Edgewater Skilled Nursing Center

Inspectors wroteBased on interview, and record review, the facility failed to ensure an allegation of missing/stolen money was reported to the California Department of Public Health (CDPH) for one of five sampled resident's (Resident 1). This deficient practice resulted in the inability of the CDPH to investigate the allegation of stolen money in a timely manner and had the potential for information pertinent to the investigation to be lost and/or forgotten.

Inspectors wroteThe facility failed to ensure a care plan was created for one of five sampled residents (Resident 1), who was at risk for constipation (a common condition where bowel movements become difficult, infrequent) due to opioid use (a drug used to reduce moderate to severe pain). This deficient practice resulted in Resident 1's transfer to a General Acute Care Hospital (GACH) for evaluation and treatment due to back pain where he was assessed with constipation. This deficient practice had the potential for Resident 1 to become impacted (a mass of dry, hard stool that cannot be eliminated by a normal bowel movement).

Inspectors wroteBased on interview and record review, the facility failed to ensure the property for one of four sampled residents (Resident 1) was documented correctly on 3/12/2026 during admission to include the contents of her wallet and on 4/5/2026 during discharge, verify a ring documented on admission as left with the resident was still with the resident, and missing property were reported to law enforcement. This deficient practice resulted in Resident 1's Family Member (FM) claiming Resident 1's cash and ring were missing and the facility's inability to determine if Resident 1 had cash in her wallet and if a ring left with Resident 1, per the Inventory List documentation on 3/12/2026, was accounted for on 4/5/2026 during discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Interdisciplinary Team (IDT- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) initiated a care conference meeting for one of two sampled residents (Resident 1) after Resident 1 experienced an alleged manhandling from Certified Nursing Assistant (CNA)1. This failure had the potential to delay addressing Resident 1's care needs which could result in a delay in necessary interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 32) had a completed informed consent (a document ensuring the resident was educated of the risks and benefits of the treatment and agreed or disagreed to continue with the treatment ) for Trazodone (medication prescribed to treat depressive disorder [a mental health condition marked by a prolonged low mood and a loss of interest or pleasure in everyday activities]) and Lorazepam [medication prescribed to treat anxiety disorders (persistent and excessive worry that interferes with daily activities)]. This failure had the potential to result in violating the resident's right to be informed of the benefits and risks of the treatment and the right to refuse the treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents/responsible party had the opportunity to formulate an advance directive (document indicating the Resident's healthcare wishes in emergency cases where they are not able to make a decision) for one of four sampled residents (Resident 11). This deficient practice had the potential to violate the resident's right to be fully informed of the option to formulate their advance directives and cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on interview, and record review, the facility failed to ensure staff were monitoring behaviors for a medication being administered for one of three sampled residents (Resident 88) when resident was taking quetiapine (a medication used to treat behavioral disorders). This deficient practice had the potential to place Resident 88 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic medication (medications that alter the chemical makeup of the brain and nervous system to treat mental health disorders, affecting mood, cognition, and behavior) for an extended period, which could result in impairment or decline in the resident's mental, physical condition, functional, and psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was implemented for one of three sampled residents (Resident 88), who received narcotic pain medication (strong prescription medications used to treat moderate-to-severe acute or chronic pain). This deficient practice had the potential to negatively affect the quality of life and wellbeing for Resident 88 to prevent them from achieving their highest practical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 40) who received hemodialysis (a medical procedure to remove fluid and waste products from the body) had a dialysis emergency kit (a prepared, accessible collection of essential medical supplies, medications, and documents designed for dialysis patients to use during emergencies) at the bedside. This failure had the potential for delayed intervention during accidental bleeding including death for Resident 40.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were in-serviced (specialized training or education provided to staff while on the job) to care for residents that was diagnosed for trauma-informed care and post-traumatic stress disorder ([PTSD], a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). This failure had the potential to result in residents being re-traumatized by staff who were not educated on PTSD and could be harmful for resident's psychosocial status.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow manufacturer's storage specifications for one of six sampled resident's (Resident 11) levalbuterol inhalation solution, USP (an inhaled prescription medicine used for the treatment or prevention of breathing difficulties). This failure had the potential to reduce the medication's effectiveness and placing the resident at risk for shortness of breath and difficulty.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure documented food preferences was followed for one of three sampled residents (Resident 75), when Resident 75 was served food items documented as resident's dislikes. This failure had the potential to contribute to reduced nutritional intake, affecting the resident's overall health and well being.

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence of COVID-19 (a contagious respiratory disease that spreads from person to person through coughing, sneezing, or talking) vaccine screening, education, administration, and/or declination for two of seven sampled staff members: Medical Doctor (MD) 1 and MD 2. This failure had the potential for an increased risk of COVID-19 exposure for facility residents and staff from delayed identification of vaccine status and missed opportunities to prevent the spread of COVID-19 within the facility.

Inspectors wroteBased on interview and record review, the facility failed to review Infection Prevention and Control Program Policy annually. This finding has the potential to increase the risk of infection for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 15 of 35 residents rooms met the 80 square feet ([sq. ft.] unit of area equal to a square one foot long on each side) per residents in multiple resident rooms. Rooms 25, 26, 27, 28, 29, 30, 31, 32, 33, and 34 housed two residents per room, and Rooms 18, 20, 21, 35 and 36 housed four residents per room. This deficient practice had the potential to result in inadequate nursing care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a history of urinary retention (inability to completely empty the bladder of urine), and was exhibiting signs of urinary retention (groin and abdominal pain), requiring indwelling catheter (flexible soft tube inserted in the body to drain urine) insertion was inserted timely by Licensed Vocational Nurse (LVN) 1 when she could not locate the indwelling catheter supply in the facility. This deficient practice resulted in Resident 1 experiencing further pain and discomfort and placed him at risk for bladder injury and infection. Resident 1 was subsequently transferred to a General Acute Care Hospital (GACH) via 911 for treatment.

Inspectors wroteBased on interview and record review, the facility failed to:1. Re-admit one of three sampled residents (Resident 1) to the facility after Resident 1 was evaluated and cleared by the General Acute Care Hospital (GACH) to return to the facility.2. Ensure the facility followed its policy and procedure (P&P), titled Bed Holds which indicated if the resident's hospitalization or therapeutic leave exceeds the bed-hold period of (7) days, the resident may return to the facility to their previous room, if available, or immediately upon the first availability of a bed, if the resident requires the services provided by the facility. This deficient practice resulted in Resident 1 being unable to return to the skilled nursing facility (SNF) that has been considered their home, for about 12 months after being deemed appropriate for transfer to the SNF. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a completed written Bed Hold notification to one of one sampled resident (Resident 1) upon transfer on 7/15/2025 to the General Acute Care Hospital (GACH). This failure had the potential to result in a resident and/or their representative being unaware of their right to return to the facility within the designated bed-hold period, potentially leading to unnecessary displacement.

Inspectors wroteBased on interview and record review, the facility failed to ensure a refund was issued within 30 days to the Responsible Party (RP 1), upon a resident's discharge for one out of three sampled residents (Resident 1). This deficient practice resulted in Resident 1's RP 1 not receiving a refund of $1,752.00.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure prompt attempts were made to resolve the resident council meeting complaints of call lights not being answered, staff being rude, and not receiving care timely or at all for 5 of 11 sampled residents (Resident 1, Resident 2, Resident 4, Resident 7, and Resident 9). This deficient practice had the potential to violate the residents' right to have their concerns addressed.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its Infection Prevention and Control Program for four of 11 sampled residents (Resident ' s 5, 6, 7 and 8) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 performed hand hygiene and used the proper personal protective equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments equipment) while providing care to Resident 5 who was on Enhanced Barrier Precautions ([EBP] infection control precautions in addition to the standard to prevent the spread of multidrug-resistant organisms). 2. Ensure CNA 1 did not throw Resident 5 ' s contaminated linen and soiled incontinence (loss of bladder and/or bowel control) brief on the floor. 3. Ensure CNA 2 wore proper PPE on while providing direct care to Resident 5. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 4) when the facility failed to provide timely incontinent (having little or no control over urination or defecation) care (assistance in cleaning up a resident after toileting in a brief [adult diaper]) to Resident 4. Resident 4 was left to sit in a soiled, wet brief for an hour. This deficient practice resulted in Resident 4 feeling uncomfortable, embarrassed , frustrated and neglected by staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its Infection Prevention and Control Program by failing to: 1. Ensure Certified Nurse Assistant (CNA) 4 ' s N95 (a disposable face mask that cover ' s the user ' s nose and mouth which offers protection from small solid or liquid droplets found in the air) was covering her nose. 2. Ensure CNA 4 washed her hands upon exiting Resident 10 ' s room after providing care to Resident 10. These failures placed residents, staff, and the community at higher risk for cross contamination, transmitting infectious microorganisms, and an increased spread of Influenza A (a contagious an infection of the nose, throat and lungs, which are part of the respiratory system) in the facility and community.

Inspectors wroteBased on interview and record review, the facility failed to notify one of three sampled resident ' s (Resident 1) resident representative (RR) 1 immediately after Resident 1 sustained a fall and was transferred to a General Acute Care Hospital (GACH) for evaluation. This failure resulted Resident 1 ' s RR 1 not being notified of Resident 1 ' s fall and transfer to the GACH until five hours and 25 minutes later. The deficient practice resulted in violation of the RR 1 ' s right to be informed of Resident 1 ' s care and services provided.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who was initially assessed and determined to be at high risk for falls and had a history of falling at the facility did not fall and continue to fall for one out of four sampled residents (Resident 1). The facility failed to: 1. Ensure the licensed nurses developed a care plan that addressed Resident 1 ' s inability to communicate his needs or use the call light when needing assistance which led to Resident 1 falling on 11/14/2024, 11/28/2024, and on 12/13/2024. 2. Ensure the nursing staff implemented interventions timely when Resident 1 fell on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to document a resident ' s change of condition in the medical record for one of four sampled resident ' s (Resident 1). This deficient practice resulted in inaccurate documentation of the care provided to Resident 1 after he sustained a fall with injury on 11/28/2024. This deficient practice had the potential for non-continuity of Resident 1 ' s care by other health care providers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four residents (Resident 8, 15, and 37) were free of unnecessary medications by failing to: 1. Ensure informed consents for the use of psychotropic medication were obtained for Resident 8 and Resident 15. 2. Ensure informed consents were obtained prior to the use of Trazadone Hydrochloride (HCL: salt used in medication) medication used to treat depression and or anxiety)150 milligram (mg: unit of meaure of mass) and Quetiapine Fumarate (brand name Seroquel) medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought), depression, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) 100mg for Resident 37. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS - a resident assessment tool) related to discharge status was accurately documented to reflect that the resident was discharged home for one of three residents (Resident 78). This deficient practice had the potential to negatively affect Resident 78's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Residents 5 and Resident 37) preadmission screening and resident review (PASRR) screening was reassessed to determine the facility's ability to provide care for the special needs of the residents. This deficient practice placed the residents at risk of not receiving necessary care and services. a. During a review of Resident 5's admission Record, the admission Record indicated the facility initially admitted Resident 4 to the facility on 7/29/2024 and readmitted on [DATE] with diagnoses including unspecified dementia (progressive state of decline in mental abilities), mood disturbance (mental health condition that affects your emotional state), anxiety, and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a trauma (a deeply distressing or disturbing event that overwhelms a person's ability to cope, causing significant and lasting negative consequences) informed care plan for one of one residents (Resident 52), who reported difficulty sleeping related to previous trauma. This failure had the potential to compromise Resident 52's emotional well-being and increas the risk of re-traumatization.

Inspectors wroteBased on interview and record review, the facility failed to review and revise care plans when medication regimens were updated for one of three sampled residents (Resident 15). This failure had the potential to result in not accurately addressing Resident 15's psychosocial care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) received her last dose of antibiotic per physican's order. This deficient practice could have potentially prolonged Resident 2's infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices during indwelling urethral catheter (Foley catheter-a thin tube that is inserted into your bladder through the urethra-the tube you pee through and left there to continuously drain your urine into a collection bag) care for one of one sampled resident (Resident 1) by: a. Failing to perform hand hygiene before and after Foley catheter care. b. Failing to ensure and the resident's urine bag was kept off the floor. This deficient practice had the potential for urinary tract infection (UTI- condition that affect the urinary tract and can cause urine to flow abnormally) recurrence. Findings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a trauma informed care plan for one of one resident (Resident 52), who reported difficulty sleeping related to previous trauma. This failure has the potential to compromise Resident 52's emotional well-being and increased the risk of re-traumatization.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of three sampled residents (Resident 36) had the required Insulin Glargine Solution (medication that controls the amount of sugar in the blood) on hand to be administered. This deficient practice resulted in Resident 37 not getting the insulin on time. During a review of Resident 36's admission record, the admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including Type II Diabetes Mellitus (DM: a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), and long-term use of insulin (hormone that regulates blood sugar levels). During a review of Resident 36's History and Physical (H&P) dated 1/14/2024, the H&P indicated Resident 36 has the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff knew the proper techinize of thawing frozen food and testing the concentration of the sanitizer. These deficient practices had the potential to cause food-borne illnesses due to improperly thawed for being served to the residdnts of the facility, and the sanitizer not being at an effective strength.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Store staff personal belongings outside the food storage area. 2. Ensure proper labeling of potatoes and green produce. These deficient practices had the potential to cause food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection control policy for two of three sampled residents (Resident 130 and 53) by: 1. Ensuring staff performed hand hygiene after providing care for a resident and before going to Resident 130's room. 2. Ensuring staff doffed (systematic removal of personal protective equipment [PPE: equipment worn to minimize exposure to injury or infection] to prevent infection and contamination after administering medication to Resident 53. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for the residents. a. During a review of Resident 130's admission record, the admission Record indicated Resident 130 was admitted to the facility on [DATE] with diagnoses including generalized weakness, cerebrovascular accident (CVA: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 15 of 35 residents rooms met the 80 square feet ([sq. ft.] unit of area equal to a square one foot long on each side) per residents in multiple resident rooms. Rooms 25, 26, 27, 28, 29, 30, 31, 32, 33, and 34 housed two residents per room, and Rooms 18, 20, 21, 35 and 36 housed four residents per room. This deficient practice had the potential to result in inadequate nursing care to the residents.

Inspectors wroteBased on interview, and record review the facility's Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to develop and implement appropriate methods to measure the success of actions implemented addressing the continued concerns from the Resident Council pertaining to a delay in call light response during the hours of 11 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct a timely Interdisciplinary Team ([IDT] health care professionals who work together with the resident to plan the residents plan of care) meeting for one of three sampled residents (Resident 1). The facility failed to ensure Resident 1's was given the opportunity to meet with the IDT to discuss any updates or concerns she has in her current plan of care. These deficient practices resulted in a delay in communication between Resident 1 and the IDT causing frustration and anxiety to the Resident 1 and had the potential to delay in the delivery of needed care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was provided the appropriate care and services to maintain her Activities of Daily Living (ADLs - routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) by failing to provide Resident 1 with a commode (portable toilet) on 7/11/2024. This failure resulted in Resident 1 being forced to use a bedpan (container used to collect urine or feces used while lying or sitting in bed) which caused Resident 1 to feel embarrassed and degraded.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was seen by the psychiatrist as indicated per the physician orders. This failure resulted in Resident 1 not receiving the required behavioral health care services and placed Resident 1 at risk to suffer further mental anguish and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was offered and provided a shower and was dressed in her personal clothing and not in a hospital gown. These deficient practices resulted in Resident 3 not receiving a shower for 28 days and her family's preference of her being dressed in her personal clothing and not a hospital gown, not being followed. This deficient practice had the potential to lower Resident 1's self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2), who had poor safety awareness and was at risk for injury, had a call light button (device used to call nursing staff) within reach. This deficient practice resulted in a delay in Resident 1's care and services and had the potential for Resident 1 to act without assistance and sustain a fall/injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents'( Resident 3) who was dependent on staff for care was returned and repositioned every two hours This deficient practice put Resident 3 at risk for skin breakdown leading to pressure injuries/ulcers wounds created by extended pressure on the skin).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions ([EBP] precautions utilized to prevent the spread of multidrug resistant organisms [MDROS - bacteria that resist treatment with more than one antibiotic [medication that treat bacterial infections] for one of three sampled residents (Resident 1) who had a pressure injury wound (wound caused by pressure on the skin) on her sacrum (buttocks), when Certified Nursing Assistant 1 (CNA 1) did not use an isolation gown when performing high contact activities such as repositioning and removing Resident 1's incontinent brief (a disposable undergarment designed to absorb urine and feces). These deficient practices resulted in Resident 1's care needs being provided without the use of EBP and placed Resident 1 at increased risk of acquiring an infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) Responsible Party (RP) was assisted in filing a grievance when Resident 1's RP found three tablets of Bictegravir- Emtricitabine-Tenofovir Alafenamide Fumarate 50-200-25 (an anti- human immunodeficiency virus medication) left in Resident 1's 30-day supply for 7/2024. This deficient practice resulted in Resident 1's RP feeling frustrated that concerns related to Resident1's medication administration was not addressed and had the potential for mismanagement of Resident 1's medication regimen.

Inspectors wroteBased on interview and record review, the facility failed to account for the disposition of eight Morphine Sulfate (a drug used to treat moderate and severe pain and can be addictive) tablets in one of two emergency medication kits (receptacle that holds emergency medications) in the facility. This failure resulted in missing medications which could potentially be accidentally ingested by a resident or the medications to be diverted to an unknown recipient.

Inspectors wroteBased on observation, interview and record review, Licensed Vocational Nurse (LVN) 2 failed to ensure the pain medication for one (Resident 1) of five sampled residents was documented immediately in the narcotic sheet (document used to keep track of inventory of narcotic [medication that is highly addictive] medications) after the medication was administered, in accordance with the professional standards of practice. This failure has the potential for Resident 1 to be subjected to risk of undermedication and/ or overmedication due to untimely documentation of administered pain medication.

Inspectors wroteBased on interview and record review, the facility failed to conduct an Interdisciplinary Team (IDT-team of health care professionals that work together toward and prioritize the resident 's needs) care conference involving one of three sampled residents (Resident 1) and Resident 1's Responsible Party (RP1) prior to discontinuing Resident 1's speech therapy (treatment that improves ability to talk and use other language skills). This deficient practice violated the Resident 1 and RP 1's rights to be informed and the right to participate in resident's plan of care.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) who had a gastrostomy tube (G-tube- surgically placed tube into the stomach, used to administer medication and nutrition), had measures in place to prevent the g-tube from being inadvertently dislodged a second time on 3/31/2024. The facility failed to revise Resident 1's care plans to include interventions to prevent future unintentional dislodgements of the G tube and the facility failed to investigate to determine the cause of Resident 1's multiple G-tube dislodgements. This deficient practice resulted in Resident 1 requiring to be admitted to the hospital for surgical intervention to replace the G-tube and had the potential for malnutrition (not enough nutrients) and underdosing of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure required in service training and skills checklist for abuse and dementia were provided to two of four sampled Certified Nursing Assistant (CNA 3 and 4). This deficient practice had the potential for the facility not 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure, the resident who was assessed as a high risk for falls and was totally dependent on staff for activities of daily living (ADL), did not fall out of bed and sustained injuries for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 had more than one staff present to provide incontinence care when the resident was found being soiled while in bed. 2. Ensure Resident 1's bed was maintained in a lowest position as care planned to prevent the resident from fall. 3. To have floor mats (high-impact foam pads which are placed adjacent to the bed on the floor to help reduce the impact from falls and help prevent injuries) at the bed side to lessened possible injury during fall as care planned. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan to place floor mats next to Resident 1 ' s bed and to have Resident 1 ' s bed in the lowest position, for one of three sampled residents (Resident 1) who was assessed as high risk for falls. This deficient practice resulted in Resident 1 falling from her bed, which was in a high position and landing on the floor without floor mats in place. Resident 1 was transferred to a General Acute Care Hospital (GACH) where she was assessed with a non-displaced (broken bone that remains in the proper alignment) left intertrochanteric fracture (fracture of the thigh bone that connects to the hip bone).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and services for two of three sample residents (Resident 1and 2) by: 1. Failing to document the presence of a low air loss mattress (special mattress that ensures air circulation around the skin and protects the residents from bedsores [injury to skin]) on the treatment administration record, ([TAR] a report that serves as a legal record of the treatments a resident was receiving) for Resident 1 and 2. 2. Failing to ensure Resident 1 had an order for a low air loss mattress. These deficient practices had the potential to result in poor wound healing for Resident 1 and 2.

Inspectors wroteBased on interview and record review, the facility staff failed to notify the responsible party (RP) when Resident 1 had a 12-pound (lbs- measurement) weight loss for one of three sampled residents (Resident 1). This deficient practice had violated the resident's responsible party's right to be inform of the care or services provided.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident rights were maintained for two of four sampled residents (Resident 3 and 4) when the facility failed to A. Notify Resident 3's physician when Resident 3's blood sugar was 404 milligrams (mg-unit of measurement) / deciliter (dL- unit of measurement) on 2/3/2024 and 432 mg/dL on 2/19/2024. B. Notify Resident 4's physician when Resident 4's blood sugar was 428 mg/dL on 2/26/2024, 405 mg/dL on 2/28/2024 and 425 mg/dL on 3/1/2024. These deficient practices resulted in Resident 3 and 4's physician being unaware of high blood sugar levels causing a delay in needed assessments and services for Resident 3 and 4.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plan interventions for three of four sampled residents (Resident 1, 3, and 4) were implemented. The facility failed to implement: A. Resident 1's care plan intervention to use an air mattress (device used to prevent skin breakdown). B. Resident 3 and 4's care plan interventions to call the physician for blood glucose (sugar) levels over 400 milligrams (mg-unit of measurement) / deciliter (dL- unit of measurement). These deficient practices had the potential to result in delayed care and services and decline in Resident 1, 3, and 4's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rights were maintained for two of three sampled residents (Resident 1 and 2) when the facility failed to: A. Notify Resident 1 's Responsible Party (RP) 1 when Protonix (medication used to treat gastroesophageal reflux disease [GERD-when stomach acid flows back into the throat]) was discontinued on 1/9/2024. B. Honor RP 1's wishes to retain Resident 1's air flow mattress (mattress that help prevent skin breakdown by promoting blood flow and stimulating circulation in the body). C. Conduct an Interdisciplinary Team (IDT-team of health care professionals that work together toward and prioritize the resident 's needs) care conference involving Resident 2 following Resident 2's fall on 2/13/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify and provide a written notice to the responsible party (RP 1) prior to moving one of four sampled residents (Resident 1). These deficient practices resulted in the violation of Resident 1's and RP 1's rights to be informed of room changes.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled resident's (Resident 1) responsible party's (RP 1) complaint regarding Resident 1 's accidental Gastrostomy tube (G-tube- surgically placed tube into the stomach, used to administer medication and nutrition) dislodgement which resulted in a hospitalization was formally logged as a grievance (complaint) and investigated as indicated in the facility's policy and procedures. This deficient practice resulted in RP1 's anxiety and worry that the facility will not address the circumstances leading to Resident 1's G-tube being accidently removed.

Inspectors wroteBased on interview and record review, the facility failed to revise one of four sampled resident's (Resident 2) care plan to include the recommendations from the director of rehabilitation (DOR- healthcare professional who oversees the facility's program that helps residents regarding strength and mobility) of reminding Resident 2 to ask for assistance when getting up. This deficient practice placed Resident 2 at higher risk for future falls.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy ensuring the accurate receiving and reconciliation (process of verifying physician orders to medication) of home medications for one of one sampled resident (Resident 1). The facility failed to track and document the date, time, or quantity of Bictegravir/emtricitabine/tenofovir alafenamide (medication used to treat human immunodeficiency virus (HIV-virus that attacks body' immune system) when nursing staff received the medication from Resident 1's Responsible Party (RP). This deficient practice had the potential for inaccurate inventory of medications causing medication shortages and underdosage of medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 1) was treated with respect and dignity by not providing not providing privacy bag for Resident 1 ' s indwelling urinary catheter bag (drains urine from the bladder into a bag outside your body). This deficient practice had the potential for Resident 1 to feel embarrassed and have low self-esteem (when someone lacks confidence about who they are and what they can do).

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to identify resident using methods of identification prior to medication administration of one of two sampled residents (Resident 2) according to the facility ' s policy and procedure (P&P). This deficient practice had the potential for medication error for Resident 2 including receiving incorrect medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and provide intervention for pain for two of two sampled residents (Resident 10 and 168) when: a. Resident 10 was not assessed for pain before, during and after wound care dressing change. b. Resident 168 was not assessed for pain when Resident 168 was admitted under hospice care on 12/23/2023. These failures resulted in Resident 10 and Resident 168 continue to suffer from pain.

Inspectors wroteBased on observation interview and record review the facility failed to ensure medication refrigerator temperature was between 36-46 degrees Fahrenheit and the Refrigerator Temperature log were not missing readings on 11pm to 7am, 7am to 3pm, or 3pm to 11pm shifts on 12/27/2023. This deficient practice had the potential for harm to residents due to potential undetected temperature excursions, the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions for residents who eat food from the kitchen by: 1. Failing to maintain refrigerated food temperatures at safe levels. 2. Putting open date and label the food stored in the refrigerator These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting (throwing up), diarrhea (loose stool), and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations to meet the resident's needs by failing to ensure the resident's television was in working order for one of two sample residents (Resident 24). This deficient practice had the potential to negatively impact the psychosocial well-being of the resident.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse (LVN) 3 failed to checked blood sugar before meals as ordered by physician for one of three sampled residents (Resident 55). This failure had the potential to result in inaccurate assessment of effectiveness of diabetic medications related to the management of type 2 diabetes mellitus ([DM] a condition in which the body fails to metabolize (process) glucose (sugar) correctly) and can lead to hypoglycemia (low blood sugar).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 15 of 34 residents rooms met the 80 square feet ([sq. ft.] unit of area equal to a square one foot long on each side) per residents in multiple resident rooms. Rooms 25, 26, 27, 28, 29, 30, 31, 32, 33, and 34 housed two residents per room, Rooms 18, 20, 21, 35 and 36 housed four residents per room. This deficient practice had the potential to result in inadequate nursing care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the family (FM 1) and physician for one of three sampled residents (Resident 1) were notified when transportation was not available to transport Resident 1 to a General Acute Care Hospital (GACH) on 9/1/2023, per the physician's order, and failed to notify Resident 1's physician when Resident 1 had no bowel movement from 9/3/2023 to 9/5/2023. This deficient practice resulted in a delay in evaluation and treatment when Resident 1 complained of abdominal pain and was not transferred to the GACH until 9/5/2023 (four days after the transfer was ordered by Resident 1's physician on 9/1/2023).

Inspectors wroteBased on interview and record review, the facility failed to ensure Lactulose (a medication use to treat constipation [difficulty passing feces]), as prescribed, was administered to one of three sampled residents (Resident 1) when Resident 1 did not have a bowel movement for three days. When an order was obtained for Resident 1 to be transferred to a General Acute Care Hospital (GACH) on 9/1/2023, Resident 1 was not transferred, per the physician's order, until 9/5/2023 (four days after the order to transfer to the GACH on 9/1/2023) These deficient practices resulted in Resident 1's complaints of abdominal pain and a delay in evaluation and treatment. Resident 1 was transferred to a GACH on 9/5/2023 and was treated with a soap suds enema (a mixture of a mild soap and warm water injected into the colon in order to stimulate a bowel movement) twice in the GACH's Emergency Department (ED).