Fortuna Rehabilitation and Wellness Center, LP

Inspectors wroteBased on observation, interview and record review, the dietary staff failed to follow recipes during meal preparation for 87 residents who ate meals from the kitchen on 6/23/26 and 6/24/26. This failure resulted in unpalatable meals and decreased the facility's potential to prevent malnutrition and weight loss.

Inspectors wroteBased on observation, interview and record review, the dietary staff failed to store food in a sanitary manner for a census of 87 residents when:The kitchen floor and mats appeared dirty;Silver storage shelves had dried white matter on the surface of the shelves and its legs;The [NAME] (CK) did not wear a hair net;Expired food was in the refrigerator;The hand-washing sink appeared dirty;The recipe holder was sticky; and,There was food splatter observed under a shelf above the cooking station. These failures decreased the facility's potential to ensure a sanitary kitchen and prevent foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure trash was stored in a sanitary manner for a census of 87 residents when trash dumpsters were observed overflowing with rubbish and filled rubbish bags were left on the ramp next to the container. This failure decreased the facility's potential to prevent a nuisance or breeding ground for insects and rodents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe and sanitary environment for a census of 92 residents when:1. Certified Nursing Assistants (CNAs) did not offer or remind residents to clean their hands before lunch service or eating;2. Resident glucometers (a small, portable electronic device used to measure the amount of sugar [glucose] in your blood) were not sanitized using the appropriate sanitizing agent;3. An Infection Prevention and Control Program (IPCP) with written standards, policies, and procedures was not maintained, reviewed and regularly updated;4. Oxygen concentrators (a medical device that provides supplemental oxygen to people with breathing-related conditions by pulling in ambient air, filtering out nitrogen, and delivering purified oxygen) had visible dust and debris in the vents and another had a dirty filter; and,5. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan for one resident (Resident 9) of five sampled residents. This failure decreased the facility's potential to ensure Resident 9 can result in missed or delayed interventions in Resident 9's plan of care and cause the resident's suffering or her condition to worsen.

Inspectors wroteBased on interview and record review, the Interdisciplinary Team (IDT, a collaborative group of healthcare professionals that assess and manage a resident's medical, functional, and social needs) failed to review and revise the comprehensive care plan for one resident (Resident 5) of five sampled residents. This failure decreased the facility's potential to ensure new interventions were included in a resident's person-centered care plan.

Inspectors wroteBased on interview and record review, the licensed nurses failed to ensure three residents (Resident 11, Resident 9, Resident 30) of seven residents were fully informed in advance of the risks and benefits of their proposed psychotropic medication (any prescription drug that changes how the brain works and alters the mood, thoughts, behavior, or feelings) when:Resident 11's informed consent was not signed by the resident who was his own Responsible Party (a person appointed to make decisions when a person is no longer able to make them for themselves);Resident 9's informed consent (a conversation between patient and physician where treatment, its risks and benefits and options are explained before the patient agrees to the treatment) was not obtained for the resident's psychotropic medication to treat anxiety disorder and insomnia (trouble falling asleep or staying asleep); [...]

Inspectors wroteBased on interview, and record review, the licensed nurses failed to ensure the admission Minimum Data Set (MDS - an assessment tool) was accurately documented for two residents (Resident 6 and Resident 51) of four sampled residents when residents' use of hearing aids and glasses were incorrectly documented. This failure placed Residents 6 and Resident 51 at potential risk for not receiving appropriate care and services for hearing and vision impairments.

Inspectors wroteBased on observation, interview, and record review, the Director of Nursing (DON) and Consultant Pharmacist failed to ensure controlled drugs (drugs or other substances that are tightly controlled by the government because it may be abused or cause addiction) that were ready to be disposed of, were securely stored inside the facility, when 30 tablets of hydrocodone (a semi-synthetic opioid prescribed to manage severe chronic pain) and 19 tablets of hydromorphone hydrochloride(a potent opioid used to treat moderate-to-severe pain) were discovered missing from the facility's locked box of controlled medications. This failure decreased the facility's potential to prevent drug diversion (the unlawful channeling of regulated pharmaceuticals from legal medical sources to the illicit marketplace or for personal, unauthorized use) of controlled drugs.

Inspectors wroteBased on interview, and record review, the licensed nurses failed to ensure communication care needs between facility staff and the hospice provider for one resident (Resident 98) of two sampled residents when the facility did not have a care plan for hospice care. This failure placed Resident 98 at a potential risk of not having her care needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the safety of one of five sampled residents, Resident #1, when they did not provide adequate supervision and monitoring to prevent Resident #1 from leaving the facility. This failure resulted in Resident #1 to leave the facility unnoticed and walk down a public sidewalk on the road in front of the facility. This had the potential for Resident #1 to experience a fall, wander into the street with traffic or become confused and scared. On 5/11/26 at 8 a.m., the Department was notified that Resident #1 had eloped from the facility on 5/9/26 at 7:45 p.m. The facility indicated the DON was notified by the facility nurse on 5/9/26 at 7:45 p.m., that Resident #1 had been observed on the sidewalk on the public road outside the facility. Resident #1 was easily redirected by staff back into the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement comprehensive care plan interventions for one of two residents (Resident 1) when the facility failed to provide documentation that fall risk and post fall care plan (written, and personalized document outlining a resident's medical, physical, and emotional needs, along with specific goals and treatment strategies) interventions were implemented. These failures resulted in Resident 1 experiencing repeated falls with potential for more severe injuries.

Inspectors wroteBased on interview, and record review, the facility failed to provide services according to professional standards of practice for one of six sampled residents (Resident 1) when 72-hour monitoring was not completed following a change of condition (COC). This finding had the potential to result in psychological distress, physical injury, and worsening mental health symptoms for Resident 1. A review of Resident 1's admission record indicated he was admitted to the facility on [DATE] with medical diagnosis which included dementia (severe decline in memory and thinking), major depressive disorder (intense sadness for at least two weeks), post-traumatic stress disorder (a mental health disorder triggered by trauma, causing lasting symptoms like flashbacks, anxiety, and avoidance), and suicidal ideations (thoughts of self-harm). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 1) of nine sampled residents was free from abuse when Resident 1 became the victim of an alleged abuse event. This failure had the potential to negatively impact the resident's psychosocial well-being. A review of Resident 1's admission record indicated he was admitted in October 2025 with the diagnosis of encounter for palliative care (specialized medical care for individuals living with serious, chronic or life threatening illness that focuses on providing relief from the symptoms, pain and stress), acute chronic systolic (congestive) heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), muscle weakness, hearing loss and absence of left leg, below the knee. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy for one (Resident 1) of nine sampled residents when a licensed nurse did not immediately document an assessment and conduct 72-hour monitoring for Resident 1 after an alleged abuse incident. This failure had the potential to deny physician and family involvement in the residents' care and result in unmet nursing needs for the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 1) was treated with respect and dignity when a licensed nurse (LN) took her call light and bed remote away from her. This failure had the potential to result in Resident 1 being unable to request assistance when needed.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse timely for one of two sampled residents, Resident 1, when Resident 1's allegation of harm was not reported to the Department within two hours. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety. On 1/31/25 at 4:40 p.m., the Department received a document titled Report of Suspected Dependent Adult/Elder Abuse (a critical document used by mandated reporters to report allegations of abuse of elders; also called SOC 341) from the facility that indicated, On 1/31/25 at 2:45 pm during chart review Nurse Consultant identified a progress note written that a resident felt that she was abused by the nurse who did her treatment on Sunday on 1/26/25 . [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one resident (Resident 1) of two sampled residents was free from a significant medication error when Resident 1 was administered an incorrect dose of Oxycodone Hydrochloride (medication used to relieve severe pain). This failure decreased the facility's potential to correctly and safely administer medication and prevent adverse side effects.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an RN (Registered Nurse) provided services at least 8 consecutive hours a day, 7 days a week for 6 days in the month of April 2025. This failure decreased the facility's potential to ensure qualified staff were present to conduct resident assessments, develop and evaluate plans of care, and administer medications that must be administered by an RN.

Inspectors wroteBased on interviews and record review, the facility failed to ensure allegations of abuse were reported to the California Department of Public Health (CDPH, the Department) within two hours and investigation summaries were submitted within 5 days of becoming aware of allegations of abuse for 11 residents (Resident 00, Resident 83, Resident 101, Resident 90, Resident 105, Resident 102, Resident 2, Resident 74, Resident 14, Resident 68, and Resident 65) of 28 sampled residents when:1. Resident 00 entered Resident 83 and Resident 101's room and started breaking their belongings, cursing profanities, and yelling at them;2. Resident 90 threw water at Resident 105;3. Resident 102 was allegedly yelled at by CNA 8 and was told she needed to stop peeing on herself;4. Resident 2 slapped Resident 74 on the hand;5. Resident 14 allegedly grabbed Resident 90 because he had called him 'dude';6. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or their Responsible Party (RP, an individual or entity who has the primary duty to make healthcare decisions) with a summary of the resident's baseline plan of care and list of medications for three residents (Resident 41, Resident 46, and Resident 96) of 28 sampled residents. This failure decreased the facility's potential to provide communication with the residents and/or their RP on how the facility planned to manage needed services and treatments while at the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive care plans for four residents (Resident 62, Resident 41, Resident 46, and Resident 96) of 28 sampled residents when:1. Care plans were not developed for care areas identified by Resident 62's Minimum Data Set (MDS- a federally mandated resident assessment tool); and,2. Discharge care plans were not developed for newly admitted residents (Resident 41, Resident 46, and Resident 96), after their initial multidisciplinary care conference. These failures decreased the facility's potential to meet residents' nursing needs and ensure safe discharges.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications in medication carts (med carts) were stored in a clean, safe and orderly manner, when:1. Crushed and loose medications were stored in Med Cart 4; and,2. One med cart (Med Cart 1) was left unlocked when unattended. These failures had the potential for residents, visitors or unauthorized personnel to access medications, and unwanted exposure or cross contamination of medications when they were in an unsanitary manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor the food preferences for three residents (Residents 14, 46, and 97) of 28 sampled residents. These failures resulted in Residents 14, 46, and 97 feeling ignored and frustrated as they were served food they disliked, which may lead to poor nutritional intake and unplanned weight loss.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure sanitary conditions were maintained and failed to follow Standard Precautions (proper cleaning and disinfection of equipment) for a census of 94 residents, when:1. Resident 1's bedside commode (BSC, a portable toilet) was not kept in a clean and sanitary manner;2. The metal ice scoop on the hydration cart was not stored in a sanitary manner; and,3. Staff did not disinfect the vital sign machine and equipment between use for five residents (Residents 83, Resident 77, Resident 82, Resident 28, and Resident 88). These failures decreased the facility's potential to prevent the spread of infection and pathogens (microorganisms or other biological agents that can cause disease) between residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for a census of 94 residents when flies were observed flying throughout the facility. This resulted in residents being bothered by flies in their room, flies in the Great Dining Room while residents were trying to eat their meals, and flies in the kitchen which could lead to contamination of food being prepared.

Inspectors wroteBased on interview and record review, the facility failed to ensure five residents (Resident 74, Resident 83, Resident 101, Resident 105, and Resident 68) of 28 sampled residents were free from abuse when:1. Resident 2 slapped Resident 74 on the hand;2. Resident 00 entered Resident 83 and Resident 101's room and started breaking their belongings, cursing profanities, and yelling at them;3. Resident 90 threw water at Resident 105; and,4. Certified Nursing Assistant 4 (CNA 4) instructed Resident 68 to urinate in her brief when Resident 68 asked for assistance to use the restroom. These failures resulted in residents being hit, feeling fear, and being neglected.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one of eight sampled residents, (Resident 2) was free of unnecessary psychotropic medications (drugs that affect the mind and brain, altering mood, perception, and behavior) when Resident 2 received: Haloperidol (an antipsychotic medication) used to treat to treat schizophrenia and Tourette's Syndrome (disorder characterized by involuntary, repetitive movements or sounds called tics); [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure for abuse for one resident (Resident 65) of 28 sampled residents when licensed nurses and the social service worker did not assess Resident 65 for emotional distress after Resident 65 reported an allegation of abuse. This failure decreased the facility's potential to ensure the safety and welfare of Resident 65 after an allegation of abuse was reported.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses provided two residents (Resident 2 and Resident 74) of 28 sampled residents care that met professional standards of practice when neurological assessments were not completed per the facility's fall protocol after Resident 2 and Resident 74 had unwitnessed falls. These failures decreased the facility's potential to provide the expected nursing care indicated in resident care plans and accepted standards of practice.

Inspectors wroteBased on interview and record review, the facility failed to recognize, report, and address the nutritive needs of one resident (Resident 62) of 28 sampled residents when Resident 62 lost 9.8 pounds between 8/6/25 and 9/5/25. This failure led to Resident 62 experiencing an unplanned weight loss without timely notification to the Director of Nursing, Physician, or Registered Dietitian per the facility's weight evaluation policy, thereby delaying necessary intervention.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure routine and emergency drugs were available for a census of 94 residents, when:1. Resident 73's routine buprenorphine - naloxone (a controlled substance used for chronic pain management) was unavailable for administration; and,2. The facility's oral and insulin emergency medication kits (e-kit) were not replaced within a timely manner. These failures decreased the facility's potential to meet residents' routine scheduled and emergency therapeutic needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nourishment that was palatable, textured, and attractive for one resident (Resident 58) of 25 sampled residents when a liquified pureed diet was provided contrary to the Responsible Party (RP, an individual or entity who has the primary duty to make healthcare decisions for a resident) and family preference and concern. This failure resulted in weight loss and a lack of dignity for Resident 58.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure frozen vegetables stored in the freezer were sealed for 90 residents who received food from the facility's kitchen. This failure could cause frozen vegetables to develop freezer burn, which could negatively affect the quality of the vegetables by causing the vegetables to be dry, tough, and flavorless and had the potential to result in cross contamination leading to foodborne illnesses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure resident safety for one resident (Resident 6) out of 25 sampled residents when the call light was out of reach. This failure decreased the facility's potential to ensure Resident 6's ability to notify staff if there was an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure three sampled residents (Resident 1, Resident 2, and Resident 3) received appropriate PASSR (Preadmission Screening and Resident Review - a federal requirement ensuring individuals with serious mental illness, intellectual disabilities, or related conditions are not inappropriately placed in Medicaid-certified nursing facilities and receive appropriate services) evaluations. This failure excluded each Resident from a complete mental health evaluation for appropriate facility placement, and non-receipt of available mental-health resources from the California Department of Developmental Services (DDS).

Inspectors wroteBased on interview and record review, the facility failed to provide face-to-face physician visits at least once every 60 days for three sampled residents (Resident 1, Resident 2, and Resident 3). This deficient practice had the potential to result in a decline in medical, health or psychosocial condition and lead to a delay in necessary care, treatment and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Nurses (LNs) administered medications to residents per physician's order for two residents (Resident 1 and Resident 2) of four sampled residents when LNs administered medications late. This finding had the potential to result in serious side and adverse effects to the residents receiving late medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate staffing with appropriate competencies was maintained to meet the physical needs of the residents, as evidenced when treatments for wound care were not provided as ordered by the Physician for four of nine sampled Residents: Resident 1, Resident 2, Resident 3 and Resident 4. This failure had the potential for delaying the healing of the wounds and increasing the risk for the wounds to become infected.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision to prevent a fall for one resident (Resident 1) of two sampled residents when Certified Nursing Assistant B (CNA B) left Resident 1 on the toilet unsupervised then left Resident 1 ' s room to attend to another resident. This failure resulted in Resident 1 sustaining a fracture (a complete or partial break of the bone) of the right distal fibula (smaller long bone of the lower leg) and the right distal tibia (larger long bone of the lower leg).

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for two residents (Resident 2 and Resident 3) of two sampled residents when the facility reported an allegation of abuse to the California Department of Public Health (the Department) three days after the incident occurred. This failure decreased the facility's potential to ensure resident safety and cause a delayed response by enforcement agencies.

Inspectors wroteBased on observation, interview, and record review the facility did not maintain a safe and functional environment when the transition strip (flooring strip designed to smooth out the junction of different flooring types) at two of four doorways was in the wrong position to make a smooth surface at the threshold, (the bottom of the doorway.) The two doorways were at room [ROOM NUMBER] and the 1st shower room on the same hall. This failure resulted in Resident 1 falling at the doorway of room [ROOM NUMBER] and breaking her arm. This failure had the potential to cause Resident 1 to fall again, as well as cause other residents, staff, and the public, (due to unsafe and poorly maintained flooring,) to fall.

Inspectors wroteBased on interviews and record reviews, the facility failed to regularly provide showers for one out of two sampled residents (Resident 1). This failure was a contributing factor for: 1.staff not identifying Resident 1 wound on top of his right shoulder, 2. the wound on top of Resident 1's right shoulder to become infected (having an infection- invasion or growth of germs in the body) that later developed into sepsis (life threatening condition, a severe form of infection).

Inspectors wroteBased on observation, interviews and record reviews, the facility failed: 1. to ensure skin assessments (process of examining entire skin for any abnormalities) was provided thoroughly, accurately documented and ensure treatment was provided when there were skin assessments forms completed but the assessment were inaccurate for one out of two sampled residents (Resident 1) 2. to provide showers regularly and as scheduled for one out of two sampled residents (Resident 1). These failures resulted in: A. inaccurate documentation of Resident 1's skin status, staff not identifying Resident 1 wound on top of his right shoulder, thereby no treatment was rendered on the wound on Resident 1's right shoulder, B. top of Resident 1's right shoulder developed a wound infection (invasion or growth of germs in the body) at the facility that was missed by the staff and, C. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that one of three sampled residents, Resident 1, was free from a significant medication error when an extra dose of Oxycodone ( Oxycodone belongs to a class of drugs known as opioid analgesics. It works in the brain to change how your body feels and responds to pain) HCL (Hydrochloride) 5 mg (milligrams) was administered by Licensed Nurse A without a physician's order. This failure had the potential to result in an adverse (having a negative or harmful effect on something) reaction to Resident 1 that could affect his health and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six residents sampled for pressure ulcer (a localized injury to the skin and underlying tissue that occurs because of intense and prolonged pressure) review (Resident 199) received care, treatment, and services consistent with physician orders and professional standards of practice to prevent and treat pressure ulcers. For Resident 199, admitted on [DATE], bed-bound and immobile, with paralysis, admitted with a pre-existing Stage 3/Unstageable pressure ulcer (a wound where the whole skin is gone and the fat layer of tissue that underlines the skin is visible) on his coccyx (tail bone): (1) The facility failed to complete a risk assessment for developing pressure injuries (Braden Scale) upon admission for Resident 199. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents sampled for falls review (Resident 4) received care and services to prevent falls in accordance with Resident 4's fall risk factors and professional standards of practice. For Resident 4, who had a documented history of falls, poor gait, poor balance, and muscle weakness: (1) The facility failed to perform a fall risk evaluation after Resident 4 fell on 5/20/22 while Resident 4 was attending physical therapy, and after a nursing assessment on 5/22/22 indicated Resident 4 had poor balance and unsteady gate; (2) The facility failed to accurately evaluate Resident 4's risk for falls when a nursing assessment dated [DATE] indicated Resident 4 had no previous falls, when Resident 4 had fallen two days earlier on 5/20/22; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six residents (Resident 6) was free of significant medications errors when Resident 6 was administered 28 units (how insulin doses are measured) of Novolog Insulin 70/30 (a medication that lowers blood sugar and starts working within 15 minutes of administration) subcutaneously (under the skin) on 7/20/22 one hour before Resident 6 was served dinner and without ensuring Resident 6 ate dinner or had a snack after the insulin administration. As result, Resident 6, who did not eat dinner or had a snack after receiving insulin and on 7/20/22, felt shaky and had a blood sugar reading of 49 mg/dl [milligrams per deciliter] (normal range is between 70 and 100 mg/dl) at 9:30 p.m This failure placed Resident 6 at risk of fainting or becoming unresponsive due to hypoglycemia (low blood sugar).

Inspectors wroteBased on interview and record review, the facility (1) failed to ensure 4 of 5 sampled residents (Residents 8, 12, 19, and 33) reviewed for physician visits had monthly, in person, physician visits during the first 90 admission or at least every 60 days thereafter; and (2) failed to ensure 21 of 52 residents (Residents 3, 6, 8, 9, 12, 13, 18, 19, 21, 22, 23, 27, 28, 29, 32, 33, 34, 39, 41, 43, and 45) (40% of the facility residents) had an assigned physician who saw them at the facility when the physician managing the care of these residents (Medical Doctor H) was based 600 miles away in southern California and did not visit the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure it employed nursing staff with appropriate competencies and skills to care for facility residents when: (1) The facility failed to provide initial orientation, initial and annual competency/skills checks, and regular performance evaluations to six of six nursing staff sampled for verification of orientation, training and competencies: three Licensed Nurses (Licensed Nurses A, F and G) and three Certified Nursing Assistants (CNAs B, N and O); [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement an effective infection control program when staff were not wearing masks inside the facility, staff touched their mask after touching a mask contaminated with SARS-CoV-2 (the virus that causes COVID-19), and housekeeping staff entered rooms of residents on contact and droplet precautions without performing hand hygiene between rooms, without wearing the personal protective equipment (PPE) required, and using one rag to clean multiple rooms. This failure potentially caused spread of COVID-19 in a vulnerable population in a facility experiencing an outbreak of COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of the positive test results for four days for one of 37 residents (Resident 1) who tested positive for COVID-19 during the first 10 days of a facility outbreak. This resulted in a delay of four days in starting the antiviral for a vulnerable resident with comorbities.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean, sanitary, and homelike environment to four of five residents when the facility (1) failed to ensure the bathrooms of two of three sampled residents (Residents 25 and 26) were sufficiently cleaned and (2) failed to ensure three of three resident rooms (Rooms 21, 24 and 25 - occupied by Residents 24 and 201) had window screens that fully covered the window frames without gaps that could serve as an entry point for insects. These failures resulted in Residents 25 and 26 using filthy bathrooms, and flies and spiders coming into rooms of Residents 24 and 201, and had the potential for flies, spiders and other insects to come into the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide showers as scheduled for two (Resident 26 and 43) out of 4 sampled residents. The failure had the potential to resulted in residents being dirty and unkempt.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate respirator care to three (Resident 17, 26 and 7) out of four sampled residents when the facility could not determine how continuous positive airway pressure (CPAP) machines were maintained for residents who required them. These failures had the potential result in being uncomfortable to the residents due to missing additives and potential respiratory infections by tubing not being maintained or replaced appropriately.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was not greater than 5% when 12 medication errors were observed during 26 medication observations of two of six residents (Residentt 6 and 7), resulting in a medication error rate of 46%, when: (1) Resident 7 was administered 10 medications on 7/20/22 outside their prescribed scheduled times, as follows: (1) Insulin Lispro 2 units (for blood sugar control) due at 7 a.m. and given at 11:10 a.m.; (2) Metformin 1000 mg [milligrams] (for blood sugar control) due 7:30 a.m. and given at 11:10 a.m.; (3) Eliquis 5 mg (a blood thinner) due 8 a.m. and given at 11:10 a.m.; (4) Albuterol Sulfate Inhaler (for lung function) due at 8 a.m. and given at 11:10 a.m (5) Lisinopril 2.5 mg (for blood pressure) due at 9 a.m. and given at 11:10 a.m.; (6) Methadone 5 mg (for pain) due at 9 a.m. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow their policy on antibiotic stewardship by not replacing the Infection Preventionist. This failure resulted in residents not being tracked and monitored regarding their antibiotic usage and efficacy creating potential inappropriate use of antibiotics and potential resistance to antibiotics. During a telephone interview on 7/26/22 at 12:35 p.m., with Infection Preventionist (IP), she stated as of 4/28/22, she was part-time, working one hour a day to assist in reporting data for the facility. IP was asked who was in charge in antibiotic stewardship and she stated she was until 4/28/22 but did not know who had taken over the role. During an interview on 7/26/22 at 1:10 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ an infection preventionist (IP) who worked at least part-time. This failure resulted in minimal oversight of the infection prevention and control program during an outbreak of COVID-19 in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide training on abuse prevention and reporting to its nursing staff (licensed nurses and certified nursing assistants) when (1) only one quarter of its nursing staff (12 of 47 staff) received annual training on abuse prevention and reporting and when (2) six of six nursing staff (Licensed Nurse A and Certified Nursing Assistants H, P, W, Y and Z) could not correctly answer basic questions about abuse prevention and reporting. These failures placed the facility residents at risk of abuse.

Inspectors wroteBased on interview and record review, the facility failed to report to the Department one allegation of physical abuse for one of two sampled residents (Resident 32). This failure prevented the Department from timely investigating the abuse allegation involving Resident 32.

Inspectors wroteBased on observation, interview and record review, the facility failed provide care and services for one of one resident (Resident 199) with an indwelling urinary catheter (Foley Catheter) (a flexible tube inserted into the bladder used to drain urine) when, during a period of 30 days, from Resident 199's admission to the facility with a Foley catheter on 6/28/22 until 7/27/22, the facility (1) did not create or implement a Foley catheter care plan for Resident 199; (2) did not monitor Resident 199 for signs and symptoms of urinary tract infections; and (3) did not provide Foley catheter care to Resident 199 every shift, as ordered. These failures placed Resident 199 at risk of developing a urinary tract infection. Resident 199 developed a urinary tract infection on 7/23/22.