Foundation Skilled Nursing

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received adequate supervision and assistance for one of three sampled residents (Resident 1) when Resident 1 who was assessed as needing a staff member to accompany her during medical appointments was transported to a doctor's appointment by herself without a staff member present. This failure resulted in Resident 1 not completing her appointment, delayed care, and placed her at risk for injuries. During a concurrent observation and interview on 6/9/26 at 10:40 a.m. with Resident 1, Resident 1 sat halfway on her bed with her feet on the floor, dressed in a facility gown, with a wheelchair nearby. Resident 1 stated she had a gynecology (GYN) appointment the previous week for evaluation of her cancer. Resident 1 stated she was dropped off at the appointment in her wheelchair, and no one accompanied her. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain accurate documentation for one of three sampled residents (Resident 2) when LVN 1 documented Resident 2's wound care and bandage change was completed on 5/15/26. This failure resulted in inaccurate wound care documentation and had the potential to result in delayed wound healing, infection and sepsis. During a concurrent observation and interview on 5/15/26 at 11:45 am with Certified Nurse Assistant 1 (CNA 1), Resident 2 was observed in her bed. CNA 1 stated the facility was treating Resident 2's foot wounds with blue protective booties. When CNA 1 exposed Resident 2's feet, Resident 2 was wearing the booties on both feet. CNA 1 said they could not see any dressings and did not know whether any should have been present. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a functioning communication system (call light system-an alerting device used by residents to request assistance from nursing staff) for 11 out of 59 resident beds (11A, 11B, 11C, 8A, 8B, 14A, 14B, 17B, 17D, 15A, 15B) when the patient call light system was not activated when the call light was pressed and one resident was missing a call light button. This failure resulted in the affected facility residents being unable to call for help or receive immediate assistance from staff, which placed residents' health and safety at risk. During a concurrent observation and interview on 3/2/26 at 9:57 a.m. with Resident 1, in the resident's room, Resident 1 stated his call light had been working intermittently since his admission on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for one of seven residents (Resident 17) when Resident 17 was assessed with poor safety awareness, did not use safe techniques in self-transfers, had unsteady gait, and suffered multiple falls on 11/18/25, 11/22/25,11/23/25 and 11/24/25. Resident 17 had been determined as high risk for falls on quarterly assessment dated [DATE]. The facility failed to follow its facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, when the facility did not implement effective interventions to prevent falls, including adequate supervision, addressing the cause of frequent self-transferring attempts and reviewing medication for a possible cause consistent with Resident 17's needs, goals and care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedures to meet professional standards of quality for one of four sampled residents (Resident 64), when Resident 64's admission medications were not available on the next dose as ordered by the physician. Resident was admitted to the facility on [DATE]. These failures had the potential to place Resident 64 at an increased risk of health complications and change of condition resulting in hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ sufficient staff with appropriate competencies and skills sets to carry out the functions of food and nutrition services for two of two kitchen staff, Dietary [NAME] (DC)1 and Dietary Manager (DM) when DC1 and DM did not follow the menu at lunch on 12/3/25. This failure had the potential to result in residents nutritional needs not being met. During a concurrent observation and interview on 12/3/25 at 12:30 p.m. with DC1 and DM in the Kitchen, DC1 was preparing a lunch with a croissant sandwich with turkey breast, fresh tomatoes, cheddar cheese, regular bacon, and lettuce. DC1 prepared two garlic bread sticks instead of one. DC1 stated the menu for the lunch sandwich was not followed. DC1 stated, she used what food she had available in the facility and she had informed the DM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ sufficient staff with appropriate competencies and skills sets to carry out the functions of food and nutrition services for two of two kitchen staff, Dietary [NAME] (DC)1 and Dietary Manager (DM) when DC1 and DM did not follow the menu at lunch on 12/3/25. This failure had the potential to result in residents nutritional needs not being met. During a concurrent observation and interview on 12/3/25 at 12:30 p.m. with DC1 and DM in the Kitchen, DC1 was preparing lunch with croissant sandwich with turkey breast, fresh tomatoes, cheddar cheese, regular bacon, and lettuce. DC1 prepared two garlic bread sticks instead of one. DC1 stated the menu for the lunch sandwich was not followed. DC1 stated she used what food she had available in the facility and she had informed the DM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow-up with a positive Preadmission screening and Resident Review (PASARR-a federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) level I screening for one of five sampled residents (Resident 7 ) when Resident 7's PASARR level I screening dated 4/8/25 required PASARR Level II mental health evaluation and was not completed. This failure had the potential for Resident 7 to not receive the appropriate services related to her mental disorders. During a concurrent observation and interview on 12/2/25 at 11:06 a.m during initial tour in the doorway of Resident 7's room, Resident 7 was standing outside of room, dressed appropriately and stated she liked to keep her door closed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services which ensured appropriate administration of medications to meet residents needs when:1. The facility Refrigerator Emergency-kit (E-kit-contains medications provided to residents during emergency situations) containing three vials of insulin (used for high blood sugar level) was opened and no form was found indicating the date and name of person who opened the E-kit and no communication to pharmacy requesting for a replacement. This failure placed residents receiving insulin at potential risk for taking expired or compromised medications which could lead to serious consequences including reduced effectiveness in treating resident's condition in an event of an emergency and potential adverse reaction.2. Marianne1. During a concurrent observation and interview on [DATE] at 8:05 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was eight percent. There were 25 opportunities for errors and two medication errors occurred for one of five sampled residents (Resident 2) when:1. Licensed Vocational Nurse (LVN) 1 prepared an expired medication of five tablets of Folic Acid (is used prevent anemia, and support cell growth)1 mg (milligram- metric unit of measurement, used for medication dosage and/or amount) with an expiration date of 11/5/25 on 12/4/25. LVN 1 did not check the expiration date of the medication prior to medication administration. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper storage and disposal of medications and biologicals in accordance with facility policy and procedures when in side 1's medication cart, Resident 17 and Resident 45's discontinued bottles of Chlorhexidine Gluconate (antimicrobial mouthwash used to treat gingivitis (gum disease) was observed not separated from medications that were in use for facility residents. This failures had the potential for medications to be administered causing underdosing or overdosing of medications, or to be administered to the wrong residents causing harm to the resident. During a concurrent observation, interview and record review on 12/4/25 at 9:27 a.m. with Licensed Vocational Nurse (LVN) 1 in side 1's medication cart. Two bottles of Chlorhexidine Gluconate was observed with active medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to provide a safe and sanitary environment for two of four sampled residents (Residents 33 and 64) when:1. Certified Nursing Assistant (CNA) 5 did not wear appropriate personal protective equipment (PPE- specialized clothing, equipment, and supplies worn by healthcare workers protect residents and themselves from potential infectious hazards) when CNA 5 provided direct care to Resident 33 who was on enhanced barrier precaution (EBP- measures used in healthcare settings to prevent the spread of infections) for a known history of Extended Spectrum Beta-Lactamase (ESBL- are a group of bacteria that commonly cause infections both in healthcare settings and communities) producing bacterial infection/colonization on 12/3/25.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a resident care equipment in safe operating condition when the facility's mechanical lift (a mechanical device used by caregivers to safely lift and transfer individuals with limited mobility from one surface to another (bed, chair, toilet) using a sling, minimizing physical strain and preventing injury) was not functional to deliver residents' care and activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). This failure resulted in a delay in implementing residents' care including residents' transfers and obtaining weights as ordered and placed residents and staff at an increased risk of accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program when flies were flying around resident's room (room [ROOM NUMBER]) on 12/2/265 and 12/3/25 and transferring from one table to another in resident's dining room during lunch on 12/3/25. This failure had the potential for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effects) and for residents to acquire food borne illnesses (are caused by eating or drinking something that is contaminated with germs). During an observation on 12/2/25 at 8:39 a.m. in room [ROOM NUMBER], multiple flies (three) were going around the round, landing on residents' clothing and privacy curtain. During concurrent observation and interview on 12/2/25 at 9:11 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and maintain a safe, clean, and sanitary environment for one of four sampled residents (Resident 2), when Resident 2's mattress on the floor beside his bed was dirty with brownish dirt built up on the top of the mattress and observed nursing staff walking on the floor mattress. This failure had the potential for Resident 2 acquiring an infection (the invasion and growth of germs in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 13) was free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when the facility did not attempt or implement behavior monitoring for Resident 13's use of olanzapine (medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thoughts]). This failure placed Resident 13 at risk for experiencing adverse effects from receiving medication without behavior monitoring. During a concurrent observation and interview on 12/2/25 at 2:40 p.m. in Resident 13's room, Resident 13 was ambulating inside the room with steady gait and appropriately dressed. Resident 13 stated he was in the acute care hospital for a week prior to admission in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure their policy on discharge was followed for one of three sampled Residents (Resident 61) when Resident 61 was discharged against medical advice (AMA-patient chooses to leave before the doctor recommends discharge) when Resident 61 was discharged AMA on 9/14/25 and there was no documentation the medical doctor and administrator were notified. This failure had the potential to put Resident 61 at risk for complications like worsening of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of four sampled residents (Resident 11) when Resident 11's use of Divalproex (medication used for mood stabilization) was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 11's care needs not met and the potential for adverse reaction to not be monitored. During a concurrent observation and interview on 12/2/25 at 12:15 p.m. during an initial tour in Resident 11's room, Resident 11 was lying in bed covered with blanket and lunch tray was on top of over the bed table. Resident 11 stated he already ate and refused to answer questions stated, Goodbye. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a level 1 Preadmission Screening and Resident Review (PASARR), (a Federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) screening notifying the state mental health authority or state intellectual disability authority promptly after a significant change for three of five sampled residents (Residents' 1, 3 and 6). This failure had the potential for Residents' 1, 3, and 6 to not receive the appropriate services related to their mental disorders. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for one of three sampled residents (Resident 13) when:Resident 13 did not have a care plan for olanzapine (psychotropic medication used to treat schizophrenia and bipolar disorder). This failure placed Resident 13 at risk for harm by not identifying and monitoring harmful side effects of medication. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure nail care was provided for two of seven sampled residents (Residents 51 and 4) when:Resident 51's fingernails were long and dirty with brownish to blackish dirt built up underneath the nails. Resident 4's fingernails were long. This failure had the potential for Resident 51 and 4 in sustaining an avoidable skin related injuries (including cuts (laceration), scrapes (abrasion), scratches, etc.) and infection (the invasion and growth of germs in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist the resident in gaining access to vision services for one of seven sampled residents (Resident 33) when Resident 33's eye specialist referral dated 5/30/25 was not implemented. This failure resulted in Resident 33 experiencing worsening eyesight on her left eye and placed Resident 33 at an increased risk of being blind (having severe visual impairment or permanent sight loss).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate services, equipment, and assistance to maintain or improve mobility for one of seven sampled residents (Resident 4), when Resident 4's Restorative Nursing Programs (is a formal, planned and organized program of care which is intended to restore a lost ability or maintain the highest level of function of the residents) were not implemented after therapy services dated 10/23/25 and 11/12/25, and Resident 4's left hand splint (is a device designed to prevent contractures [a permanent tightening and shortening of muscles, tendons, ligaments, or skin, which restricts movement and causes stiffness or deformity in a joint, preventing normal motion] by gently stretching and maintaining the position of affected joints, such as the hand, wrist, or foot) and left leg boot (a device that provide support, [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure dental services were provided for one of seven sampled residents (Resident 4) when Resident 4 was not seen and evaluated by a dentist (a doctor who specializes in teeth, gums, and mouth) as necessary to manage Resident 4's oral health. This failure had resulted in Resident 4 experiencing toothache (pain in or around the tooth) and had the potential to put Resident 4 at an increased risk of dental problems including tooth infection (happens when bacteria invade the tooth's inner pulp, causing pus buildup, severe pain (throbbing, sharp), swelling, fever, and sensitivity), tooth cavities, and gums disease.

Inspectors wroteBased on observation during the survey period of 12/2/25 through 12/9/25, the facility failed to ensure each bedroom accommodated no more than four residents in three of 19 rooms (Rooms' 1, 2, and 14). This failure had the potential to adversely effect care provided to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent falls for one of four sampled residents (Resident 1) when Resident 1 was assessed as being at high risk had poor safety awareness (not paying attention to the dangers around you, a history of self-transferring to get to the bathroom, frequent urination (act of releasing liquid waste that your kidneys make to remove excess fluids and waste products from your body) and needed to be supervised by a staff member during transfer and the facility did not implement individualized interventions to prevent falls, including supervision and addressing the cause of frequent self-transferring attempts, consistent with the resident's needs, goals and care according to the resident assessment and plan of care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent falls for one of five sampled residents (Resident 3) when Resident 3 who was assessed as being a fall risk, had poor safety awareness and needed to be supervised while ambulating (walking) and the facility did not implement effective interventions to prevent falls, including adequate supervision, consistent with the resident ' s needs, goals and care. This failure resulted in Resident 3 ' s three unwitnessed falls within two weeks, one on 5/9/25, 5/19/25 and 5/22/25 and placed Resident 3 at risk for significant injury.

Inspectors wroteBased on interview and record review, the facility failed to treat one of two sampled residents (Resident 1) with respect and dignity when the skilled nursing facility (SNF) failed to ensure Resident 1 had adequate transportation from a doctor ' s appointment back to the SNF on 11/22/24. This failure resulted in Resident 1 staying in the doctor ' s office for several hours after the end of his appointment without an adequate meal for lunch and left him feeling hungry, forgotten, sad, and anxious.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) when staff did not implement Resident 1 ' s fall risk care plan to have Resident 1 thoroughly placed on the facility ' s Red Sneaker Program (RSP- the facility ' s fall prevention program which was characterized by a visual symbol of red sneakers placed by the resident ' s name placard outside the resident ' s room door, a symbol of red sneakers above the head of resident ' s bed and a red bracelet the resident wears). This failure placed Resident 1 at risk to experience another fall and had the potential to result in fall related injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed as being a fall risk, with a history of falls in the facility, and a known behavior of placing herself on the floor when tired, received adequate supervision and assistance to prevent falls when Resident 1 ambulated (walked) to an area of the facility unattended and was found on the floor by staff. This failure resulted in Resident 1's unwitnessed fall to the floor sustaining a skin tear (traumatic wound caused by direct contact of the skin to another object) to the back side of her right elbow on 9/25/24.

Inspectors wroteBased on observation interview and record review, the facility failed to maintain a safe, comfortable, and homelike environment for three out of 12 sampled residents (Residents 22, 29, and 42) when the dining room temperature was below the temperature range of 71 to 81 degrees Fahrenheit (F). This failure placed Residents 22, 29, and 42 at risk to develop symptoms of cold exposure and cold related illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for three of 24 sampled residents (Residents 8, 13, 16 ) when: 1. Resident 13's care plan was not developed to reflect interventions to address his refusal of medications. This failure had the potential for Resident 13's medical needs to not be met. 2. Resident 8's care plan was not implemented for skin assessments to monitor for skin tears, bruising or wounds. This failure placed Resident 8 at risk for skin injuries. 3. Resident 16's care plan was not implemented for placement of Resident 16's call light within reach of Resident 16. This failure had the potential for Resident 16's needs to not be met and put Resident 16 at risk for injury

Inspectors wroteBased on interview and record review, the facility failed to provide services which met professional standards of practice for 7 of 24 sampled residents (Residents 13, 40, 42, 100, 101, 102, and 151) when: 1. Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 failed to explain the medication names and indications to Residents 40, 100, 101, 102, and 151 during medication administration. This failure had the potential to place Residents 40, 100, 101, 102, and 151 at risk of receiving the wrong medication and experience unnecessary side effects. 2. The facility failed to notify the Attending Physician of Resident 13's ongoing refusal of Fluticasone-Salmeterol (medication to prevent inflammation and narrowing of airway) inhaler. This failure had the potential to place Resident 13 to not receive appropriate care and not to be able to attain the highest well-being. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications (medications which affect the mind, emotions, and behavior) for one of seven residents (Resident 39) when Resident 39 was given divalproex (an anticonvulsant medication used to treat seizures [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness]) without a specific condition diagnosed and documented in Resident 39's clinical record. This failure had the potential for Resident 39 to receive unnecessary psychotropic medications and placed Resident 39 at an increased risk for developing adverse (harmful) side effects due to taking divalproex.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when the high temperature dishwasher did not reach the required temperature during the wash cycle of 155 degrees Fahrenheit (F). This failure had the potential to place 52 out of 55 highly susceptible residents who received food from the kitchen at risk for foodborne illness (illness caused by ingestion of contaminated food or beverages) due to cross-contamination (the transfer of harmful substances or disease-causing microorganisms).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent the presence of pests when flies were observed in the kitchen area on 8/20/24 and 8/21/24. This failure had the potential to lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for residents who ate food from the kitchen.

Inspectors wroteBased on observation during the survey period of 8/19/24 through 8/23/24, the facility failed to ensure each bedroom accommodated no more than four residents in three of 19 rooms (Rooms' 1, 2, and 14). This failure had the potential to adversely effect care provided to residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of three sampled residents (Resident 1) when Resident 1 was assessed to be at high risk for falls requiring one-on-one observation for safety and Certified Nursing Assistant (CNA) 2 left the resident unattended and out of sight while she assisted another resident. This failure resulted Resident 1 falling and sustaining lacerations (skin and underlying tissues are cut or torn) and contusions (bruise caused by a direct blow to the body) to his head requiring the resident's transfer to the emergency department (ED) for treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from physical abuse for one of four sampled residents (Resident 1) when Resident 1 experienced an incident on 10/26/23 where Resident 2 entered Resident 1 ' s room, unattended and unsupervised, and used a stuffed cat/toy that belonged to Resident 1 to inflict facial and eye injuries. On 2/1/24, Resident 1 was found to have facial and eye injuries of unknown origin. The unwitnessed incident resulting in Resident 1 ' s facial injuries was not reported immediately by CNA 1 in accordance with facility policy and procedure. These failures resulted in Resident 1 to experience avoidable physical, psychosocial, and emotional harm. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the policy and procedure titled In-service Training to ensure Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) received and demonstrated competency in skills and techniques necessary to care for residents with Dementia [a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning] care needs when: 1. 44 of 99 LNs and CNAs had not attended and completed the annual mandatory in-service training for Dementia Module 2 titled Accepting the Challenge. 2. 99 of 99 LNs and CNAs had not attended and completed the annual mandatory in-service training for Safety and Accident Prevention. 3. 29 of 45 CNAs had not attended and completed the annual mandatory in-service training for Elopement Prevention and Action. [...]

Inspectors wroteBased on interview and record review, the facility failed to report a resident abuse according to the facility ' s Policy and Procedure (P&P) titled, Abuse Investigation and Reporting, for one of four sampled residents (Resident 1), when Resident 1 was hit with a cat stuffed toy [a life size mechanical cat made of soft and hard plastic materials, four pounds in weight] by Resident 2 on 10/26/23 resulting in multiple facial bruises and swelling. This abuse incident was not reported to the California Department of Public Health (CDPH, a government agency for the State of California in charge of protecting the public's health and helping shape positive health outcomes for individuals, families and communities). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies and procedures regarding the safe and appropriate prescribing and administering of antipsychotic (medications used to treat psychosis-which is a condition that affects the mind, where there has been some loss of contact with reality) medications and ensure three of three sampled residents (Resident 38, Resident 47, and Resident 150) were free from unnecessary medications when: 1. For Resident 47, staff administered Aripiprazole (an antipsychotic medication used to treat severe mental disorder in which thought, and emotions are so weak that contact is lost with external reality) without monitoring for side effects. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two food service staff, Evening [NAME] (EC) had appropriate competencies to safely and effectively carry out the functions of food service when EC was unable to verbalize the cool down process after cooking and/or reheating food. This failure had the potential for residents to consume food that was not safely prepared which could result in residents getting a foodborne illness and further compromise the nutritional and medical status of residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure menus were followed when Lead [NAME] (LC) did not follow the menu during the preparation of the fresh green salad on 7/12/2022. This failure had the potential for residents to receive inadequate nutrients in their meals.

Inspectors wroteBased on interview and record review, the facility's Pharmacy Consultant (PC) failed to identify and report medication irregularities for four of four sampled residents (Resident 25, Resident 38, Resident 47, and Resident 150) when: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety when: 1. A white plastic fork, spoon and eight clear plastic lids were stored on the floor under one of two pantry shelves. 2a. Two of Two pantries did not have a room thermostat or thermometer to monitor room temperature of the pantries. 2b. Two of Two pantries did not have a temperature log to document daily temperatures in the pantries. These failures placed residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for eight of 32 sampled residents (Residents' 3, 8, 9, 11, 12, 30, 38 and 48) when Residents' 3, 8, 9, 11, 12, 30, 38 and 48 daily activities participation was not documented in their electronic medical record (EMR). These failures placed Residents' 3, 8, 9, 11, 12, 30, 38 and 48's activities interests at risk to not be met and had the potential to negatively affect their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person centered care plan for one of six sampled residents (Resident 8) when Resident 8 did not have an individualized activities care plan to identify her activity preferences. This failure had the potential to result in Resident 8's activities needs and preferences to go unmet and placed Resident 8 at risk of inappropriate activities resulting in possible decreased psychosocial well being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 25) was free from unnecessary medication when: 1. Atorvastatin (medication used to lower cholesterol (a type of fat) in the blood) was administered for an excessive duration without adequate indication for use from 10/8/18 to daily for the diagnosis of hyperlipidemia and labs were not monitored to determine efficacy of the medication. 2. Ferrous Sulfate (form of the mineral iron that is used to treat anemia (low number of red blood cells)) was administered for an excessive duration without adequate indication for use from 6/24/14 to daily for the diagnosis of anemia and labs were not monitored to determine efficacy of the medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled in accordance with acceptable professional standards of practice when Resident 30's inhaler (a device used to give medications in the form of a spray that is breathed in through the mouth) was administered and did not have a resident identifier, an open date or expiration date on the medication. This failure had the potential for the medication to be given to the incorrect resident which could cause adverse reactions (harmful, unintended result caused by a medication) and decreased medication potency and could compromise the therapeutic effectiveness of Resident 30's inhaler.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective infection control and prevention program when a dirty linen was found on the floor. This failure had the potential to result in cross contamination and infection.

Inspectors wroteBased on observation during the survey period of 7/11/22 through 7/15/22, the facility failed to ensure each bedroom accommodated no more than four residents in three of 19 rooms (Rooms' 1, 2, and 14). This failure had the potential to adversely effect care provided to residents.