East Terrace Rehabilitation & Wellness Centre, LP

Inspectors wroteBased on interview and record review, the facility failed to ensure the individual financial record was given quarterly and upon request for one of three sampled residents (Resident 1). This deficient practice had the potential to deny Resident 1 the right to review and manage personal funds, which could interfere with the resident's financial autonomy and self-determination, and increase financial errors or discrepancies would not be identified or corrected in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) for one of four sampled residents (Resident 3), when Resident 3 reported that Resident 4 hit her on the forehead on 3/30/2026 and Resident 3 sustained a purplish discoloration. This deficient practice resulted in a delay in investigation by the CDPH and placed Resident 3 at risk for continued abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one out of three sampled residents (Resident 10) did not elope (the act of leaving a facility unsupervised and without prior authorization) while wearing a Wander Guard device (a wearable device that tracks movement and triggers alarms when a resident is near a restricted area). This failure resulted in Resident 10 leaving the facility with no arrangements for medical care or housing.

Inspectors wroteBased on interview and record review, the facility failed to ensure a license staff had the specific competencies and skills set necessary to care for one of three resident's (Resident 1) who was readmitted with wound. This failure had the potential to deliver poor quality nursing care and services and placed Resident 1 and other residents with wounds at risk for poor healing and contribute to its worsening wound conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1), received the necessary services, consistent with professional standards of practice to promote wound healing. The facility failed to:Create a resident-centered plan of care with interventions to manage Resident 1's sacral (lower back) pressure injury (damage to the skin and underlying tissues caused by prolonged pressure, often over bony areas, which can range from mild redness to deep tissue necrosis) when admitted to the facility on [DATE]. Update Resident 1's care plan, titled at risk for potential impairment to skin integrity., with interventions to prevent the wound from worsening and promote healing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report an injury of unknown source (injury of unknown source when all of the following criteria are met: the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury [e.g., the injury is located in an area not generally vulnerable to trauma]) for one of five sampled residents (Resident 1). This failure delayed the investigation by the California Department of Public Health (CDPH) and placed Resident 1 at risk for abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish).

Inspectors wroteBased on observation, interview and record review, the facility failed to investigate an injury of unknown source (injury of unknown source when all of the following criteria are met: the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury [e.g., the injury is located in an area not generally vulnerable to trauma]) when one of five sampled residents' (Resident 1) left dorsal hand (back of hand) had yellowish-purplish skin discoloration on 1/21/2026 and ecchymosis (a type of bruise caused by blood leaking from broken blood vessels into the skin, resulting in a flat, discolored patch) on 1/23/2026. This failure placed Resident 1 at risk for severe injuries, including hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services to one of five residents (Resident 1), were provided in accordance with professional standards of practice, by failing to: 1). Ensure Resident 1's left dorsal hand (back of hand) redness was monitored according to the physician 's (MD) order. 2). Ensure a follow-up call was made to the MD regarding Resident 1's change of condition (COC) on 1/20/2026. 3). Ensure Treatment Licensed Vocational Nurse's (LVN) did not change left dorsal hand assessment done on 1/2/2026. These failures had the potential to affect the care and services provided to Resident 1 and the potential to delay care, resulting in complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for four of 25 sampled residents (Resident 1, 11, 14, and 53) by failing to develop a comprehensive care plan for:1. Resident 1's significant weight loss (a weight loss greater than 5 percent ([%] unit of measurement) in one month, greater than 7.5% in three months and greater than 10% in 6 months) of 39 pounds ([lb.] unit of weight)/19.7 % in 6 months.2. Resident 11's psychiatric diagnoses (a clinical classification of mental health conditions, identifying patterns of distressing thoughts, emotions, and behaviors).3. Resident 14's colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) care.4. Resident 53's oxygen therapy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dietary staff did not use one (1) scooper, for two (2) food items, during tray line (a healthcare foodservice assembly system where staff add specific food items, utensils, and condiments to patient meal trays). This deficient practice had the potential to result in cross contamination of food and placed the residents with food allergies at risk for allergic reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of one sampled resident (Resident 102) with long thick elongated (nail plate grows longer than the nail bed) toenails received podiatry (profession dealing with specialized care of the feet) care services. This deficient practice had the potential to result in Resident 102 experiencing discomfort and decline in physical mobility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen was administered as prescribed for one of 8 sampled residents (Resident 53). This deficient practice had the potential to result in oxygen desaturation for Resident 53.

Inspectors wroteBased on interview and record review, the facility failed to ensure competency assessment skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual needs to perform work roles or occupational functions successfully) checks were performed annually for two out of five randomly selected staff. This deficient practice had the potential for the facility not to be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident will not be performed within the acceptable standards of practice.

Inspectors wroteBased on interview and record review, the facility failed to ensure Performance Evaluations (a process that organizations follow to assess an employee's work quality and skills over a specific period) were performed yearly for two out of five randomly selected staff. This deficient practice had the potential to compromise resident care and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 8), who was receiving Quetiapine Fumarate (a psychotropic medication [any drug that affects brain activities associated with mental processes and behavior] to treat certain mental/mood disorder), was monitored for behavior and its side-effects (an effect of a drug that is in addition to or beyond its desired effect). This deficient practice had the potential for Resident 8 using an unnecessary psychotropic medication that could cause be harmful to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label a floor stock medication bottle with an opened date in Medication cart one. This deficient practice had the potential to result in administering an expired medication which could affect the health and condition of the residents.

Inspectors wroteBased on interview and record review, the facility failed to implement the physician's orders to draw monthly laboratory tests (a medical analysis of a body sample (blood, urine, tissue) to check health, diagnose diseases and monitor chronic conditions) for one of one sampled resident, (Resident 1). This deficient practice had the potential to result in the delay of identification of medical concerns, delaying the care and services necessary for the affected resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene (cleansing hands with soap or an alcohol-based rub) prior to putting on personal protective equipment ([PPE] protection equipment that includes face shields, gloves, goggles and glasses, gowns, head covers, masks, respirators, and shoe cover to protect against the transmission of germs through contact and droplet routes) and prior to caring for one of seven residents, Resident 96. This failure had the potential for cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one object or person to another, with harmful effect) and risk to expose Resident 96 to infectious organisms (germs).

Inspectors wroteBased on interview and record review, the facility failed to revise and provide an updated average daily census of the Facility Assessment Tool (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services). This deficient practice had the potential to place residents at risk for not receiving the appropriate care and services necessary to maintain their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene before entering one out of two sampled resident's (Resident 1) room, touching Resident 1's clothing, and exiting the room. This failure had the potential to result in Resident 1 being exposed to infectious organisms and getting sick.

Inspectors wroteBased on interview and record review, the facility failed to implement their Policy and Procedure (P&P) titled, Bed Hold which indicated the facility would hold the resident's bed for up to seven (7) days if the resident was transferred to a General Acute Care Hospital (GACH) for one of 7 sampled residents (Resident 7). This deficient practice violated Resident 7's right to a Bed Hold and had the potential for result in Resident 7 not being able to return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Notice of Proposed Transfer and Discharge form was signed by of 1 of 3 sampled residents (Resident 1), and / or its family representative, and provided to, prior to discharge to a lower level of care on 9/4/2025. This failure had the potential to result in the resident's discharge to a Residential Care Facility for the Elderly (RCFE- a licensed assisted living facility that provides non-medical care and supervision for adults aged 60 and over who need help with daily living but not 24-hour skilled nursing care) where the resident needs for activities of daily living will not be met and provided.

Inspectors wroteBased on interview and record review, the facility failed to report an unwitnessed fall with injury for one out of three sampled residents (Resident 7) to California Department of Public Health (CDPH). This deficient practice caused a delay in an investigation of a fall with injury by CDPH.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of three sampled residents (Resident 1) had a care plan after an injury to his right hand. This deficient practice had the potential to place Resident 1 at risk for infection and worsening of the injury to the right hand.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of the five sampled residents (Resident 3, Resident 4, and Resident 5) had an individualized resident care plan developed for Coronavirus ([COVID-19]- highly contagious viral infection) infection. This deficient practice had the potential to place the residents at risk for complications of COVID-19 infection and had the potential for the COVID-19 virus to spread, placing other residents and staff at risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed report facility's two coronavirus ([COVID-19]- a highly contagious viral infection) confirmed cases to the California Department of Public Health (CDPH), for two of 3 residents (Residents 2 and 3), as indicated in the facility's policy and procedures (P&P) titled Unusual Occurrence Reporting, reportable disease outbreak (are those that, by law or regulation, must be reported to public health agencies when diagnosed by healthcare providers or laboratories) This failure delayed the investigation by the CDPH and had the potential for the COVID-19 virus to spread in the facility, potentially infecting other residents, visitors and staff.

Inspectors wroteBased on interview and record review, the facility failed to protect one of four residents (Resident 1), from sexual abuse (a non-consensual sexual contact of any type with a resident). The facility failed to: 1). Ensure Resident 2 ' s (perpetrator) whereabouts (location) was monitored onb 6/10/2025. 2). Ensure Resident 2 who was alert and can make self-understood, did not went into Resident 1 ' s room (victim). This failure resulted in Resident 2 sexually assaulting Resident 1 on 6/10/2025. This failure had the potential to cause psychosocial harm to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to report an act of sexual abuse (a non-consensual sexual contact of any type with a resident) for two of four sampled residents (Resident 1 and Resident 2), within two (2) hours as indicated in the facility ' s Policy and Procedure (P&P) titled Abuse Prevention and Management. This failure delayed the investigation by the California Department of Public Health (CDPH) and placed the other residents at risk for abuse.

Inspectors wroteBased on interview and record review the facility failed to provide a two-person assist (one on each side of the bed) for one of three sampled residents (Resident 1), who was dependent on staff for turning and repositioning. Certified Nurse Assistants (CNA 1 and CNA 2) repositioned Resident 1 while both were standing on the left side of the resident's bed. This failure resulted in Resident 1 falling onto the floor, sustaining a femur (thigh bone) fracture (broken bone) experiencing pain and fear, and was transferred to a general acute care hospital (GACH) for evaluation and treatment.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Implement its policy and procedures (P&P), for one of 5 sampled residents. (Resident 3). This deficient practice resulted in Resident 3 sustaining unknown bruises and skin tears.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Investigate all areas of skin discoloration (a change in the color, texture, or pigmentation of the skin) and skin tears for one of five sampled residents (Resident 3). This deficient practice had the potential to place Resident 3 and other vulnerable residents at increased risk of abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had diagnoses including hypertension (HTN-high blood pressure), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (a mental health condition that involves a prolonged low mood or loss of interest in activities), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and suicidal ideation (intrusive thoughts and preoccupation with death and dying), who was brought to the facility by the paramedics to be admitted on [DATE] at 9:50 p.m. was not left unattended, by failing to: 1. Provide Resident 1 with orientation of the facility. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Implement its policy and procedure (P&P) titled Resident Right-Quality of Life revised 3/2017, which indicated the facility staff would not handle or move a resident ' s personal belongings without the resident ' s permission for one of three sampled residents (Resident 1). This deficient practice violated Resident 1 ' s rights and had the potential negatively impact Resident 1 ' s psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a resident ' s refusal to take Olanzapine ([antipsychotic] medication to treat mental health condition) for one of three sampled residents (Resident 3). This deficient practice had the potential to result in Resident 3 delusional thoughts (false beliefs) and resulted in Resident 3 to engaging in physical abuse with Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled Readmission, revised 10/01/2013, which indicated the facility would provide readmission of the residents who require skilled nursing care at the facility, and allow residents who were previously at the facility to be readmitted to the facility for one of three sampled residents (Resident 3). This resulted in the denial of Resident 3 ' s right to return to his home in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement resident-centered care plan interventions for one of three sampled residents (Resident 5), who was at risk for wandering (walk from place to place) and had physician orders for one-to-one sitter ([1:1]-a single staff member is assigned to constantly observe and supervise a patient). This deficient practice had the potential to negatively affect all resident ' s well-being and privacy at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one on one sitter ([1:1]-a single staff member is assigned to constantly observe and supervise a patient) as indicated in the resident care plan for one of three sampled residents (Resident 4). This deficient practice resulted Resident 4 falling, sustaining a laceration (a deep cut in the skin) on the forehead and had the potential to place Resident 4 at risk for recurrent falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and complete the personal belongings inventory list for one of three sampled residents (Resident 1). This deficient practice resulted in incomplete medical records and misappropriation of Resident 1 ' s personal property.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Provide a privacy bag on a foley catheter for one of five sampled residents (Resident 2). 2. Ensure one out of six sampled residents (Resident 72) dignity was maintained after placing bilateral bedrails (metal rails that are attached to the side of a bed to help to prevent patients from falling out). This deficient practice had the potential to affect resident's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure an updated Physician's Order for Life Sustaining Treatment (POLST-(POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) form was transferred to the hospital for one out of three sampled residents (Resident 38). 2. Ensure an Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) acknowledgement form was obtained for one of three sampled residents (Resident 90). 3. Ensure one out of six sampled residents (Resident 17) had an updated code status (a patient's documented wishes regarding what life-saving measures should be taken if their heart stops beating or breathing ceases). [...]

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 28) misssing glasses and dentures both were replaced. 2. Provide a homelike environment for two of five sampled residents (Residents 10 and 6). This failure resulted in Resident 28 not having a pair of eyeglasses to see and dentures to chew and Resident 10 and 6 not being in a homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to create an individualized comprehensive nursing care plan (a document that summarizes the care and treatment) for two of two sampled resident (Resident 90 & 28). This failure resulted in Resident 90's gastrostomy tube (G-tube-a plastic tube inserted into the stomach to provide nutrition) being dislodged three times and Resident 28 not able to chew without dentures.

Inspectors wroteBased on interview and record review, the facility failed to prevent the hospitalization for one of one sampled resident (Resident 90). This failure resulted in Resident 90's going to the hospital for treatment due to a dislodged gastrostomy tube (G-tube-a plastic tube inserted into the stomach to provide nutrition).

Inspectors wroteBased on interview and record review the facility failed to secure a gastrostomy tube (G-tube-a plastic tube inserted into the stomach to provide nutrition) to prevent dislodgement for one of one sampled resident (Resident 90). This failure resulted in Resident 90's G-tube being dislodged three times.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of six sampled residents (Resident 72) had the call light within reach. This deficient practice on not having the call light within reach placed the resident at risk for not receiving goods and services.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a Pre-admission Screening Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) was submitted for one of five sampled residents (Resident 84). This deficient practice had the potential to result in residents not receiving mental health care and services needed.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a Pre-admission Screening Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) was resubmitted for one of five sampled residents (Resident 10). This deficient practice had the potential to result in resident not receiving mental health care and services needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of six sampled residents (Resident 42) toenails were trimmed. This deficient practice of not trimming Resident 42's toenails had the potential to cause discomfort.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of six sampled residents (Resident 9) had the correct settings for low air loss mattress ([LAL]-a type of mattress used to help prevent and treat pressure wounds). This deficient practice of not having the correct LAL mattress setting placed Resident 9 at risk for pressure injuries (a localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of six sampled residents (Resident 17) splints (a medical device used to gradually stretch and prevent further tightening of a muscle or joint to improve range of motion) were placed on by the Restorative Nurse Assistant (RNA) as scheduled. This deficient practice of not placing splints on Resident 17 as scheduled had the potential to cause contractures (a permanent tightening of the muscles tenon, ligaments, or skin that limits normal movement of a body part).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to Resident 89 when she wandered into Resident 34's room and was pushed by him after facility's knowledge of her wandering behavior. This failure had the potential for Resident 89 to be injured.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure oxygen tubing was dated for one of five sampled residents (Resident 63). This deficient practice had the potential for the resident to develop a Respiratory Infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of six residents (Resident 72) had a consent (the process in which a health care professional educates a patient about the risk, benefits, and alternatives of a given procedure or intervention) for bedrails (bars attached to the side of a bed to help patients move and reduce the risk of falling out of the bed). This deficient practice of not having a consent for the risk and benefits for bedrails use placed Resident 72 at risk for entrapment.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of six residents (Resident 72) had a physician order for bedrails. This deficient practice of not having a physician order for bedrails for Resident 72 placed the resident at risk for entrapment (when a patient gets trapped in a hospital bed, usually in the side rails).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: 1. Food in the kitchen was not stored in the kitchen past the used by date. 2. Food was labeled with the dates it was opened and to be used by. The failure had the potential to result in a foodborne illness (an illness that comes from eating contaminated food) in the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of four trash dumpsters had their lid closed completely. This failure had the potential to attract pests (like flies and rodents) that could spread diseases and bacteria to the residents.

Inspectors wroteBased on interview and record review, the facility failed to assist one of three sampled residents (Resident 2) in exercising the resident ' s right to vote by failing to provide voting materials to the resident. This failure resulted in Resident 2 feeling frustrated and sad due to not being able to exercise the right to vote.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a resident's refusal to take Risperdal ([antipsychotic] medication to treat mental health condition) for one of four sampled residents (Resident 10). This deficient practice resulted in Resident 10 experiencing auditory hallucinations (an experience involving the perception of something not present and/or hearing voices that don ' t exist) and engaged in physical abuse to Resident 9.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), was spoken to, and treated with respect and dignity. This deficient practice had the potential for Resident 1 to have decreased feelings of self-worth. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included schizophrenia (a mental illness that can affect thoughts, mood, and behavior) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free from physical abuse for one of four sampled residents, (Resident 9). This deficient practice resulted in Resident 9 being choked by Resident 10 and had the potential for Resident 9 to have psychological and/or psychosocial distress.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged physical abuse for two of four sampled residents (Resident 9 and Resident 10), by failing to: 1. Ensure facility staff report no later than two hours, the alleged resident to resident physical abuse to the California Department of Public Health (CDPH). 2. Ensure the facility report the results of the investigations within five (5) working days. These deficient practices resulted in a delay of an onsite investigation by CDPH and had the potential to place all residents in the facility at risk for further abuse.

Inspectors wroteBased on interview, and record review the facility failed to implement its abuse policy and procedure (P&P) by failing to investigate a resident-to-resident physical abuse between two of four sampled residents (Resident 9 and Resident 10). This deficient practice resulted in unidentified abuse in the facility to Resident 9 and failed to protect other residents in the facility from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 4), had a fall risk reassessment done again after Resident 4 was found on the floor on 10/12/2024 and on 10/19/2024. 2. Ensure one of four sampled residents (Resident 5), had floor mats at the bedside to prevent injury from a fall. These deficient practices resulting in Resident 4 ' s fall risk assessment not being re-evaluated to prevent future falls and had the potential for injury if Resident 5 were to have a fall.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse Policy and Procedure (P&P) titled, Abuse Reporting and Investigations which indicated the facility would report allegations of abuse to the California Department of Public Health (CDPH) within two hours of initial report, after one of six sampled residents (Resident 1) alleged Certified Nurse Assistant (CNA) 1 hit him. The deficient practice resulted in a delay in the investigation by the CDPH. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure licensed nurses accurately assessed and monitored one of one sampled resident (Resident 1) according to the physician ' s order and the resident ' s Care Plan. This deficient practice had the potential to result in Resident 1 not receiving the care and interventions needed to address his behaviors and placed facility residents at risk of harm by Resident 1.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the call light was within reach for one out of six sampled residents (Resident 2). This deficient practice had the potential to result in Resident 2 not being able to call for assistance and a delay in care for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four residents (Resident 2) who was receiving enteral feeding (a way of delivering nutrition directly to the resident ' s stomach), was provided care and services to prevent aspiration (food or liquid entering the airway or lungs) by failing to ensure the resident ' s head of the bed (HOB) was elevated. This failure had the potential to result in aspiration, difficulty in breathing, lung infection and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach for two of three sampled residents (Resident 2 and Resident 3). This deficient practice created the potential for Resident 2 and Resident 3 to be unable to call staff for assistance or alert staff of a medical emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was functional for one of three sampled residents (Resident 1). This deficient practice led to a delay in Resident 1 having her incontinence brief changed, and created the potential for Resident 1 to be unable to call staff for additional assistance or alert staff of a medical emergency.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Abuse Prevention and Management , dated 6/12/2024, for two of two sampled residents (Resident 1 and Resident 2), when the following occurred: 1. Staff failed to report an allegation of Resident 2 touching Resident 1's neck without permission on 6/12/2024 to the State Agency (SA) within two hours. 2. Facility failed to report the findings of their investigation into the alleged incident within five working days to the SA. These deficient practices had the potential to cause a delay in the notification of necessary agencies and the timeliness of their investigations, and the potential for further abuse to occur between Resident 2 and other facility residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to address one of 3 residents ' (Resident 1) refusal with Restorative Nurse Assistant (RNA, nurse that assist residents with range of motion exercise) program in the plan of care. This deficient practice had the potential to to contribute to Resident 1 ' s decline in both upper and lower extremities range of motion and not identify alternate interventions to maintain the highest practicable physical, mental and psychosocial well-being of the resident.

Inspectors wroteBased on interview and record review, for 1 of 3 residents (Resident 1), the facility failed to: 1. Provide documentation on the explained risks and benefits when Resident 1 refused to participate with the Restorative Nurse Assistant (RNA, nurse that assist residents with range of motion exercise) treatment. 2. Ensure an accurate documentation in the RNA flow sheet for three consecutive months (December 2022-February 2023). This deficient practice had the potential to contribute to Resident 1 ' s decline in both upper and lower extremities range of motion.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Follow the minimum data set ([MDS] a standardized assessment and care screening tool), which indicated two staff members will assist in providing care for one of two sampled residents (Resident 1) 2. Ensure Resident 1 ' s physician order, dated 11/10/2023, which indicated half siderails on both upper parts of the bed was implemented as ordered. These deficient practices caused Resident 1 to fall face down, from the bed, sustain a cut with bleeding to the right upper lip that required the resident to be transferred to a General Acute Care Hospital (GACH) for evaluation and treatment.

Inspectors wroteBased on interviews and record reviews, the facility failed to: 1. Verify admission inquiry (resident's facility documents seeking admission) from the transferring facility for accuracy to reflect Resident 1's wandering (going from place to place without a plan or purpose) and exit seeking behavior, and to ensure resident did not elope (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) from the admitting facility on 1/25/2024, for one of three sampled residents (Resident 1). 2. Follow Resident 1's physician orders from the transferring facility dated 1/17/2024, upon admission, which indicated to monitor episodes of wandering and elopement risk and document resident's location every hour. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan (the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) was formulated for seven of 20 sampled residents (Residents 1, 21, 30, 47, 88, 3, and 83). These deficient practice had the potential for the affected residents not to receive the care and services they need and the provision of a poor quality care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. The hot water/coffee machine water filter were monitored and maintained for safe operation to help prevent sediments build up in the water. 2. Perishable food items for one of 20 sampled residents (Resident 28), were placed in the refrigerator. This failure had the potential to result in an unsafe water used to supply residents with hot water or coffee when needed. This failure had the potential to result in foodborne illnesses (food poisoning caused by eating contaminated food) for Resident 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control program by failing to: 1. Follow its policy and procedure, titled Resident Isolation-Categories of Transmission- Based Precautions, to keep room doors closed while residents are in the room and to post a sign by the resident's door to check in at the nursing station before entering a resident's room, for two (2) of six residents, (Residents 81 and 83). Resident 81, COVID-19 confirmed (a virus to potentially cause severe respiratory illness) and Resident 83, who had Candida Auris (a type of yeast that can cause severe illness and spreads easily among patients in health care facilities). This failure placed the facility at a high risk for an increase in COVID-19 and C. Auris cases, and placed residents, staff, and the community at risk for contracting the COVID-19 and C. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow-up the durable power of attorney (DPOA) or conservator (a person appointed by the judge to act or make decisions for the person who needs help) for one of 21 residents, Resident 41 who cannot make healthcare decisions. This failure had the potential to result in conflict of interest between the facility and the resident's wellbeing and resulted in a resident representative not notified nor having a resident advocate for Resident 41.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 20 sampled residents (Resident 41 and Resident 8) had an Advance Directive (written statement of a person's wishes are carried out should the person be unable to communicate them to a doctor). This failure had the potential to result residents' health care instructions will not be honored and will affect the quality of life.

Inspectors wroteBased on interview and record review, the facility failed ensure the physician was promptly notified when one of one sampled resident (Resident 47), had a change of condition (a change in resident's normal physical, mental, or behavioral state). Resident 47 had an aggressive behavior. This deficient practice had the potential for a delay in providing care and interventions necessary to maintain the highest practicable physical, mental and psychosocial well-being of the resident.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for one of 21 sampled resident, Resident 60. This failure had the potential to place Resident 60 to not receive appropriate care and/or services.

Inspectors wroteBased on observation, interview, and record review, for one of 21 residents (Resident 56), the facility failed to ensure: 1. The oxygen (air) nasal cannula (a nasal device used to deliver supplemental oxygen) tubing was stored properly and changed every seven days per policy and procedure (P&P). 2. The humidifier (liquid that moistens the air) bottle was labeled with date of change and was changed every seven days per P&P 3. Resident 56 had a physician order for its oxygen use. These failures had the potential to cause respiratory infection, incorrect amount of oxygen delivered to Resident 56 and the potential to result in resident respiratory distress and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide behavioral health services in a timely manner for one of one sampled resident (Resident 47). This deficient practice had the potential to prevent Resident 47 from maintaining the highest practicable mental, physical, and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Remove two multi-dose unopened vials of expired influenza vaccine (a vaccine that protect against infection by influenza viruses) from the facility's medication refrigerator room. 2. Label opened medication containers with date it was opened. This deficient practice had the potential for expired medications administered to the residents and can cause severe drug adverse reactions including hospitalization.