three sampled residents (Resident 2). This deficient practice resulted in nursing staff failing to adequately assess and monitor Resident 2's sleep patterns per the Care Plan and resulted in nursing staff to be unaware of the clinical indications that lead to the physician's order for Trazodone. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Responsible Party (RP), who was a Conservator (a person appointed by a court to manage the financial or personal affairs of someone who is unable to do so themselves due to illness, disability, or other incapacitation), appointed by the Los Angeles County Office of the Public Guardian, for one of four sampled residents (Resident 1) was informed of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) and allowed to give their consent for Resident 1 to continue use of the medication, versus providing this information to Resident 1's FM and allowing her to give consent for Resident 1's use of the medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Responsible Party (RP), who was a Conservator (a person appointed by a court to manage the financial or personal affairs of someone who is unable to do so themselves due to illness, disability, or other incapacitation), appointed by the Los Angeles County Office of the Public Guardian, for one of four sampled residents (Resident 1) was involved in the development of Resident 1's a discharge plan to reflect Resident 1's discharge needs, goals, and treatment preferences. This deficient practice resulted in Resident 1 being inappropriately discharged from the facility with a Family Member (FM), who was not Resident 1's Conservator and placed Resident 1 at risk for decline in health and non-continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the spread of infection for 91 of 91 residents in the facility by failing to: 1. Ensure the hot water temperature logs of the washing machines were accurate and monitored daily.2. Implement policies and procedures (P&P) of proper washing machine temperatures and accurate documentation logs. This deficient practice had the potential to spread infection to all 91 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper medication storage according to requirements indicated on the pharmacy label and labelling medications when: 1. One vial of unopened Humulin R [type of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication)] was not stored inside the refrigerator. 2. One bottle of unopened latanoprost eye drops (medication used to manage elevated pressure in the eye) was not stored inside the refrigerator. 3. One bottle of artificial tears (lubricating eye drops used to help relieve dry and irritated eyes) was not labeled with resident's full name, bottle showed room number, had a broken seal, and no open date. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 85 out of 91 total residents in the facility by failing to:A. Ensure food items were labelled, dated, and sealed properly. B. Discard expired thickened water and kiwi strawberry flavored syrup for juice dispenser. C. Follow a meal ticket/tray card during tray line (Resident's trays are assembled and check for accuracy before food is delivered to them). D. Ensure [NAME] (CK) 2 did not wear jewelry while serving food during tray line. E. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate documentation for two of 16 sampled residents (Resident 6 and Resident 15) by failing to:a. Ensure Resident 6, who had a diagnosis of depression (a serious mood disorder that affects how you think, feel, and handle daily activities) and taking an antidepressant medication (medications used to treat depression and other conditions) was documented on the medical diagnosis list.b. Ensure Resident 15's Medication Administration Record for the month of August 2025 was accurate when it indicated Resident 15 received Naloxone (a medicine that rapidly reverses an opioid [strong pain medication] overdose) on 8/1/2025, when Resident 15 did not receive Naloxone. [...]

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to ensure the call light device was in reach for one out of three residents (Resident 1). This deficient practice had the potential to result in a delay of care and the Resident 1 needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to investigate a claim of missing belongings for one of eight sampled residents (Resident 8). This deficient practice resulted in Resident 8 missing her blanket for three months.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications (medications that affect brain activities associated with mental processes and behavior) were not used unnecessarily for one of five sampled residents (Resident 66) by failing to define and monitor resident specific, measurable target behaviors related to the use of Seroquel [an atypical antipsychotic used to improve mood, thoughts, and behaviors] for people with schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs)] for Resident 66. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one out of two sampled residents (Resident 6) had their Level 1 Preadmission Screening and Resident Review ([PASRR], a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) completed accurately. This deficient practice had the potential to delay care for Resident 6 and had the potential of not receiving the proper level of care or services required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan for two of the three sampled residents (Resident 52 and Resident 6) by failing to:A. Ensure Resident 52 had a care plan for impaired hearing. B. Ensure Resident 6 who had a diagnosis of post-traumatic stress disorder ([PTSD], a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it), had a care plan and included the use of psychotropic medications for mood disorders. These deficient practices had the potential to negatively affect the quality of life and wellbeing for Resident 6 and Resident 52 and could result in preventing them from achieving their highest practical well-being or needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication listed on the oral medications' Emergency kit (Ekit) index (list) matched the medication found inside the Ekit. This failure had the potential to result in a delay in the administration of emergency medication and medication error.

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to document monitoring on the medication administration record (MAR) for signs and symptoms of bleeding for one out of three residents (Resident 63) who is on Apixaban (a medication that thins the blood, prevents clots). This deficient practice had the potential to result in Resident 63 having blood in the stool or urine, bruising or severe headaches.

Inspectors wroteBased on interview and record review, the facility failed to protect the health, welfare, and rights for 94 of 94 residents by failing to implement the facility's written abuse policy and procedure (P&P) to suspend Certified Nurse Assistant (CNA) 1 and CNA 2 who were involved in the alleged abuse allegation. This deficient practice placed all residents at risk of abuse and had the potential for Resident 1 to feel unprotected and unsafe in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the personal belongs for one of two sampled resident's (Resident 1), who was discharged from the facility on 1/17/2025, were made available to Resident 1 and/or Resident 1's Responsible Party (RP) and/or Family Member (FM). This deficient practice resulted in Resident 1's being discharged to a Board and Care ([B&C] a type of small, residential facility that provides housing and personal care services to individuals who need assistance with ADLs) facility without her personal belongings and had the potential for Resident 1 to feel detached in her new environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who was diagnosed with dementia (a progressive state of decline in mental abilities), and who lacked the capacity to understand and make decisions was discharged appropriately from the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 1) who was observed with a discoloration on her forehead, black eye and eye swelling was reported to California Department of Public Health (CDPH). This failure resulted in CDPH being unable to investigate Resident 1's injury of unknown origin in a timely manner

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) who was observed with discoloration on her forehead, black eye and eye swelling on 3/20/2025 was investigated into the history of her injury and to rule out abuse and neglect. This deficient practice had the potential to result in unidentified abuse and/or neglect in the facility and the failure to protect residents from abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from sexual abuse. This deficient practice resulted in Resident 2 entering Resident 1's room unbeknownst to staff on 3/17/2025 at approximately 11 p.m., unfastening her (Resident 1's) incontinent brief and touching her private area, causing Resident 1 to feel scared and helpless. This deficient practice had the potential for Resident 1 to suffer emotional consequences and for other residents in the facility to be subject to the same abuse.

Inspectors wroteBased on interview and record review, the facility failed to conduct thorough investigation for one of three sampled residents (Resident 1), when they did not interview other residents in the facility, following an allegation made by Resident 1 that Resident 2 came to her room, which was confirmed by the facility's video surveillance, and touched her private parts. This deficient practice resulted in the inability of the facility to determine if Resident 2 had a behavior of entering other resident's rooms and touching them.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled resident's (Resident 1) discharge planning and discharge procedures were implemented and documented prior to and when was Resident 1 was discharged from the facility (2/27/2025). This deficient practice resulted in Resident 1 being discharged from the facility without prior discharge planning or documentation that he received discharge instructions when he left the faciity on 2/27/2025. This deficient practice had the for Resident 1 to be unaware of his care needs and follow up appointments.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 5) was supervised by the facility staff while smoking. This deficient practice resulted in Resident 5 smoking unsupervised on/near the facility's parking lot with the use of a cigarette lighter, without wearing a smoking apron, or having a receptacle to safely dispose of his used cigarette(s). This deficient practice had the potential for Resident 5 to sustain burn injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Occupational Therapist (OT- a healthcare provider who helps a person meet goals to develop, recover, improve, and maintain skills needed for daily living and working) 1 accurately documented on the OT Discharge Summary Note the discharge goals for one of three sampled residents (Resident 3). OT 1 documented on 9/13/2024, Resident 3 tolerated thin hand rolled washcloth for four hours in her left hand without irritation or skin breakdown, when it should have been the documented for the right hand. This deficient practice resulted in inaccurate documentation of Resident 3's OT Discharge Summary Note and had the potential to affect Resident 3's plan of care and treatment.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident (Resident 3) who had a designated Advocate (AD 1) was invited to participate in the Interdisciplinary Team Meeting ([IDT] a team of health care professionals from different disciplines who work together to provide care for a resident) to discuss and participate in the revision of the care plan (a document that summarizes a resident ' s health conditions, care needs, current treatments, goals, and action plan) for one out of three sampled residents (Resident 3). This deficient practice resulted in Resident 1 ' s AD 1 not attending the IDT meeting and had the potential to result in a care plan that was not person-centered (designed specifically around the individual needs, preferences and goals of the resident receiving care) and would not meet Resident 3 ' s needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of five sampled residents (Resident 3 and Resident 4), who were high-risk for falls, had wheelchairs that locked. This deficient practice had the potential to cause Resident ' s 3 and Resident 4 to sustain falls and injuries resulting from the fall such as a hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel), fractures (broken bones), hospitalization, and possible death resulting from complications of the fall.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of medical records upon written request from an authorized legal representative ([LR] a person who is legally authorized to act on behalf of another) for one of five sampled residents (Resident 2) within two working days. This deficient practice violated Resident 2 ' s right to obtain a copy of their medical record and delayed their appeal to Health Insurance Provider (HIP) ' s decision to deny Resident 2 covered (paid for by insurance) stay at the facility.

Inspectors wroteBased on interview and record review the facility failed to retain, accurately document, systematically organize, and have readily accessible medical records for one of five sampled residents (Resident 2) according to the facility ' s policy and procedure (P&P) titled, Documentation Retention. This deficient practice had the potential Resident 2 to have unnecessary stress and fear of being kicked out of the facility due to Health Insurance Provider (HIP) not being given the clinical documents needed to support her continued insurance coverage to stay at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was able to return to her room upon readmission from a General Acute Care Hospital (GACH). This failure resulted in Resident 1 experiencing frustration and sadness after being placed in a new room upon return from the GACH.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents, who were on dysphagia (difficulty chewing and swallowing) minced and moist (mechanical-soft texture modified diet for difficulty chewing and swallowing) diet received food consistent with diet order and according to the minced and moist diet menu recipe for seven of eight sampled resident (Resident 10, 11, 50, 53, 62, 81, and 83). The facility failed to: 1. Ensure the Dietary Supervisor (DS), who was overseeing meal preparation, [NAME] (CK 1) who was preparing the residents' meals, and Licensed Vocational Nurse (LVN 4), who was validating the meal on residents' trays for diet appropriateness and food texture before meal was served to the residents, ensured Resident 10, 11, 50, 53, 62, 81, and 83 received correct food consistency per their prescribed diet. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility ice machine was cleaned and maintain per manufacturer guidelines for 83 out of 85 sampled residents. This deficient practice had the potential to cause the growth of microorganisms (an organism that can be seen only through a microscope) and could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization for all residents, staff, and visitors consuming the ice from the ice machine.

Inspectors wroteBased on interview and record review, the facility failed to provide annual documentation including the Quality Assessment Assurance Committee([QAA] to develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) team signatures to verify reviewing of their dietary department policies. This deficient practice had the potential for the facility staff to perform outdated practices.

Inspectors wroteBased on observation, interview, and record review, the Quality Assessment Assurance Committee([QAA] to develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) failed to identify skills competencies of the dietary staff and assessments of the residents meal trays to ensure therapeutic diets were served as prescribed by the physician. This failure resulted in placing the residents at risk for not receiving the appropriate meal tray based on their diet orders and potentially choking on their food.

Inspectors wroteBased an observation, interview, and record review the facility failed to ensure nursing staff including licensed vocational nurses (LVNs) and certified nursing assistants (CNAs) were competent on food textures including physician prescribed diet of dysphagia (difficulty chewing and swallowing) minced and moist diet (mechanical-soft texture modified diet for difficulty chewing and swallowing) to ensure correct food consistency were distributed to seven of eight sampled residents (Resident 10, 11, 50, 53, 62, 81, and 83). This deficient practice resulted in Resident 10, 11, 50, 53, 62, 81, and 83 received a lunch tray on 8/14/2024 that contained a ground pimento cheese salad sandwich (sandwich included 2 slices of white bread, including the crust, with a scoop of ground pimento cheese in between the bread, sliced in half) while on a dysphagia minced and moist (ground) diet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. ensure follow up appointment for dental pain evaluation/ referral was completed for one out of two sampled residents (Resident 51). b. ensure follow up appointment for routine foot care podiatry (study of feet) evaluation/ referral was completed for one out of two sampled residents, Resident 56. These deficient practices resulted in a delay of necessary foot care and dental services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dietary staff including the registered dietician (RD), dietary supervisor (DS), the cook (CK 1), and dietary aide (DA 1) were competent about preparing and serving a physician prescribed diet for dysphagia (difficulty chewing and swallowing) minced and moist diet (mechanical-soft texture modified diet for difficulty chewing and swallowing). As a result of this deficient practice, 7 out of 8 sampled residents (Resident 10, resident 11, Resident 50, Resident 53, Resident 62, Resident 81, and Resident 83) on a dysphagia minced and moist (ground) diet received a lunch tray on 8/14/2024 that contained a ground pimento cheese salad sandwich (sandwich included 2 slices of white bread, including the crust, with a scoop of ground pimento cheese in between the bread, sliced in half). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure resident's medical records were updated to show documentation that an advance directive (legal document that states your wishes for medical care if you are unable to communicate with them due to illness or injury) was discussed and written information was provided to the resident or responsible party for one out of three sampled residents (Resident 72). This failure resulted in a violation of the residents' and/or residents representatives' right to be fully informed of the option to formulate their advance directive and had the potential to cause conflict with the resident's wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess mental capacity (ability to make decisions) and provide information to one of three sampled residents (Resident 83) before signing the arbitration agreement (AA- a way of resolving a dispute without filing a lawsuit and going to court). This failure had the potential to result in Resident 83 not fully understanding their right to limit opportunities to initiate judicial proceedings that challenge unfavorable decisions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an interdisciplinary team meeting (conference discussing the residents care plan comprised of different members of the healthcare team from different specialties]), including one of three sampled resident (Resident 1) and Resident 1's Responsible Party (RP1), convened to discuss the status of Resident 1's hearing loss, pending audiologist (specialists who evaluate, diagnose, treat, and manage hearing loss) appointment, and status of the requested hearing aids (sound amplifying device used to assist people with hearing loss). These deficient practices violated Resident 1's rights and resulted in Resident 1 and RP 1 feeling frustrated leading to a potential decline in Resident 1's psychosocial health.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1), who had hearing loss and requested hearing aids (sound amplifying device used to assist people with hearing loss) had an appointment with the audiologist (specialists who evaluate, diagnose, treat, and manage hearing loss) to perform an audiogram (hearing test) after the Otolaryngologist (specialist who treats conditions of the ears, nose and throat) ordered for the resident to see the audiologist on 1/5/2024. These deficient practices resulted in a delay in the process for Resident 1 to acquire hearing aids leading to a potential decline in Resident 1's psychosocial health. As of 5/8/2024, four months after the order was made, Resident 1 has not had the audiogram.

Inspectors wroteBased on interview and record review, the facility failed to ensure records were provided within 48 hours following a request by Responsible Party 1(RP 1) for one out of two sampled residents (Resident 1). This deficient practice resulted in the inability of Resident 1 and/or Resident 1's RP to access requested records and violated Resident 1's rights to have access to his records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene before applying new gloves when cleaning the gastrostomy tube ([G- tube]-a tube inserted through the wall of the abdomen directly into the stomach) and applying a dry dressing for one out three sampled residents, Resident 2. This deficient practice had the potential to cause cross contamination (transfer of germs from one object to another) and cause a serious skin infection.

Inspectors wroteBased on interview and record review, the facility a. Failed to develop individualized interventions for one of three resident's (Resident 1's) care plan to prevent falls, and b. Failed to develop a care plan for one of three resident's (Resident 1) noncompliance with the use of call lights and noncompliance with ambulating without assistance. This deficient practice placed Resident 1 at higher risk for falls.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one resident's( Resident 1) fall risk evaluation, dated 8/19/2023, was accurate. The deficient practice resulted in an incorrect depiction of Resident 1's fall risk and potentially impacted the care rendered and received by Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection control program which prevents the spread of infection and COVID-19 (a respiratory disease caused by a coronavirus called SARS-CoV-2) when: a. Staff failed to complete a self-screen for temperature and symptoms of COVID-19 prior to starting their shift. b. Staff failed to [NAME] and Doff before entering a contact precaution room (Resident 23). This deficient practice could potentially spread and expose residents and staff to COVID-19.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of three sample residents' (15, 25, 59) call lights were within reach. For residents 15, 25, and 59, their call lights were lying on the floor underneath the residents' beds. This deficient practice had the potential to prevent Residents 15, 25, and 59 from maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three randomly selected residents (Residents 28) reviewed for changes in Medicare coverage were provided with the Notice of Medicare Non-Coverage (NOMNC) appeal process in a timely manner. This deficient practice had the potential to result in responsible parties not being able to exercise their right to file an appeal.

Inspectors wroteBased on observation and interview, the facility failed to provide one of one residents (34) privacy during wound care. Resident 34's privacy curtain would not pull completely to the end of the track, exposing Resident 34 to the hallway. This deficient practice did not allow Resident 34 the right to privacy during care.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident 41's lost prescription reading glasses was resolved in a timely manner. This deficient practice resulted in the resident having decreased vision and negatively affected the resident's quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive, resident-centered care plan for two of two residents (Resident 41 and 75). a. Resident 41 had impaired vision and did not have a care plan to address the impaired vision. b. Resident 75 had an intravenous (IV) site and was receiving IV iron (Venofer) for anemia, however, there was no care plan for the IV site and no care plan for receiving iron with a diagnosis of anemia. These deficient practices placed the residents at risk for harm and injury and impact the residents' quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the correct volume of oxygen ordered by the physician for one (1) out of the two (2) sampled residents (Resident 42). This deficient practice resulted in Resident 42 receiving incorrect oxygen than required and can negatively impact the resident's health and well-being. During a review of the Resident's 42 admission record (Face Sheet), the face sheet indicated Resident 42 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 42 diagnoses included acute kidney failure (kidneys are not working well), acute respiratory failure with hypoxia (not enough oxygen in the blood), partial intestinal obstruction (food is prevented from passing normally through the bowel). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide foot care for one of one residents (75). The toe nails on Resident 75's two big toes were long and curved. The facility did not know the last time Resident 75 had seen a podiatrist. This deficient practice had the potential to cause Resident 75 to experience discomfort and complications with mobility and foot health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately record fluid intake for one of one sampled resident (Resident 11) with fluid restrictions. This deficient practice had the potential to cause fluid overload or swelling for Resident 11.

Inspectors wroteBased on observation and interview, the facility failed to date/label a peripheral intravenous (IV) site dressing for one of one residents (75), per facility policy and staff were unsure how often the dressing should be changed. This deficient practice had the potential for Resident 75 to experience medication leaking around the IV insertion site, redness, swelling, and infection at the IV site.

Inspectors wroteBased on observation, interview and record review, the facility failed to a. ensure oxygen tubing was labelled with a change date for one of one resident (Resident 42). This deficient practice had the potential for complications associated with oxygen therapy for the resident. b. follows their policy and procedure for displaying a No smoking on the door for two of two sample residents (Resident 42 and 62) who was receiving oxygen therapy. This deficient practice had the potential to place residents at risk of injury due to a fire hazard.

Inspectors wroteBased on observation, interview, and record review, the staff failed to reassess the pain level (intensity) to determine if one of one resident (Resident 177) could benefit from an as needed pain medication in between the routine pain medications to ensure the breakthrough pain was relieved. This deficient practice resulted in Resident 's 177 experiencing pain during dressing changes.

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

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure that it is free of a medication error rate of less than five percent as evidenced by the identification of two out of two medication errors based on 27 medication opportunities, that yield a facility medication error rate of 7.41percent during medication administration. The following two medication errors occurred for: 1. The facility failed to administer scheduled blood pressure medications for Resident 16 as ordered. 2. The facility failed to administer full dose of medication for Resident 69 as ordered. This deficient practice had a potential to place two out of two resident's at risk for causing the resident discomfort and/or jeopardizes his or her health and safety.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure three out of three residents were free from significant medication error by failing to: 1. To administer scheduled blood pressure medications as ordered. 2. To administer full dose of medication as ordered. 3. Ensure medications at resident bedside had a physician order. This deficient practice had a potential to place four out of four residents' at risk for causing the resident discomfort or jeopardizes his or her health and safety.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure medications were stored in accordance with current accepted professional standards in the medication storage room by failing to dispose of two of two expired oral (given by mouth) medications in station 3 medication storage room and insulin being opened past 28 days. These deficient practice resulted in unsafe storage of the medication, the potential to administer altered medication potency and strength to residents and could have resulted in medication errors.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain dish washer temperature 120 degrees Fahrenheit as outline in the facility policy. This deficient act placed residents at increased risk for food borne illness related to improper sanitation dishes.

Inspectors wroteBased on interview and record review, the facility failed to complete a process to identify, track, and evaluate effectiveness of antibiotic administration for four of four residents (Residents 69, 237, 238, and 239) from April 2021 through November 2021. This deficient practice has the potential to increase antibiotic resistance and provide antibiotics without justification in violation of the standard of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection control program which prevents the spread of COVID-19 (a respiratory disease caused by a coronavirus called SARS-CoV-2) when Resident 42 were not tested with COVID 19 when he had symptoms consistent with COVID 19. This deficient practice could potentially spread and expose resident and staff with COVID-19.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that freezer thermometer was working. This deficient practice place residents at increased risk for food borne illness related to improper temperature control of frozen food.