Foothill Heights Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections or diseases in the healthcare setting) were followed for one of two sampled residents (Resident 1) when staff did not sanitize the hoyer lift (a mechanical device used by caregivers to safely transfer individuals with limited mobility from one surface to another, such as from bed to wheelchair or the toilet) after use to transfer Resident 1, as indicated in the facility's policy and procedure. This deficient practice had the potential to result in resident developing infections and spreading infection among staff and other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician reviewed and took timely action on a medication regimen review (MRR, consists of a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) irregularity (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) identified by the facility's pharmacy consultant for three of five sampled residents (Residents 1, 7, and 9) reviewed for unnecessary medications by failing to ensure:Resident 1's March 2026 MRR was addressed by the physician for the use of Benadryl [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure (P&P) by failing to:a. Label food in the kitchen with item name and use by date (the last date recommended for the use of the product) and/or open date.b. Keep the refrigerator temperature log updated every shift.c. Discard expired food items in the kitchen.d. Ensure kitchen floor was clean and dry when water overflowed from dishwashing machine onto the floor.e. Ensure the ice machine's drainpipe had an air gap (physical separation between a water supply outlet and the flood-level rim of a receiving vessel like a sink or drain). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage was properly disposed of in accordance with the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal. This deficient practice had the potential to attract pests and rodents and may cause disease and other health issues to residents, staff, and the community.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to obtain an accurate water temperature reading and ensure the water used to wash one load of soiled linens (bedsheets, pillowcases and blankets) were washed at 160 for a minimum of 25 minutes Washer two (2) as indicated in the facility's policy. This deficient practice had the potential to compromise infection control measures to eliminate disease causing germs (microscopic [extremely small and invisible to the naked eye], living organisms including bacteria, viruses, fungi, and protozoa) on linens which could get residents sick and potentially spread infection in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that advance directives (a legal document indicating resident preference on end-of-life treatment decisions) were discussed and written information was provided to one (1) of 1 sampled resident (Resident 7) reviewed for advance directive. This deficient practice violated Resident's 7 and/or the resident's responsible party's (RP) right to be fully informed of the option to formulate their advanced directives and had the potential to cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician regarding the change of condition (COC, tool used by health care professionals when communicating about critical changes in a resident's status) of weight loss for one (1) of two (2) sampled residents (Resident 3) reviewed under nutrition. This deficient practice had the potential to result in delayed provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 25) reviewed for beneficiary notification was informed of the changes in Medicare (federal health insurance program) coverage and provided with the Advanced Beneficiary Notice (ABN, written notice provided to Medicare beneficiaries when Medicare payment is expected to be denied for certain services or items) in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to result in Resident 25's Responsible Party (RP) not being able to exercise their right to file an appeal and had the potential to cause stress to the resident's RP for not being able to make adequate arrangements for charges that may be incurred.

Inspectors wroteBased on interview and record review, the facility failed to provide Restorative Nursing Services (a program available in nursing homes to help residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) treatments (total of 10 missed treatments) for one of two sampled residents (Resident 3) reviewed for limited range of motion (ROM, full movement potential of a joint) in accordance with the physician's order. This deficient practice placed Resident 3 at risk for decline in physical functions and develop contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in the extremities (a limb of the body, such as the arm or leg) for not receiving the ordered exercises.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy to develop and implement a care plan that included strategies and interventions to maintain the safety for one of three sampled residents (Resident 36), reviewed for accidents and assessed as at risk for elopement (the act of leaving a facility unsupervised and without prior authorization) /wandering (moving without any clear purpose or direction). This deficient practice resulted in Resident 36 wandering into Resident 28's room on 5/4/2026, which had the potential to result in harm and injury to both residents.

Inspectors wroteBased on interview and record review, the facility failed to provide nutritional care and services for one (1) of two (2) sampled residents (Resident 44) reviewed for nutrition by failing to monitor and document the resident's meal intake in accordance with the care plan. This deficient practice had the potential to place Resident 44 at risk for further weight loss and negatively affect the resident's overall wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 5) reviewed for tube feeding received gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) feeding on 5/4/2026 in accordance with the physician's order. This failure had the potential to cause preventable malnutrition (lack of proper nutrition in the body) and/or weight loss for Resident 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care services for one of one sampled resident (Resident 11) reviewed for oxygen by failing to ensure oxygen (O2- a colorless, odorless, and tasteless gas essential for the survival of living things which use it for breathing and respiration) was administered to Resident 11 via nasal cannula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental O2) according to the physician's order. This deficient practice placed Resident 11 at risk for experiencing complications such as respiratory distress (a condition that occurs when the body needs more O2, resulting in difficulty breathing, rapid breathing, and low blood O2 levels) that can lead to serious illness and/or death.

Inspectors wroteBased on interview and record review, the facility failed to provide trauma-informed care (an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of traumas) for one of two sampled resident (Resident 8) reviewed for behavior and diagnosed with post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services for one (1) of six (6) sampled residents (Resident 42) observed for medication administration by failing to ensure Licensed Vocational Nurse 5 (LVN 5) administered Carvedilol (medication used to treat hypertension [high blood pressure] and congestive heart failure [CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling]) with food on 5/5/2026 to Resident 42 as indicated on the physician's order and facility policy. This deficient practice had the potential for Resident 42 to experience gastrointestinal discomfort, nausea, and the risk for side effects such as dizziness, fainting, and sudden low blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Medication Cart 1 remained locked while unattended during medication administration on 5/5/2026 as indicated in the facility's policy. This deficient practice had the potential for unauthorized access to medications by residents, staff and visitors which could lead to medication overdose (taking a toxic or poisonous amount of a drug or medicine), unauthorized use, adverse reactions (any unexpected or dangerous reactions to a drug), or harmful drug interactions (a reaction between two or more drugs or between a drug, and a food, beverage, or supplement).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse staffing information (real-time data regarding the number and types of nursing staff currently on duty) was updated and posted daily on 5/2/2026 and 5/3/2026, according to the facility's policy. As a result, the current resident census, total number of staff and the actual hours worked by the staff were not readily accessible to residents and visitors.

Inspectors wroteBased on interview and record review the facility failed to ensure one (1) of two sampled residents (Resident 1) with history of attempted elopement (occurs when a resident leaves a facility without authorization or supervision) was provided safety protocols, supervision and ensure monitoring to prevent elopement when the front door was left unsupervised on 3/14/2026 around 9 pm. This failure resulted in Resident 1 having a successful elopement and had the potential to lead to endangerment, accident and injury while outside the facility's premises without supervision from staff. Resident 1 was returned to the facility on 3/15/2026 at 1:15 PM.

Inspectors wroteBased on interviews and record review, the facility failed to maintain accurate documentation of wound care treatments for one (1) of two (2) sampled residents (Resident 1) on the resident's Treatment Administration Record (TAR) in accordance with the facility's policy. This deficient practice had the potential to result in miscommunication among staff and resulted in inaccurate representation of care provided to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to formulate comprehensive person-centered care plans for one (1) of 3 sampled residents (Resident 1) as indicated on the facility's policy by failing to: Having care plan and document evidence to monitor the side effects and effectiveness of the use of two antibiotic medications (a drug used to treat infections caused by bacteria and other microorganisms) Document evidence of Resident 1's Right hip dislocation and care plan to implement hip precautions and monitor Resident 1's condition. These deficient practices had the potential negative effects, worsening outcomes/conditions and lead to hospitalization for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary wound care and treatment for one (1) of three (3) sampled residents (Resident1) accordance with facility's policy ( Wound Care) when: a. Licensed Nursing staff did not monitor Resident 1 for signs and symptoms of infection, pain and discomfort of the right hip abscess (collection of pus in any part of the body) on every shift from 6/1/2025 - 6/23/2025.b. Treatment orders were not provided on every shift from 6/1/2025 - 6/23/2025. These deficient practices had the potential to delay in healing Resident 1's right hip abscess which can lead to worsening of the wound and affect the resident's overall well-being and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report allegation of sexual abuse for one of three sampled residents (Resident 2) to the California Department of Public Health (CDPH), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility ' s policy and procedure. This deficient practice potentially delays the investigation and prevention of abuse, and put Resident 2 and other residents in the facility at risk of further abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light system was functioning for one out of three sampled residents (Resident 1). This deficient practice at risk in delay response to resident's requests, ensure resident's safety and fulfill the needs of resident's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage of food was done in a safe and sanitary conditions according to the facility's policy and procedure (P&P) for twelve (12) residents reviewed for kitchen by failing to ensure: 1. Opened container of pancake and waffle syrup and creamy Italian dressing were dated with the use by date. 2. Frozen vegetables stored in the freezer were labeled with the name of the food item and dated with the use by. This deficient practice had the potential to result in residents ingesting expired food which can result in foodborne illnesses (food poisoning) with symptoms including upset stomach, vomiting, diarrhea, and fever and had the potential for the facility to serve food items not included in the scheduled menu.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for five (5) of nine (9) sampled residents (Residents 9, 40, 42, 150 and 17) as indicated on the facility policy and procedure (P&P) when the facility failed to: 1-4. Ensure facility staff donned (put on) full personal protective equipment (PPE; clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and/or a N95 respirator (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) before entering a Coronavirus (SARS-CoV-2/COVID-19; a disease caused by coronavirus characterized mainly by fever and cough and can progress to severe symptoms) positive room under contact (a type of transmission-based precaution [TBP; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide dignity and respect for one of one sampled resident (Resident 36) when Certified Nursing Assistant 4 (CNA 4) took food items from Resident 36's bedside table and washed Resident 36's boots without asking permission. These deficient practices have the potential to negatively affect Resident 36's sense of self-esteem and self-worth and can lead to social isolation/ distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a documented evidence that restorative nursing (a program available in nursing homes that helps residents maintain any progress made during rehabilitation therapy treatments, enabling the residents to function at a high capacity) care was provided on 4/1/2025 to 4/8/2025 and 4/10/2025 to 4/13/2025 for one of two sampled residents (Resident 18) with limited range of motion (ROM- the extent of movement of a joint) and limited mobility: This deficient practice placed Resident 18 at risk for further decline in physical function and contractures (condition of shortening and hardening muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care to prevent complications of a gastrostomy tube (g-tube; a surgical opening fitted with a tube device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for one (1) of four (4) sampled residents (Resident 32) in accordance with the facility's policy and procedure (P&P) by not ensuring Licensed Vocational Nurse 2 (LVN 2) checked Resident 32's g-tube placement prior to administering a water flush (the process of gently pushing water through the g-tube to keep it from clogging) and medication administration. This failure had the potential to result in Resident 32 aspirating (when something enters the airway of lungs by accident) which could lead to lung problems such as pneumonia (a lung infection) and result in death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post a No Smoking/Oxygen in Use sign outside of the room entrance door for one of one sampled resident (Resident 98) to indicate the presence of oxygen as indicated in the facility's policy and procedure (P&P). This deficient practice had the potential to place the residents, staff, and visitors at risk for injury in an event of a fire.

Inspectors wroteBased on interview, and record review, the facility failed to ensure psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) were not used unnecessarily for one of five sampled residents (Resident 35) reviewed for unnecessary medications by failing to: 1. Implement the gradual dose reduction (GDR- is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) recommendation from the consulting pharmacist to decrease Resident 35's Lexapro (medication used to treat depression [mood disorder characterized by a persistent sad, hopeless, or empty mood that can interfere with daily life] and anxiety [a feeling of apprehension, worry, or nervousness, often related to an impending threat of danger]). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a bowel and bladder assessment was documented accurately for one (1) of 12 sampled residents (Resident 33) as indicated in the facility policy. This failure had the potential for Resident 33 not to receive the appropriate incontinent (unable to control the blader or bowels resulting in the involuntary release of urine or feces) bowel and bladder care, which could lead to skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a visible and audible alarm activated by a call button) for one of 12 sampled residents (Resident 23) was within reach as indicated on care plan and facility's policy. This failure placed Resident 23 at risk for experiencing a delay in receiving assistance from facility staff which could lead to a fall or accident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 13 of 21 resident rooms (rooms 1, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21) met the square footage requirement of 80 square feet (sq. ft., unit of measurement) per resident in a multiple resident room. This failure had the potential to affect the residents' personal space, decrease freedom of mobility, and could compromise the provision of care.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of alleged sexual abuse (the act of engaging in sexual activity with someone without their consent, or by using force or coercion) for one (1) of three sampled residents (Residents 1) within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB) (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement when OMB and local law enforcement went to the facility to investigate the allegation of sexual abuse made by Resident 1 on 3/5/2025. This deficient practice had the potential to compromise or impede the protection of Resident 1, which could affect resident's physical, emotional, and mental wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to post the accurate and complete Census and Direct Care Service Hours Per Patient Day (DHPPD, refers to the actual hours of work performed per patient day by a direct caregiver) in accordance with the facility's policy and procedure by: 1. Facility did not post the DHPPD on 9/16/2024 in a prominent place readily accessible to resident and visitors. 2. Facility failed to ensure the posted DHPPD for 9/8/2024 to 9/12/2024 were complete and indicated the total number and actual hours of licensed and unlicensed nursing staff who worked and directly responsible for resident care. These deficient practices had the potential for the Nurse Staffing Information not to be available to the residents and visitors at any given time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (a device used by patients to call for assistance from hospital staff) was within reach (an arm's length) of one of three sampled residents (Resident 2). This deficient practice had the potential to result in delayed provision of services, delay in care and not receiving assistance with activities of daily living (ADLS, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating).

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a fall (unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) for one (1) out of three (3) sampled residents (Resident 1). On 5/26/2024, Resident 1 was trying to transfer to bed, Certified Nurse Assistant (CNA) 1 was present in the room and did not assist the resident while transferring to bed. This deficient practice has resulted to Resident 1 had a fall on 5/26/2024 and sustained laceration (measurement not indicated) on her left eyebrow.

Inspectors wroteBased on interview and record review, the facility failed to readmit one of one sampled resident (Resident 1) back to the facility on 5/22/2024 after the resident was hospitalized at the General Acute Care Hospital (GACH). This deficient practice resulted in the violation of Resident 1's right to resume residency at the facility and had the potential to cause psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged violation of abuse within two hours AND to California Department of Public Health (CDPH) for one of one resident (Resident 1) as indicated in the facility's policy and procedure (P&P). This failure resulted in the facility not reporting the occurrence of alleged abuse to all entities indicated in facility policy. Findings During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include legal blindness, anxiety disorder (mental disorder involves persistent and excessive worry that can interfere with daily activities) and type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood). [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent further allegations of abuse against the Social Services (SS) by failing to suspend SS after initial alleged violation and failing to submit the 5 day follow up investigation report to California Department of Public Health (CDPH) for one of one sampled resident (Resident 1) as indicated in facility's policy & Procedure (P&P). This deficient practice resulted in the facility's failure to provide evidence that the alleged violation of abuse was thoroughly investigated and had the potential risk of failure to protect Resident 1 from abuse.

Inspectors wroteBased on interview and record review, the facility failed to transmit a Minimum Data Set (MDS, a standardized assessment and care-screening tool) Discharge Tracking Form (DTF, submitted when a resident has been discharged from the facility) to CMS (Centers for Medicare and Medicaid Services) within 31 days after a resident's DTF was completed for two of four sampled resident (Resident 17 and 37). This failure had the potential to result in an inaccurate assessment of the facility's quality indicators (standardized, evidence-based measures of health care quality that can be used with readily available in the healthcare setting) and/or care area concerns for review.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove and discard ground beef from the refrigerator after it was past the use by date according to the facility's policy and procedure (P&P) titled, Refrigerators and Freezers. This failure had the potential to result in residents to experience food-borne illnesses (an illness that comes from eating contaminated food. The onset of symptoms may occur within minutes to weeks and often presents itself as flu-like symptoms, as the ill person may experience symptoms such as nausea, vomiting, diarrhea, or fever).

Inspectors wroteBased on interview and record review, the facility failed comply with requirements of Binding Arbitration Agreements (require that persons who signed them resolve any disputes by binding arbitration [alternative dispute resolution in which both parties agree to have their case heard by a neutral party instead of a judge and jury], rather than in court before a judge and/or jury) for three of three sampled residents (Residents 12, 19, and 200) when: 1. Facility failed to ensure Resident 12, who signed an Arbitration Agreement, dated 3/13/2024, understand what a Binding Arbitration Agreement was. 2. Facility failed to ensure Resident 19's Arbitration Agreement, dated 11/20/2020 was not signed in two locations/ options. It indicated, Resident 19 agreed to enter a Binding Arbitration Agreement and indicated the resident declined to enter a Binding Arbitration Agreement with the facility. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to maintain an infection control measure designed to provide safe, sanitary equipment and prevent the development and transmission of disease and infection by failing to sanitize blood pressure cuff (device for measure blood pressure) between residents' use for two of six sampled residents (Residents 12 and 34). This deficient practice has the potential for communicable disease (also known as contagious disease, an infection transmissible by direct contact with an affected individual or the individual's body fluids or by indirect means like contaminated object) to spread out to others.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consents (a process in which a health care provider educates a resident about the risks, benefits, and alternatives of a given procedure or intervention) for the use of psychotropic medications (medications that affect the mind, emotions, and behavior) for two (2) of five (5) sampled residents (Resident 44 and Resident 101) as indicated on the facility policy and procedure. 1. Facility failed to obtain an informed consent from Resident 44's Responsible Party (RP) prior to use of Seroquel (Antispychotic medication). 2. Facility failed to obtain an informed consent from Resident 101 prior to use of lorazepam (Antianxiety medication) and quetiapine (Seroquel). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal their need for assistance from staff) was within sight and within reach for four (4) of 14 sampled residents (Residents 16, 35, 41, and 100) while in bed. This failure had the potential for Residents 16, 35, 41, and 100 to not be able to call for assistance if the residents desired to.

Inspectors wroteBased on interview and record review, the facility failed to ensure the responsible party (RP, responsible for guiding, informing, assisting, and advocating for residents in the healthcare system) for one (1) of two (2) sampled residents (Resident 38), who did not have the capacity to understand, received information regarding resident's right to formulate an advance directive (a legal document that states resident's wishes about receiving medical care if that resident is no longer able to make medical decisions because of a serious illness or injury). This failure had the potential to violate Resident 38's and Resident 38's RP's right to formulate an advance directive.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician (MD) of a change of condition for one of 14 sampled residents (Resident 22) after a fall on 4/24/2024. This deficient practice had the potential to not provide the necessary care and services needed by Resident 22, which can affect resident's overall wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan (initial goals based on admission orders which provides instructions for immediate care of the resident) for one (1) of 14 sampled residents (Resident 101) within 48 hours of Resident 101's admission to the facility. This failure had the potential for Resident 1 to not receive adequate and appropriate care.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan to address resident's behavior of getting up out of the wheelchair unassisted for one of 14 sampled residents (Resident 22) as indicated on the facility policy and procedure. This deficient practice had the potential for Resident 22 to fall and result in injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a nephrostomy (a surgical opening from the outside of the body to the renal pelvis [part of the kidney that collects urine] connected by a urinary tube/catheter [a plastic like tube placed in the body to drain and collect urine from the bladder {sac like that collects urine}]) bag was positioned below the bladder, the nephrostomy bag was placed on bed next to the resident, for one of two sampled residents (Resident 26), This deficient practice had the potential for urinary tract infection if the urine in the tubing or drainage bag back flow into kidney.

Inspectors wroteBased on interview and record review, the facility failed to act upon the pharmacist's recommendations for A1C blood test (a blood test that provides information about levels of blood sugar over the past 3 months, used to diagnose type 2 diabetes [a disease that occurs when blood sugar is too high] and prediabetes) from medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication by pharmacist) for one (1) of 14 sampled residents (Resident 44). This failure had the potential to result in resident had uncontrolled blood sugar level that cause affect their health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe keep of medications when medications were left unattended during a medication administration observation for one of four sampled residents (Resident 34). This failure had the potential to result in loss of medications and/or other residents accessing the medications which could result in adverse effect (a harmful and undesired effect resulting from a medication or intervention) in the event that the medications were ingested.

Inspectors wroteBased on interview and record review, the facility failed to implement its Policy and Procedure (P&P) for Influenza (a highly contagious viral illness that infect the nose, throat, and lungs) and Pneumococcal (pneumonia, infection of one or both lungs) Vaccination (treatment to a particular infectious disease) for one (1) of five (5) sampled residents (Resident 12) by failing to ensure: a. Resident 12's influenza vaccine and pneumococcal vaccine administration was recorded in Resident 12's Immunization Record. b. Resident 12 was monitored for side effects after Resident 12 received an influenza and a pneumococcal vaccine. These failures had the potential for Resident 12 to not receive care and treatment for side effects from the influenza and pneumococcal vaccines.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 13 out of 21 rooms (1, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20 and 21) met the square footage requirement of 80 square feet (sq. ft., unit of measurement) per resident in multiple resident rooms. This deficient practice has the potential to cause the residents in these rooms not to have enough room for activities of daily living and hinder staff from providing care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for its staffs. This failure had the potential to result in staff not appropriately trained to improve resident safety, enhances the resident's quality of care and quality of life, and reduce the number of adverse events or other resident complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive resident - centered care plan for one (1) of three (3) sampled residents (Resident 1) per facility ' s policy. This deficient practice had the potential for Resident 1 to not receive specific interventions to prevent decline in the resident ' s functional ability, which could result in injury and harm.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Licensed Vocational Nurses (LVNs) annual competency skills were checked and completed based on the facility's policy and procedure. This failure had the potential to not meet the specific competency requirements of the Licensed Nurses competency skills annually, which could affect the residents during provision of nursing services. Findings During an interview with the Director of Staff Development (DSD) 1 on 12/27/2023 at 3:32 PM, DSD 1 stated she does not have a licensed competency skills log for the licensed nurses. During an interview with the Director of Nursing (DON) on 12/27/2023 at 3:41 PM, the DON stated, Annual competency is conducted on the Licensed Nurse's anniversary date, which is every year on the LVN's employment date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for one (1) of five (5) sampled residents (Resident 1) in accordance with the facility's policy and procedure when: 1. Resident 1's oxygen humidifier bottle was empty and did not have sterile water (water that is free of any microbes [tiny living things that are found all around us and are too small to be seen by a naked eye], used to prevent growth of organisms and bacteria in the water). This deficient practice had the potential to create discomfort and dryness to the nasal passages which can lead to serious complications. 2. [...]