Elk Grove Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove from use discontinued medications for a census of 129 residents, when medications belonging to discharged residents were stored with active residents' medications. This failure increased the facility's potential to administer discontinued medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the recipe for nine residents of a census of 129, when [NAME] (C) 1 added unmeasured amounts of water and milk to pureed (smooth, lump-free, moist food with the consistency of pudding) meals. This failure decreased the facility's potential to serve food that was easy to swallow and retained its nutrients.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper kitchen and food safety measures for a census of 129 residents, when:1. Kitchen floors were wet for three days;2. Frozen waffles were stored unsealed in the reach-in refrigerator;3. Food boxes were stored directly on the floor and on top of upside-down milk crates in the walk-in freezer with food stored on rusty metal shelving;4. Four steam table pans were stored wet; one steam table pan was found with a clumpy beige residue on the outside; and5. Four spice bottles were stored with open lids. These failures decreased the facility's potential to ensure kitchen safety and safely store and serve food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained for a census of 129 residents, when garbage dumpsters were left uncovered for three consecutive days. This failure decreased the facility's potential to maintain sanitary conditions in the garbage storage area and reduce the risk of pest infestation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe operating condition for kitchen equipment for a census of 129 residents, when a damaged thermometer was used for the automatic dishwashing machine. This failure decreased kitchen staff's potential to know if dishware was sanitized for resident use.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 37) was free from abuse, when Resident 117 hit Resident 37. This failure had the potential to negatively impact Resident 37's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to submit in a timely manner a Minimum Data Set (MDS, a federally mandated assessment tool) assessment for one of 30 sampled residents (Resident 17), when Resident 17's discharge MDS was completed after 14 days of discharge. This failure had the potential to delay the transmission of Resident 17's data to the Centers for Medicare and Medicaid Services (CMS).

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment was recorded accurately for one of 30 sampled residents (Resident 140), when Resident 140's resuscitation (the emergency act of reviving someone who is not breathing, or heart has stopped beating) instructions were inaccurately documented in the MDS.This failure decreased the facility's potential to maintain accurate assessments for Resident 140's end of life care, treatment, and preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards of care for two out of 30 sampled residents (Resident 1 and Resident 139), when:1. Resident 139's blood pressure medication was not administered on time; and2. Resident 1 did not have an order for an indwelling urinary catheter (a tube placed in the bladder to drain urine which is collected in a bag). These failures decreased the facility's potential to follow physician orders for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu for two residents (Resident 6 and Resident 72 ) of a census of 129, when food items were omitted from lunch menus. This failure decreased the facility's potential to serve meals complete in nutrient value.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were available to use for two of 30 sampled residents (Resident 100 and Resident 140), when:1. Resident 140's touch pad call light was not within reach; and2. Resident 100's regular call light was not within reach. These failures decreased the facility's potential to assist residents in a timely manner when needed.

Inspectors wroteBased on interview and record review the facility failed to replace one of four sampled residents (Resident 1's) personal belongings in a timely manner when Resident 1's eyeglasses were lost. This failure had the potential to compromise Resident 1's vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident right to be free from physical abuse for two of five sampled residents (Resident 1 and Resident 2) when Resident 2 struck Resident 1 and Resident 1 scratched Resident 2 during an altercation on 2/21/26. This failure resulted in physical injury to Resident 1 and Resident 2 and had the potential to result in psychosocial harm for both residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a home like environment for facility residents for a census of 130 when three out of five shower rooms were unclean and unsanitary. This failure resulted in lack of provision for a home like environment for facility residents when the shower rooms were unclean. A review of Resident 1's admission record indicated Resident 1 was admitted in January of 2025 with a diagnosis of Type two Diabetes Mellitus (a chronic condition where the body does not regulate sugar levels in the body, that can cause slowed wound healing). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 1/21/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, tool that tests cognition) score of 15 out of 15 indicating Resident 1 was cognitively intact. During an interview on 2/6/26 at 10 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean environment for facility residents when three out of 4 shower rooms in use were left unclean for a census of 130. This failure had the potential to spread infections to facility residents. During a concurrent observation and interview on 2/6/26 at 10:17 a.m. with Licensed Nurse (LN 1) in the South Station Shower room (SS), LN 1 confirmed there was mold on the shower curtain, a used tan bandage on the floor of the shower, a ball of hair on the shower drain, a used bandage on the shelf adjacent to the shower, and the sharp container was full and had razors sticking out. LN 1 further confirmed there were broken tiles in the shower room. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for two out of six sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2's room was cluttered with multiple medium sized brown boxes, an empty soda can, two white towels, overripe bananas, and multiple personal items of their roommate. This failure had the potential to result in an unsafe and unsanitary environment for Resident 1 and Resident 2 to receive care and services and risk for the residents not to achieve their highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's rights for one of six sampled residents (Resident 1) when Certified Nurse Assistant (CNA) 1 kissed Resident 1's forehead without consent. This failure reduced the facility's potential to treat Resident 1 with dignity and respect.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safety of residents when they failed to provide adequate monitoring and supervision for Resident 1 identified as at risk for elopement for a census of 129 residents. This failure resulted in Resident 1 wandering out of the facility to a coffee shop unaccompanied by staff. A review of Resident 1's clinical record indicated Resident 1 was admitted in November 2025 with a diagnosis of end stage renal disease (a condition where waste and fluid buildup in the body because the kidneys cannot remove them properly). A review of Resident 1's Minimum Data Set (MDS- an assessment tool) dated 12/1/25 indicated Resident 1 had moderately impaired cognition (memory or thinking problems). During a review of Resident 1's progress note dated 12/10/26, the progress note indicated Resident 1 . [...]

Inspectors wroteBased on interviews, and record review, the facility failed to protect the right to be free from physical/mental abuse for one of six sampled residents (Resident 1), when Resident 2 forcefully grabbed Resident 1 by his throat during an altercation on 12/26/25. This failure had the potential to cause significant physical and emotional injury to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) was free from abuse when Resident 2 threw a water pitcher towards Resident 3. This failure had the potential to result in physical injury and psychosocial distress to Resident 3.

Inspectors wroteBased on interview, and record review, the facility failed to provide a written bed hold notice upon transfer to the hospital to Resident 4 or her family. This failure had the potential risk to deny Resident 4 re-admission to the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled patients (Patient 1) with a known elopement risk had adequate supervision to ensure safety when Patient 1 could not be located by facility staff. This failure resulted in Patient 1 leaving the facility unaccompanied on 9/13/25 and 9/14/25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of five sampled residents (Resident 1) from abuse when Resident 2 pushed Resident 1 during an altercation. This failure resulted in Resident 1 falling into the ground and had the potential for Resident 1 to experience fear or distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards of practice were followed for one of 5 sampled residents (Resident 3) when Resident 3's medication was not administered as ordered and was left at bedside. This failure had the potential to result in contamination of the medication and for Resident 3 not having the desired effects of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of four sampled residents, Resident 1, when:1. Licensed Nurse 1 (LN 1) did not follow the physician's order; and2. LN 1 and Treatment Nurse (TN) demonstrated different techniques and knowledge in applying [NAME] wraps (adjustable compression wraps used to manage swelling associated with lymphedema, [swelling of a body part, usually an arm or leg, due to a buildup of fluid]) to Resident 1. These failures decreased the facility's potential to safely implement the physician's orders and possibly risk Resident 1's safety.

Inspectors wroteBased on observation, interview and record review the facility failed to follow guidelines for Enhanced Barrier Precaution (EBP, an infection control intervention to reduce transmission of multi-drug-resistant organisms) that utilize the use of gown, glove and to practice hand washing/sanitizing for one of four sampled resident, Resident 1 when:1. Licensed Nurse 1 (LN 1) did not wear gloves when she handled Resident 1's inhaler canister; and 2. LN 1 did not sanitize her hands before donning on clean gown and gloves. This deficient practice had the potential to spread multi-drug-resistant organisms (MDRO's, bacteria that resist treatment with more than one antibiotic) among residents, staff and visitors.

Inspectors wroteBased on interview and record review, the facility failed to provide Resident 1 with information regarding her medical condition and plan of treatment and failed to notify Resident 1's Family Member (FM) of change in condition, when Resident 1 had an episode of decreased responsiveness due to hypoglycemia (low blood sugar). This failure resulted in Resident 1 and Resident 1's FM being unaware of Resident 1's medical condition and treatment plan with the potential for worsening medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for one resident (Resident 1) when resident left the facility unnoticed, for a census of 134. This failure resulted in Resident 1 not receiving nursing care and was exposed to unsafe environment for over 24 hours.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident safety for one resident (Resident 1) out of a census of 130 when Resident 1 eloped the facility premises even with a Wanderguard monitor bracelet in place. This failure resulted in Resident 1 missing and eloping from the facility and has reduced the facility's potential in keeping Resident 1 safe from harm.

Inspectors wroteBased on interview and record review, the facility failed to provide effective pain management for one of three sampled residents (Resident 1) when upon admission to the facility, Resident 1's pain medication for moderate to severe pain was not available. This failure resulted in Resident 1 experiencing decreased comfort and participation with physical and occupational therapy.

Inspectors wroteBased on record review and interview the facility failed to timely assess a change of condition (COC) in accordance with professional standards and practices for one of three sampled residents, Resident 1. This failure resulted in a delay in Resident 1 being transferred to an acute care hospital for decreased oxygen saturation and increased lethargy (a lack of energy and diminished mental alertness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for one of four sampled residents (Resident 2), when the Certified Nursing Assistant 2 (CNA 2) did not apply the required Personal Protective Equipment (PPE, gloves, gown and/or goggles/face shield) while changing linen in Resident 2 ' s room placed on an Enhanced Barrier Precaution (EBP, infection control intervention to reduce transmission of resistant organisms). This failure had the potential to spread infection among the facility ' s residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three out of five sampled residents (Resident 1, Resident 2, and Resident 3) were assisted with nail care as part of their Activities of Daily Living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), when Resident 1, Resident 2, and Resident 3 were found with long untrimmed nails. This failure had the potential for Resident 1, Resident 2, and Resident 3 to sustain injury and to acquire an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional foot care was delivered to one of five sample residents (Resident 1), when Resident 1 did not receive podiatry (foot) services in a timely manner. This failure had the potential for Resident 1 ' s toenails remaining uncut and overgrown.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one of three sampled residents (Resident 1) when Resident 2 threw a cup filled with coffee towards Resident 1 splashing hot coffee onto Resident 1's right arm causing an injury. This failure reduced the facility's potential to protect Resident 1's right to be free from any type of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of care for four of 32 sampled residents (Residents 21, 27, 92 and 82), when: 1. Resident 21 had no physician's order and no plan of care for self-catheterization (a procedure that involves inserting a hollow tube into one's own bladder). 2. Resident 27 did not receive an antibiotic (a drug used to treat infections caused by bacteria) order as prescribed. 3. Resident 92 had no plan of care for the use of a mouth guard. 4. Resident 82 did not have consistent and accurate documentation for urine output monitoring. These failures had the potential to compromise the residents' care and could have resulted in serious health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for two of 129 residents when: 1. An expired resident's controlled medications (prescription medications with more risk of addiction and harm) were not removed from the medication cart for seven days, which had the potential to result in drug diversion. 2. Resident 27's Physician Order was not followed, and six omitted doses were still in the medication room without notifying the physician or pharmacy which had the potential to negatively affect Resident 27's treatment of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored correctly when: 1. An opened multi-dose bottle of oseltamivir oral suspension (an antiviral medication used to treat or prevent influenza) was found in the refrigerator without an expiration date. 2. Staff personal belongings were kept in the medication storage room. These failures had the potential for unsafe or ineffective medication use, spread of infectious pathogens, and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff had appropriate competencies and skill sets to safely carry out certain functions of the food and nutrition service when: 1. Staff were not sure of the appropriate dish machine temperature needed to appropriately clean, 2. Staff were not sure how to appropriately test the red buckets (often called sanitizer buckets, used to hold sanitizer solutions, ensuring proper sanitization of surfaces and equipment, and are easily identifiable to prevent cross-contamination) to see if the sanitizer was at the correct concentration, 3. Hand hygiene not done according to policy, 4. A cook was observed using a yellow cutting board (used for raw poultry) to cut cooked roast beef, instead of the brown board. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1) Food labels were lacking or mislabeled, 2) Kitchen areas found dirty and/or rusty, 3) Smallware not discarded when no longer able to be sanitized, 4) Bin of clean plates found with food residue and a sugar packet on a plate, 5) Three steam table pans were stored wet, and one had food residue in the pan, 6) Hairnets not used consistently used in the kitchen, 7) Resident tray containing chocolate pudding was brought down the hall without a cover on top, and 8) Sprinkler cleaning occurred over food production and clean dishes that were drying. These failures had the potential to lead to food borne illness for the 125 Residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 129 when: 1. Three facility staff did not wear required personal protective equipment (PPE) when assisting Resident 44 and Resident 22 whom were both on enhanced barrier precautions (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use); 2. Resident 22's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not labelled and properly stored when not in use; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition when: 1. Walk-in freezer found with ice build-up on the floor, 2. The ice machine leaked, and a bucket was placed underneath the unit to catch the water, 3. The dish machine temperature gauge was not moving and did not indicate the temperature of the water, and 4. Food service (tray line) rack did not hold position and was held in position with plastic wrap. These failures had the potential of leading to food borne illness for the 125 Residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light system was accessible for four out of 32 sampled residents (Resident 41, Resident 11, Resident 52, and Resident 20), when call light buttons were observed not within reach. This failure had the potential to result in residents' needs not being met and prevent communication for assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect two out of 32 sampled residents' (Resident 8 and Resident 20) right to be treated with respect and dignity when facility staff were standing over Resident 8 and Resident 20 while feeding them during the 2/24/25 lunch meal. This failure resulted in Resident 8 to experience emotional distress and felt disrespected and potential for Resident 20 to feel that he was not being treated with respect and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for one of 32 sampled residents (Resident 20) when Resident 20's call light system was not appropriate and was not within reach. This failure placed Resident 20's safety at risk and had the potential for Resident 20's needs to be not met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of 32 sampled residents (Resident 24 and Resident 47) were assisted with nail care as part of their Activities of Daily Living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) when both residents were found with long untrimmed nails. This failure had the potential for Resident 24 and Resident 47 to sustain injury and to acquire an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 32 sampled residents (Resident 13) were offered resident centered activities. This failure decreased social interactions and increased the potential for negative impact on the physical, mental and psychosocial well-being of Resident 13.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two out of seven sampled residents (Resident 44 and Resident 59) received treatment and care in accordance with professional standards of practice, and facility's policy and procedure (P&P) when Resident 44 and Resident 59 physician's order for low-air loss mattress (LALM- a medical-grade mattress designed to prevent and treat pressure injuries by reducing moisture and heat buildup) monitoring of settings and functioning was not consistently done. This failure had the potential for Resident 44 and Resident 59's wounds to get worse, and for the residents to not achieve their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper delivery of respiratory care consistent with the facility's policy and procedures (P&P) for one out of 32 sampled residents (Resident 8) when Resident 8's physician's order for oxygen therapy was not followed. This failure had the potential to result in unsafe delivery of oxygen to Resident 8 and for Resident 8 to not achieve her highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 32 sampled residents (Resident 17) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 17's pain medication order was not followed. This failure had the potential for Resident 17 to develop medication dependence (the inability of the individual to function normally in the absence of the drug), overdose, and not attain his highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food in accordance with the physician's prescribed diet for one out of 32 sampled residents (Resident 16) when Resident 16 whom was on No Added Salt diet (NAS- a dietary restriction that limits the intake of salt) received two salt packets during the 2/25/25 lunch meal. This failure had the potential to negatively affect Resident 16's medical condition and for Resident 16 to not achieve his highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders were followed in accordance with professional standards of care for one of three sampled residents (Resident 1) when PRN (given as needed or requested) Clonidine hydrochloride (Clonidine HCl-medication used for high blood pressure) was not given as per physician order. This failure had the potential to negatively affect Resident's 1 health condition and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided consistent with professional standards of practice, the comprehensive care plan, and the resident's choices for one of 3 residents (Resident 1) when Resident 1's pain was not assessed and managed timely. This failure resulted in Resident 1 not experiencing adequate pain relief and not attaining the highest possible level of comfort.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from sexual abuse by a resident, when one of four sampled residents (Resident 1) had her breast touched and massaged by Resident 2. This failure had the potential to negatively impact Resident 1 ' s psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper delivery of respiratory care consistent with the facility's policy and procedures (P&P) and the professional standards of practice for two out of five sampled residents (Resident 4 and Resident 6) when Resident 4 and Resident 6's physician's orders for oxygen therapy were not followed and their oxygen therapy was not care planned. These failures had the risk to result in unsafe delivery of oxygen to Resident 4 and Resident 6 and potential for Resident 4 and Resident 6 to not receive appropriate respiratory care and not achieve their highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement measures to prevent an avoidable fall for one of four sampled residents (Resident 1) when she was transferred from her bed to a chair without the use of a mechanical lift. This failure resulted in Resident 1 sustaining a left distal femur (lower end of thigh bone) fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accurate and safe pharmaceutical services to meet the needs of 22 residents for a census of 124, when: 1. Licensed Nurses (LN 6 and LN 3) administered residents' medications scheduled for 9 a.m., more than an hour later than the scheduled time; 2. Resident 153 missed her morning dose of medication to treat restless leg syndrome (involuntary leg movement which causes uncomfortable sensation in legs) and 3. Resident 203's pain medication was not signed as given in a timely manner. These failures had the potential for ineffective medication therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was served with an appetizing temperature for 8 out of 31 sampled residents (Resident 34, Resident 88, Resident 1, Resident 403, Resident 10, Resident 49, Resident 43 and Resident 37). This failure had the potential for the residents not consuming their meals and may cause weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident rights to personal privacy and confidentiality of his or her personal medical information was maintained for a census of 124 residents when: 1. Meal tray tickets with resident identifiers were found in the general trash and 2. A computer screen was left unattended with Protected Health Information (PHI) visible to anyone walking by. These failures had the risk potential to compromise resident privacy and confidentiality for a census of 124 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment for the residents when the sliding door curtains in rooms 46, 47, 53, and 54 were torn, had holes, loose threads, brown stains and the walls in rooms 33, 46, 47, 53 and 54 had gouges, scratches, and peeling wallpaper. These failures resulted in the residents residing in these rooms not being provided a homelike environment and had the potential to negatively impact their psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to follow their policies and procedures to ensure professional standards of quality was maintained for one of 31 sampled residents (Resident 34) when the attending physician was not notified of a delay in obtaining STAT (immediately) laboratory samples for Resident 34. This failure had the potential to cause delay in the management of Resident 34's change of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received the necessary care and services in accordance with professional standards of quality and their individualized person-centered care plans for five of 31 sampled residents (Resident 76, Resident 82, Resident 60, Resident 58, and Resident 54), when the staff failed to respond to their call lights (alerting devices to call nursing staff) for assistance with personal care in a timely manner; leaving residents in wet or soiled briefs for extended periods of time. These failures resulted in the delay in providing the necessary care, causing physical discomfort, frustration, and had the potential to affect the resident's dignity, health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure effective pain management was provided for one of 31 sampled residents (Resident 62) who was on hospice (end of life care that includes pain management), when the facility's licensed staff did not notify Resident 62's hospice team that his pain medication was ineffective. This failure resulted in Resident 62's enduring uncontrolled pain and suffering.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for one of 31 sampled residents, (Resident 91) who received hemodialysis (HD, a medical procedure that helps remove waste and excess fluid from the blood when the kidneys are unable to perform this function), when his intake, output and weights were not accurately measured as ordered. These failures increased Resident 91's risk in developing fluid overload.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 31 sampled residents (Resident 68) was free from unnecessary medications when a psychotropic medication (any drug that affects brain activity associated with mental processes and behavior) was ordered in the absence of a diagnosis of depression. This failure placed Resident 68 at risk for adverse effects from use of a psychotropic medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain food safety requirements when: 1. two cutting boards were found to have a sticky substance on the cutting surface that could get in contact with food being served to 120 residents eating food prepared at the facility; 2. Resident 37's food tray was left at bedside when he was out on an appointment; and 3. Resident 403's food tray was left at bedside when she was out at dialysis treatment. These failures had the potential to contaminate food and cause illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective infection prevention and control measures were followed for a census of 124 when: 1. the toilet in room [ROOM NUMBER] had white linen on the floor with brown stains, the toilet bowl had brown splashes and the hand washing sink had a used paper towel on the side of the faucet; 2. the laundry room ceiling had brownish discoloration and the vents were covered with black substances; and 3. the laundry machine pipes had a gray and whitish build up and the sides had white, and brown build up. These failures had the potential to spread germs and cause infections among residents and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the walk-in freezer in a safe operating condition for a census of 120 residents who received meals prepared by the facility when ice build-up was found on the entire ceiling, walls and food storage racks, and the freezer door seal was modified with black insulation tape. These failures had the potential to alter the food quality and safety for 120 residents who received meals prepared in the facility's kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS, an assessment tool used to identify resident needs) was completed in a timely manner for 1 of 31 sampled residents (Resident 1) when the MDS was not completed no less than once every 3 months as required by the regulations. This failure had the potential to delay Resident 1's care planning process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document and identify food preferences for one of 31 sampled residents (Resident 305), when Resident 305 liked ice cream, but the meal ticket indicated he disliked ice cream. This failure had the potential to result in Resident 305's food preferences not being honored and followed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system was accessible for one of 31 sampled residents (Resident 303), when Resident 303's call light was placed hanging on the curtain and not within reach. This failure had the potential to negatively affect Resident 303's safety by preventing the resident from communicating a request for assistance when needed.

Inspectors wroteBased on interview and record review, the facility failed to provide the required two-person staff participation to use the toilet for one of three sampled residents (Resident 1), when Resident 1 was left alone while on the toilet, fell, and hit her head. This failure resulted in Resident 1 spending five days in the hospital to receive treatment for an acquired subdural hemorrhage (a severe and sudden loss of blood from a damaged blood vessel in the brain).

Inspectors wroteBased on interview and record review, the facility failed to provide required supervision for one of three sampled residents (Resident 1), when Resident 1 was left on the toilet, fell, and hit her head. This failure resulted in Resident 1 spending five days in the hospital to receive treatment for an acquired subdural hemorrhage (a severe and sudden loss of blood from a damaged blood vessel).

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision and assistance for one of four sampled residents (Resident 1) when Resident 1 who required two-person assistance for bed mobility as per the Minimum Data Set (MDS, an assessment tool) fell from the bed while being assisted by one staff instead of two during incontinent care. Additionally, the one staff who was assisting the Resident turned away from her to grab a garbage bag on the floor. This failure resulted in Resident 1 sustaining a laceration (a deep cut or tear) on her left forehead, a left midclavicular (the bone connecting the breastbone and shoulder) fracture, and a left rib fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received appropriate assistance in a timely manner when: 1. Resident 3 requested assistance to the restroom, waited an hour for assistance from the proper number of CNAs, and ended up soiling his clothes in front of his family members; and, 2. Resident 2's dinner tray was dropped off onto his bedside table without assistance to eat or communication as the Certified Nurse Assistant (CNA) was going on a break. This failure decreased the facility's potential to provide prompt assistance to residents for their activities of daily living when they need it.

Inspectors wroteBased on observation and interview, the facility failed to ensure two dumpsters and a trash bin were covered. This failure decreased the facility's potential to prevent the attraction of pests which eat of disposed food and taking refuge within facility property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medical information was safeguarded from public view for one resident (Resident 1) of three sampled residents. This failure decreased the facility's potential to protect confidential resident information.