Fountain Valley Post Acute

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with the appropriate respiratory care. * The facility failed to ensure Resident 1's oxygen tubing was changed accordingly. This failure had the potential to lead to respiratory infection and affect the overall health status of Resident 1.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors. * Resident 1 received more than the recommended dose of insulin (medication to lower blood sugar levels) as order by the physician. This failure posed the risk for hypoglycemia (a condition characterized by abnormally low blood sugar) and other health complications for Resident 1.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1's baseline care plan showed treatment and interventions related to mycotic nails. This failure had the potential for Resident 1 not to receive the necessary treatment and services to meet the individualized care needs.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety guidelines were followed for the protection of 130 residents who received food prepared in the kitchen. 1. Cleaning cloths were not stored properly in the sanitizing solution. 2. The thawing process for meat was not followed. 3. Hair restraints were not worn properly. 4. The manual dishwashing procedure was not followed. 5. Frozen food was not stored properly. 6. Dry food was stored properly. 7. Two of two ice/water dispensers did not have an air gap. These failures posed the risk for food borne illnesses in 130 residents who received food prepared in the kitchen.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 17) reviewed for physical restraint was informed of the use of the restraint. * The facility failed to ensure the informed consent was obtained prior to the use of the bed and chair alarms for Resident 17. This failure had the potential for Resident 17 not to be informed of the potential risks and benefits of the restraints.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 28 final sampled residents (Resident 130) was assessed to self-administer medications. * Resident 130 had medications on the resident's bedside table. Resident 130 was not assessed to self-administer the medications. This failure had the potential to negatively impact on the resident physiological well-being and could administer the medication inaccurately.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide information regarding the rights to formulate the advance directives to three of five final sampled residents (Residents 13, 83, and 130) reviewed for the advance directives. * The facility failed to ensure the advanced directive copy of Resident 13 was available in the resident's medical records. * The facility failed to ensure the formulation of the advance directive for Resident 83 was followed up. * The facility failed to ensure the advance directive copy for Resident 130 was available in the medical records. These failures had the potential for the residents' wishes related to the provision of medical treatment and services to not be followed if the residents were unable to make medical decisions for themselves.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 17) reviewed for physical restraint was free from unnecessary restraints. * The facility failed to assess the need for the use of the wheelchair alarm, determine least restrictive interventions before physical restraints were utilized, and develop and implement interventions to prevent and address any risks related to the use of the restraints for Resident 17. These failures had the potential for increased risk of physical harm and negative potential outcome to the resident.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of one final sampled resident (Resident 83) reviewed for psychotropic medication use was free from the unnecessary psychotropic drugs. * The facility failed to ensure Resident 83's monthly behavior summary was accurately monitored and recorded for the use of mirtazapine (antidepressant) medication. This failure had the potential to place the residents at risk of receiving unnecessary medications and increased risk of serious medication adverse reactions.

Inspectors wroteBased on interview, medical record review, and facility P&P review the facility failed to timely notify and accurately sent the Notification of Proposed Transfer/Discharge to the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes) when two of three sampled residents (Residents 156 and 158) reviewed for closed records. * The facility failed to ensure notification of proposed transfer was sent to the Ombudsman timely for Resident 156. * The facility failed to ensure the Notice of Proposed Transfer was accurately sent to the Ombudsman for Resident 158. These failures had the potential for the Ombudsman not to be able to advocate for the residents in protecting their rights from inappropriate transfer and discharge.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop a comprehensive plan of care to reflect the individual care needs for one of 28 final sampled residents (Resident 20). * The facility failed to develop a care plan problem to address Resident 20's nephrostomy tubes (a thin catheter inserted through the back into the kidney to drain urine directly into a bag, bypassing a blockage or leak in the urinary tract). This failure posed the risk of not providing appropriate, consistent, and individualized care to this resident.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest physical well-being for two of 28 final sampled residents (Residents 9 and 31). * The facility failed to initiate a change of condition, notify the physician and resident representative when Resident 9 was involved in an allegation of abuse. * The facility failed to ensure Resident 31 was continuously monitored when the resident had dysuria (painful or difficult urination) and antibiotic use. These failures had the potential for the residents not to receive the appropriate care and monitoring to prevent the development of complications and/or delayed medical treatments.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one of three final sampled residents (Resident 20) nephrostomy tube (a small tube inserted through the back into the kidney to drain urine when the normal urinary pathway is blocked). * The facility failed to ensure a physician's order was obtained for the care and monitoring of nephrostomy tube for Resident 20. This failure had the potential for the risk of infection and affected the well-being of the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate GT care and services were provided for one of two final sampled residents (Resident 101) reviewed for GT. * The facility failed to ensure Resident 101's enteral formula bottle was labeled with the correct name of the resident. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure the recommendation from Dialysis Center and fluid restriction were followed for two of three final sampled residents (Residents 10 and 113) reviewed for dialysis. * The facility failed to ensure the physician's order for 1500 ml of fluid restriction was followed and carried out accordingly for Resident 10. * The facility failed to follow up on a dialysis recommendation to check Resident 113 for C-diff (a harmful bacterium causing diarrhea and colitis often triggered by antibiotic use that disrupts gut bacteria). These failures had the potential of not identifying potential negative outcomes for the residents on dialysis.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure one of 20 kitchen staff (Dietary Aide 3) was competent in preforming the task in the food and nutrition department. * The facility failed to ensure Dietary Aide 3 was competent in the manual dishwashing procedure. This failure posed the risk for the dishes, pots, and pans used to cook the residents' food to not be cleaned and sanitized properly.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the menu and recipes were followed. * The facility failed to ensure 75 of 75 residents on regular diets were served the correct portion size for the entree of the lunch meal. * The facility failed to ensure the puree broccoli recipe was followed for 19 of 19 residents on the puree diet. These failures posed the risk for 75 residents on regular diets and 19 residents on puree diets to not meet their nutritional needs.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure a vegetarian meal substitute was served for two nonsampled residents (Residents 94 and 163) who were on vegetarian preference diet. * The facility failed to ensure Residents 94 and 163 received a vegetarian meal substitute equivalent in nutritive value to the main entree served. This failure posed the risk for the residents' nutritional needs, specifically protein needs to not be met.

Inspectors wroteBase on observation, interview, and facility document review, the facility failed to ensure the proper food texture was followed for 12 of 12 residents on an IDDSI Level 6 diet (Soft and Bite-Sized diet, for people who can chew but need food that's soft, tender, moist, and cut into small pieces (about 1.5cm x 1.5cm for adults) that mash easily with a fork, requiring chewing before swallowing). * The facility failed to ensure the meat, vegetables, and bread were properly prepared for the 12 residents on IDDSI Level 6 diet. This failure posed the risk for the 12 residents with swallowing and/or chewing difficulties on mechanically altered diets to not receive the diet texture as ordered by the physician.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary adaptive equipment was provided for one of 28 final sampled resident (Resident 11). * The facility failed to provide Resident 11 with a plate guard as per the physician's order. This failure had the potential for Resident 11 not being able to consume his food and drinks without the necessary assistive device.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment was complete. * The facility failed to ensure the Facility Assessment included the active involvement of the required individuals in developing the Facility Assessment, plan to maximize recruitment and retention of direct care staff, and a contingency plan for staffing needs. This failures had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on interview, medical record review, facility documents review, and facility P&P review, the facility failed to maintain an accurate medical record for five of 28 final sampled residents (Residents 13, 15, 87, 99, and 113). * The facility failed to ensure the section D of the POLST was completed for Resident 15, 87, and 99. * The facility failed to ensure Resident 113's blood pressure access site was accurately documented in the resident's medical record. * The facility failed to document the correct site of the blood pressure reading for Resident 13 who had an AVF in the right upper arm. These failures had the potential for the residents' care needs not being met as their medical information was inaccurateFindings: [...]

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the facility had the contract to provide the necessary care for one of two final sampled residents (Resident 2) reviewed for hospice services. * The facility failed to ensure Resident 2 had an election of hospice benefit contract between the facility and hospice provider. This failure posed a risk of delayed communication and the provision of hospice care between the hospice provider and the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * The two washing machines used for residents were not maintained to ensure cleanliness and free from potential contamination. * The facility failed to ensure CNA 3 donned the appropriate PPE when providing care to Resident 40 on EBP. These failures had the potential for the spread of infection in the facility.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs for two of 28 final sampled residents (Residents 87 and 99). * The facility failed to ensure Resident 87 and 99's call light were within the residents' reach. This failure posed a risk in a delay in providing care to the residents and the potential to negatively impact on the residents' well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure privacy was provided for one of 28 final sampled residents (Resident 2). * The facility failed to ensure Resident 2 was provided with privacy when the resident received wound treatment in front of two other residents in the activity room. This failure had the potential to negatively affect the dignity of the resident and violate the resident's rights to privacy.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for one of one final sampled resident reviewed for respiratory care (Residents 150). * The facility failed to ensure Resident 150's nasal cannula was stored in a sanitary condition. This failure posed the risk for the resident's oxygen equipment to become contaminated with pathogens and had the potential to negatively impact the resident's medical condition.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications in the medication room was stored properly. * The facility failed to ensure the bisacodyl (use for constipation) suppository medications were stored separately from eye drop medications. This failure had the potential for the medication degradation and contamination.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was provided appropriate respiratory care. * The facility failed to ensure Resident 1's oxygen orders were administered by a license nurse and carried out as ordered by the physician. In addition, the facility failed to ensure Resident 1's MDS was accurately coded when the resident was on oxygen. These failures had the potential to affect the respiratory health and well-being of the resident in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents' (Resident 3) medical record was accurate and complete. * The facility failed to ensure the documentation for monitoring Resident 3's condition for 72 hours each shift was completed after the resident's fall incident. This failure posed the risk for changes in Resident 3's health condition to go undetected and possibly delay necessary care and treatment.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement their abuse P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report in a timely manner an allegation of staff-to-resident abuse to the local State and Federal agencies for one of three sampled residents (Resident 1). This failure had the potential for the abuse allegation going unreported and uninvestigated.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement their abuse P&P related to investigation of the physical abuse for one of three sampled residents (Resident 1). This failure posed the risk for the potential abuse to remain unidentified and for the residents to go unprotected.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the safe respiratory care to meet the needs for eight of eight final sampled residents (Residents 5, 43, 57, 63, 68, 110, 595, and 793) and one nonsampled resident (Resident 72) reviewed for respiratory care * The facility failed to ensure Resident 793's physician's order for the use of CPAP machine was followed up with and failed to ensure Resident 793 was utilizing the CPAP machine as ordered by the physician. In addition, the facility failed to ensure Resident 793's nasal cannula was stored in a sanitary manner. * The facility failed to ensure Resident 5's nasal cannula was changed as per the facility procedures and Resident 5's nebulizer mask storage bag was labeled per the facility policy. [...]

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the menu was followed when: * The pureed fresh green salad with dressing was not served to 20 residents who were on pureed diets. * Resident 46's lunch tray was observed with pureed food in accordance with the menu, except the fresh green salad with dressing was missing from the lunch tray. Additionally, Resident 46's lunch tray did not contain V8 juice puree. * Resident 444's lunch tray was observed with pureed food in accordance with the menu, except the fresh green salad with dressing was missing from the lunch tray. These failures had the potential to place 20 residents on pureed diets at risk of not receiving the menu as planned.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure the expired food items in the kitchen were discarded. A bin containing thawed packages of mechanically separated turkey had a use-by date of 11/3/24, and a bin containing thawed chicken had a use-by date of 11/3/24, were seen in the kitchen refrigerator. * The facility failed to ensure the kitchen utensils were clean, free of food particles, and not worn out. These failures posed the risk for food borne illnesses in highly susceptible resident population of 132 facility residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, and P&P review, the facility failed to ensure the call light was within reach for one of 30 final sampled resident (Resident 394) and one nonsampled resident (Resident 132). This failure had the potential for Residents 132 and 394 not receiving care timely.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 76) who was readmitted to the facility had a Level 1 PASARR screening. This failure had the potential of not providing the residents screened for mental illness or intellectual disabilities with additional resources if needed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive person-centered care plans were developed and implemented for five of 30 final sampled residents (Residents 34, 43, 63, 76, and 743) as evidence by the following: * The facility failed to develop and implement an EBP care plan for Resident 34. * The facility failed to develop and implement an oxygen care plan for Resident 63. * The facility failed to develop and implement a LAL mattress for Resident 76. * The facility failed to develop and implement an EBP care plan for Resident 743. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 60) who needed a communication board (pre-printed board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) to communicate the needs was provided with the communication board in the resident's language to communicate care needs to the facility staff. This failure had the potential to result in a delay of care services and needs for Resident 60.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of three final sampled residents (Residents 43, 62, and 76) with high risk for skin breakdown were provided the necessary care and services as evidence by the following: * The facility failed to ensure Resident 76's LAL mattress setting was not appropriate to the resident's weight. * The facility failed to ensure the use of LAL mattress with specific direction for settings for Residents 43 and 62. These failures had the potential for the residents not to receive the appropriate care and services to promote skin healing.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the disposed narcotic count sheets were signed by two licensed nurses. This failure had the potential for medication diversion (the illegal use or distribution of a prescription medication that was not originally intended by the prescriber).

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 30 final sampled residents (Residents 29 and 38) were free from the unnecessary drugs. * Resident 29 received amitriptyline (antidepressant medication) and bupropion hydrochloride (antidepressant and smoking cessation); however, the facility failed to identify what target behaviors to monitor and did not monitor the episodes of behaviors for two antidepressant medications. * The facility failed to document specific behaviors prior to prescribing Zoloft (antidepressant) and implement non-pharmacological interventions for Resident 38. These failures had the potential for Residents 29 and 38 to have adverse complications from the medication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication rate was less than 5%. The facility's medication error rate was 12%. * LVN 2 failed to administer Systane (eye drops, use for dry eyes) for Resident 22 as per the facility's P&P. * LVN 4 failed to check Resident 12's bowel pattern for loose stool prior to administering docusate sodium (stool softener). * LVN 1 failed to check Resident 97's bowel pattern for loose stool prior to administering docusate sodium.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure for the safe storage of the medications and supplies. * The Central Supply Room was observed to contain expired supplies and medications along with other supplies without a manufacturing or expiration date. * Medication Cart D was observed to contain multiple expired antifungal cream tubes. * Medication Cart C was observed to contain a bottle of aspirin 81 mg without an expiration date and medication for a discharged resident. * An antifungal cream was kept at the bedside for one final sampled resident (Resident 12). *The facility failed to ensure Medication Cart E was not left unlocked and unattended. * For Resident 82, facility failed to ensure A&D ointments (barrier cream/ointment) were not kept at Resident 82's bedside. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two nonsampled residents (Residents 14 and 132) observed during the dining observation received the appropriate mechanically altered diets (the texture of the diet is altered) as ordered by the physician. * Resident 132 was not served the milk and coffee as ordered. * Resident 14 was not served the correct diet as ordered. This failure posed the risk of aspiration (inhalation of a foreign object into the airway and/or lungs) and resident's nutritional needs not being met.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled residents (Resident 53) was provided with an assistive eating device during mealtimes. This failure had the potential to impact Resident 53's nutritional status.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the P&P regarding outside food for residents was followed. * The facility failed to ensure the facility staff responsible for handling food brought for the residents from the outside and family/visitors who brought food for residents from the outside were educated on safe food handling procedures. This failure posed the risk for food borne illness in residents who consume food from outside sources.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control was maintained as evidenced by: * The facility failed to ensure Residents 34 and 743 with indwelling urinary catheters and midline IV (intravenous) catheter were placed on EBP as per the facility's P&P. * The facility failed to conduct surveillance of infections for the residents who showed signs and symptoms of infection but were not on antimicrobials. * The facility failed to identity organisms on the surveillance line listing. * Resident 38's indwelling urinary catheter drainage bag was on the floor and a urinal with scant amount of yellow urine was observed hanging from the trash can adjacent to Resident 38's bed. These failures put the residents a risk for increased risk of infection and transmissions of diseases.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure six of six final sampled residents (Residents 38, 60, 76, 443, 596, and 743) reviewed for pneumococcal vaccinations were educated and offered the pneumococcal vaccination as evidenced by: * The facility failed to offer the educational materials of the risks and benefits for the pneumococcal vaccines to Residents 60, 76, 443, 596, and 743 as per the facility's P&P. * The facility failed to offer Resident 38's responsible party the PPSV 23 (pneumococcal polysaccharide vaccine) vaccine. These failures put the residents at risk for infection and transmission of pneumococcal infections.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure six of six final sampled residents (Residents 38, 60, 76, 443, 596, and 743) reviewed for COVID-19 vaccinations were educated and offered the COVID-19 vaccination as evidenced by: * The facility failed to offer the educational materials of the risks and benefits for the COVID-19 vaccines to Residents 60, 76, 443, 596, and 743 as per the facility's P&P. * The facility failed to offer Resident 38's responsible party the seasonal COVID-19 vaccine. These failures put the residents at risk for increased risk of infection and transmission of COVID-19.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to promote the dignity and respect for one of 30 final sampled resident (Resident 103) and one nonsampled resident (Resident 116). * The facility failed to ensure the CNA was seated at eye-level while assisting Resident 103 with his meal. * The facility failed to ensure the LVN was seated at eye-level while assisting Resident 116 with his meal. These failures posed the risk of not treating the residents with dignity and respect.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 137) was assessed for self-administer medications and had an order and established care plan prior to self-administered the medication. This failure had the potential for unsafe medication administration.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the mail package was delivered unopened as per the facility's policy for one of four residents (final sampled resident, Resident 57) interviewed during the resident council meeting. This failure had the potential for the resident's mental anguish.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary care and services to prevent the development or worsening of pressure injuries for two of two sampled residents (Residents 1 and 2). * The facility failed to assess Resident 1's skin when readmitted to the facility and failed to develop a care plan to address Resident 1's coccyx wound. * The facility failed to revise Resident 2's care plan to address Resident 2's Stage 3 pressure injury and failed to ensure Resident 2 received his wound treatment with his own wound medication supply. These failures had the potential for Residents 1 and 2 not to receive the appropriate care and services to promote healing of the pressure injury.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement their P&P to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility staff failed to immediately report an abuse allegation involving a CNA to the facility's Administrator or DON for one of two residents reviewed for abuse (Resident 1). This failure had the potential for not protecting the resident from abuse.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) was administered the parenteral fluids in accordance with the physician's order. * Resident 1's IV antibiotics was held without a physician's order. This posed the risk of Resident 1 receiving ineffective treatment.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to thoroughly investigate an allegation of abuse for one of seven sampled residents (Resident 1). * The facility was made aware Resident 1 allegedsomeone hit him; however, they failed to conduct an investigation. This failure put Resident 1 at risk of abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure coordination of care with Hospice A for one of seven sampled residents (Resident 1). * Resident 1 experienced a fall in the facility, and neither Family Member 1 nor Resident 1 ' s physician was notified in a timely manner. This failure had the risk of a delay in necessary care and services for Resident 1.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by the following: * The facility failed to ensure three of three ice machines were maintained in a sanitary condition. * The facility failed to ensure thawed meat was dated when the thawing process was started. * The facility failed to ensure safe storage of food items. * The facility failed to ensure food was covered during delivery to the residents. * The facility failed to ensure proper washing of produce. * The facility failed to ensure kitchen equipment was maintained in a sanitary condition. * The facility failed to ensure food preparation equipment was air dried. These failures had the potential to cause foodborne illness for residents who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the dish machine was repaired in a timely manner to ensure the dish machine water temperature reached a minimum of 160 degrees Fahrenheit (F). This failure had the potential to cause foodborne illness for residents using dishes that were not properly sanitized.

Inspectors wroteBased on observation, interview, facility document review, facility P&P review, and prescribing highlights review, the facility failed to ensure the residents' drugs and biologicals were stored in a safe manner and labeled properly. * Eye drops, inhalers, nebulizer inhalation, and nasal spray were opened and not labeled. This failure posed to potentially expose the residents to the expired medications with questionable potency and efficacy. * The facility failed to ensure the medication storage rooms were accessible only to the licensed nursing personnel. The Maintenance Director was able to access Medication room [ROOM NUMBER]. This had the potential for unauthorized persons to access the medications. * Resident 31 had the Wixela inhaler (a bronchodilator medication, used to relax the muscles in the airways and increases air flow to the lungs) at the bedside. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure two of two RDs (RDs 1 and 2) were competent in their job duties when: * RD 1 failed to address a dish machine failure as per the facility P&P and federal food code standards. This failure caused an equipment failure to not be addressed in a timely manner which could lead to residents' dishware to not be sanitized. *RD 2 failed to address an unplanned severe weight loss of 25 pounds (lbs.), 12 % in a 28-day time frame for one of 26 sampled residents (Resident 16) with the IDT members and implement interventions. In addition, RD 2 failed to update the care plan for Resident 16 to reflect the unplanned severe weight loss. These failures posed the risk for the unplanned severe weight loss to go unaddressed which could lead to further medical complications.

Inspectors wroteBased on interview and medical record review, and facility P&P review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 26 final sampled residents (Resident 16) whose unplanned severe weight loss of 25 pounds was not care planned. This failure had the potential for Resident 16 to have compromised nutritional status and to not receive necessary care and services.

Inspectors wroteBased on interview and medical record review, the facility failed to revise or update the plans of care for two of 26 final sampled residents (Residents 50 and 51). This failure had the potential for the residents to not receive appropriate care and interventions. * Resident 51's plan of care was not updated to reflect the current hospice provider and discontinuation of peripheral IV. * Resident 50's plan of care was not revised when the lorazepam (a medication used to treat anxiety) was discontinued.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one nonsampled resident (Resident 68). * LVN 6 failed to administer the correct dose of Refresh (an eye drop lubricant and moisturizes the eyes) to Resident 68 as ordered by the physician. This failure posed the risk for the resident to not receive the therapeutic benefits.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to effectively assess and identify the potential source of one of 26 final sampled residents (Resident 16)'unplanned severe weight loss and implement the necessary interventions as evidenced by: * The facility failed to ensure the IDT (a group of professionals who work together to provide the greatest benefit for the resident) analyzed and implemented the necessary interventions to address Resident 16's unplanned severe weight loss of 25 lbs which was equivalent to 12% in 28 days; * The facility did not notify the physician of Resident 16's unplanned severe weight loss of 25 lbs, 12% between 10/7/21 and 11/4/21. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the respiratory care in accordance with the physician's order for two of 26 final sampled residents (Residents 447 and 597). The oxygen was not administered as ordered for Residents 447 and 597. This posed the risk for complications related to respiratory treatment.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to one nonsampled resident (Resident 699) to assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of the resident. * The facility failed to ensure Resident 699's oxycodone tablets were administered as ordered by the physician. Resident 699 was given oxycodone 15 mg (short acting narcotic pain reliever, ordered for moderate to severe pain) instead of the routine oxycodone 15 mg ER (extended release-long-acting narcotic pain reliever) tablet. This failure had the potential of negatively impacting Resident 699's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 31) was free from unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure an informed consent was obtained when sertraline (antidepressant) medication for Resident 31. In addition, the facility failed to monitor the behavior related to the use of sertraline. These failures posed the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operations of the Food and Nutrition Services Department when: * FSW 1 was unable to provide the correct dish machine water temperatures. In addition, FSW 1 was not able to demonstrate how to test the sanitizing solution used for the dish machine. This failure had the potential for unsafe food practices which may lead to food borne illness in a highly susceptible population of 124 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, facility document review and facility's P&P review, the facility failed to ensure the menus were followed and the residents' nutritional needs were met when: * The puree recipe for glazed ham was not followed for 11 residents who received a puree diet. * The facility failed to follow the menu for the renal CCHO diet (a diet for residents with diabetes and end stage kidney disease). * The facility failed to provide a vegetarian menu for Resident 20. These failures had the potential for residents receiving puree, renal or vegetarian diets to not have their nutritional needs met which may lead to nutritional related health complications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the resident's food preferences were followed for one of 26 final sampled residents (Resident 20). This failure caused the resident to receive foods she did not prefer.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to implement their P&P to ensure proper storage of food in the residents' room as evidenced by: * Resident 347 had the unlabled container filled with muffins at bedside. This had the potential to result in foodborne illnesses in a highly susceptible resident population.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the residents' identifiable information and medical record were maintained to ensure confidentiality and accessibility. * The facility failed to ensure the resident identifiable information was kept private when the confidential resident rosters were found in the survey binder. This failure put the residents at risk for retaliation. * The facility failed to ensure the Neurological Evaluation Flow sheets for Resident 16 for three of six falls were accessible and available. This had the potential for the residents' care needs not being met as the clinical information was not available.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services for one of 26 final sampled residents (Resident 51). * Resident 51's calendar of prospective hospice provider's visit was not included in the medical record. In addition, the hospice provider failed to ensure Resident 51's hospice certification from the physician was included in the medical record. These failures had the potential for delayed or uncoordinated care between the facility healthcare team and hospice agency

Inspectors wroteBased on interview and medical record review, the facility failed to complete the admission MDS assessments timely for two of 26 final sampled residents (Residents 51 and 446). These failures put the residents at risk for not having their care needs met.

Inspectors wroteBased on interview and medical record review, the facility failed to complete the quarterly MDS assessments timely for one nonsampled resident (Resident 12). This failure put the resident at risk of not having their care needs met.