French Park Care Center

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of one of 14 sampled residents (Resident 6) and one nonsampled resident (Resident A). * Resident 6 waited for 30 minutes for the staff to assist her to be cleaned which resulted in the resident to be lying in her bowel for a long time and feeling dirty. * Resident A waited for 32 minutes for the staff to assist her to change her wet clothing which resulted in the resident feeling upset. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the resident's rights to be free from the verbal abuse by a resident for one of seven sampled residents (Resident 5) investigated for abuse. * Resident 5 received a verbal altercation from Resident 2 resulting for Resident 5 to feel upset and angry. This failure had the potential for not protecting the resident and negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, facility record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of an abuse in accordance with section 1150B for one of seven sampled residents (Resident 2). * The facility failed to ensure the abuse allegation was reported timely to the CDPH L&C Program, ombudsman and local law enforcement when Resident 2 used derogatory language towards Resident 5 as documented on 6/28/26. This failure had the potential for the abuse allegation to go unreported and for the resident to not be protected from further abuse.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for abuse investigation for one of seven sampled residents (Resident 2). * The facility failed to immediately begin an investigation when Resident 2 used derogatory language towards Resident 5 as documented on 6/28/26. This failure had the potential for the abuse allegation to remain unidentified and put the residents at risk for further abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop a comprehensive person-centered care plan for one of 14 sampled residents (Resident 5). * The facility failed to ensure a care plan was developed when Resident 5 was allegedly verbally abused by Resident 2. This failure had the potential for the resident to receive inconsistent, inappropriate, and inadequate care.

Inspectors wroteBased on interview, medical record review, and P&P review, the facility failed to revise the comprehensive care plan for one of 14 sampled residents (Resident 2). * The facility failed to ensure Resident 2's comprehensive care plan was revised after an incident when Resident 2 used derogatory language towards Resident 5. This failure posed the risk of not providing appropriate, consistent, and individualized care for the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the timely and accurate administration of the medications for three of three sampled residents (Resident 1, 3, and 4) reviewed for medication administration, and the facility failed to ensure the controlled drugs were signed off by two licensed nurse witnesses for one of two medication carts (Medication Cart A) reviewed for controlled drugs reconciliation. * Resident 1 was not administered with the prescribed amlodipine (medication to lower blood pressure) on 7/6/26. * The medications due at 0900 hours were administered late to Residents 1, 3, and 4 by LVN 4. * Medication Cart A's controlled drugs record was only signed off by one licensed nurse on 7/14 and 7/15/26, for the 0700-1500 and 1500-2300 shift. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medications were administered as ordered for one of five sampled residents (Resident 4). * Resident 4's medications were not administered timely. This failure posed the risk to negatively impact Resident 4's medical condition.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the plan of care was revised to address the residents' specific care needs for one of 10 sampled residents (Resident 7). * The facility failed to ensure Resident 7's care plan was revised to reflect the resident's treatment and management of diabetes. This failure had the potential to negatively impact the resident's health and well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were stored in a safe manner for one of ten sampled residents (Resident 10). * The facility failed to ensure the medications for Resident 10 were not left unattended on by resident's bedside table. This failure had the potential for the medication to be accessed by unauthorized individuals.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P (Policy and Procedure) review, the facility failed to ensure two of five residents (Residents 74 and 179) reviewed for accidents remained free from accident hazards. * The facility failed to ensure Resident 179 was safely transferred from her bed to her wheelchair. This failure resulted in Resident 179 hitting her leg on a wheelchair and sustained a 10-cm (centimeters) abrasion and large hematoma (a collection of clotted blood outside blood vessels, caused by trauma or injury, leading to swelling, pain, and skin discoloration) on her right anterior (situated at or toward the front of the body) shin. * The facility failed to ensure Resident 74's cigarettes and cigarette lighters were stored safely in accordance with the facility's Resident Smoking P&P. [...]

Inspectors wroteBased on observation, interview, medical record, and facility P&P review, the facility failed to ensure the appropriate respiratory care was provided for five of eight final sampled residents (Residents 2,11, 14, 20, and 72) and one nonsampled resident (Resident 31) reviewed for respiratory care. * The facility failed to ensure Residents 2 and 11's oxygen concentrator filter was free of thick, dust like particles. * The facility failed to ensure Resident 14's nebulizer administration set-up was changed every seven days according to the facility's P&P. * The facility failed to ensure Resident 20 was provided with oxygen as ordered. Additionally, the facility failed to ensure the CPAP tubing and headgear was changed weekly as ordered by the physician and as per the facility policy. * The facility failed to ensure Resident 31's nebulizer breathing mask was changed weekly. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for two of three final sampled residents (Residents 17 and 20) reviewed for pain management. * The facility failed to accurately document the pain level and administer the oxycodone (narcotic pain medication) according to the physician's orders for Resident 17. * The facility failed to administer the hydrocodone-acetaminophen (narcotic pain medication) according to the physician's orders for Resident 20. These failures had the potential to put Residents 17 and 20 at risk for ineffective pain management and/or adverse effects related to the use of unnecessary pain medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate hemodialysis care was provided for four of 35 final sampled residents (Residents 14, 26, 49, and 72) and three nonsampled resident (Residents 39, 41, and 97) who were receiving dialysis services. * The facility failed to ensure a hemodialysis emergency kit was available at the bedside for Residents 14, 26, 39, and 97. * The facility failed to ensure Resident 41's dialysis communication record was complete and the hemodialysis center's recommendation to hold Resident 41's metoprolol (blood pressure medication) on dialysis days was followed and communicated to the physician. In addition, the facility failed to ensure Resident 41's hemodialysis access was monitored as per the care plan. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary medication therapy/management for three of four residents (Residents 31, 129, and 187) observed for the medication administration which resulted to a medication error rate of 12.5%. * The facility failed to ensure the medications were administered as ordered by the physician for Residents 31 and 129. * The facility failed to ensure the medications via GT were administered as per the facility's P&P and accepted standards of practice for Resident 187. These failures had the potential for the residents to experience GT complications and ineffective medication therapy management by not receiving medications timely.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications for four of five medication carts and two of two medication rooms inspected, and two of 35 final sampled residents (Residents 12 and 16) who had medications at bedside. * The facility failed to ensure the residents' medications had appropriate pharmacy labels in accordance with regulations and the facility's policy and procedure. * The facility failed to ensure the expired medications were not mixed with active medications and were properly separated for proper disposal. * The facility failed to ensure the multi-use, multi-dose injectable medication vials and insulin pens were properly labeled with the open dates immediately after being removed from the medication refrigerator. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed. * The facility failed to ensure the residents were served the sour cream sauce with the pork cutlet (as per the menu), instead of the sweet glaze sauce. The food substitution was not communicated in advance to the residents. * Resident 54 was not offered the alternative menu when he refused to eat his breakfast and lunch. These failures had the potential to not meet the residents' nutritional needs and negatively impact the residents' nutritional health.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the dietary texture guidelines were followed as per the facility's P&P for 22 residents who were on the pureed texture diet. * The pureed pork cutlet, pureed green beans, pureed bread, and pureed orzo rice (rice-shaped pasta) were observed to be runny and failed to hold their shape. This failure posed a risk to cause residents' choking or aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airway) episodes.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the proper labeling of food in the kitchen. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the items in the kitchen was discarded after the use-by date. These failures had the potential for exposure to food-borne illnesses for a medical vulnerable population of 155 residents who received food prepared in the kitchen.

Inspectors wroteBased on interview, observation, medical record review, facility document review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections. * The facility failed to maintain an accurate infection control surveillance program for January through April 2026. The facility conducted surveillance only on the residents who exhibited signs and symptoms of infection and were prescribed antimicrobial medications. The facility failed to ensure the residents exhibited signs and symptoms of an infection, met the facility's criteria of a true infection (Mc Geer's Criteria) but were not prescribed antimicrobial medications. * The facility failed to ensure Residents 2, 8, 44 and 93's tube feeding pump were clean and free from dusts and dried up formula. [...]

Inspectors wroteBased on interview, medical records review, facility document and facility P&P review, the facility failed to implement their antibiotic stewardship program when the facility failed to conduct an assessment for the McGeer's criteria to determine the true infection for two of two residents (Residents 10 and 11) who were located at the SNF and sub acute unit. * The facility failed to ensure the infection treated for Residents 10 and 11 reviewed was classified as CAI, HAI, if met or did not meet the Mc Geer's criteria. This failure had the potential for inaccurately identification of true infections and potentially inhibited the residents' physicians from discontinuing unnecessary antimicrobials.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide dignity and respect for one of one final sampled resident (Resident 203) and one nonsampled resident (Resident 123) reviewed for dignity. * CNA 7 was observed standing over Resident 123 while assisting the resident with her meal. * The facility failed to provide a privacy bag to cover Resident 203's indwelling urinary catheter drainage bag. These failures posed a risk for the residents to not be treated with dignity and respect.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident or responsible party was fully informed and an informed consent was obtained prior to the use of the psychotropic medications for one of one final sampled resident (Resident 159) reviewed for the psychotropic medication. * The facility failed to ensure Resident 159's informed consent forms were completed prior to Resident 159's use of olanzapine (antipsychotic medication), escitalopram oxalate (Lexapro, antidepressant), and Depakote (medication used to treat epilepsy, bipolar mania, and prevent migraines) medications. These failures had the potential for the resident and the responsible party to be unaware of the risks associated with the psychotropic medications and the potential side effects.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were safely administered to two of 35 final sampled residents (Residents 20 and 54). * Resident 54 had the Albuterol HFA inhaler (a breathing treatment) at the bedside. Resident 54 did not have a physician's order to keep this medication at bedside. * Resident 20 had Blink geltears (treats moderate to severe dry eye) eye drops, GeriCare artificial tears (lubricating eye drops formula provides extended comfort and hydration for dry, irritated eyes) eye drops, and Comfort Ear natural moisturizer (soothes and comforts dry irritated ears) ear drops on top of the bedside table. These failures had the potential for the residents to administer the medications inaccurately, develop adverse reactions from the medications, and negatively affect the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain a copy of an advance directive for one of four final sampled residents (Resident 203) reviewed for the advanced directive. * The facility failed to obtain and maintain a copy of Residents 203's advance directive in the medical record. This failure had the potential for Resident 203's wishes not followed related to the provision of medical treatment and services.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the physician was notified timely for one of three residents (Resident 41) reviewed for acute care hospitalizations. * The facility failed to notify the physician timely to obtain orders for Resident 41's critically low hemoglobin levels of 6.6 g/dL. When Resident 41's physician was notified, an order to transfer Resident 41 to an acute care hospital for further evaluation and treatment was documented (over nine hours after the licensed nurse reviewed the laboratory results). This failure had the potential to delay the medical interventions for Resident 41.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of six residents (Resident 17) reviewed for unnecessary medications was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 17 was monitored for the specific behavior of restlessness and inability to relax related to the use of the lorazepam (antianxiety medication). This failure had the potential for the resident to receive unnecessary medication and experience the adverse effects from the psychotropic medications. In addition, it has potential for not providing the correct data to the prescriber necessary to adjust the dosage of the psychotropic medication.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to timely report an abuse allegation for one of four final sampled residents (Resident 12) investigated for abuse. * The facility failed to report Resident 12's allegation of abuse, when the Ombudsman and Family Member 1 (Resident 12's family member) reported Resident 12 stated she felt a sensation of a wooden stick/spoon penetrate her body by a CNA. This failure placed the resident at risk for potential ongoing abuse, lack of protection from potential abuse, and resulted in a delay for CDPH and local law enforcement intervention.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to timely investigate an abuse allegation for one of four final sampled residents (Resident 12) investigated for abuse. * The facility failed to investigate Resident 12's allegation of abuse, when the Ombudsman and Family Member 1 (Resident 12's family member) reported Resident 12 stated she felt a sensation of a wooden stick/spoon penetrate her body by a CNA. This failure placed the resident at risk for potential ongoing abuse and lack of protection from potential abuse.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the PASRR Level 1 screening was performed prior to the resident's admission to the facility for one of two residents (Resident 10) reviewed for PASRR. * The facility failed to ensure the PASRR Level 1 screening was performed prior to Resident 10's admission to the facility. This failure posed the risk for inappropriate placement in a long-term care nursing home and if a PASRR Level II Mental Health Evaluation was required, the facility subsequently could not provide the resident with the necessary recommended specialized mental health service.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to meet the resident care needs for five of 35 final sampled residents (Residents 19, 49, 87, 129 and 179). * The facility failed to conduct quarterly care conference meetings and obtained the hospice plan of care for Resident 19. * The facility failed to ensure the insulin injection sites were rotated for Residents 49 and 129. * The facility failed to ensure Resident 87's neurological assessment was complete after Resident 87 had an unwitnessed fall on 4/7/26. * The facility failed to obtain and document the measurements of Resident 179's wound on the initial assessment when Resident 179 sustained an abrasion and large hematoma on her right anterior shin during a staff assisted transfer from her bed to her wheelchair. [...]

Inspectors wroteBased on observation, interview, medical record review, and the facility P&P review, the facility failed to ensure the necessary care and services were provided for two of eight final sampled residents (Residents 20 and 28) reviewed for weight loss. * The facility failed to ensure the physician was informed of Resident 20's weight loss of 5.19 % in one month. * The facility failed to ensure the RD recommendation for weekly weight for four weeks was followed when Resident 28 had a significant weight loss of 11.8% in six months. These failures had the potential for Residents 20 and 28 to not receive the necessary intervention to prevent further weight loss.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the appropriate care and services for the use of GT for one of two final sampled residents (Resident 5) reviewed for GT care. * The facility failed to ensure Resident 5's enteral feeding formula bottle was labeled with the start time. This failure had the potential for Resident 5 to receive outdated GT feeding formula and posed a risk for complications related to use of the GT.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV accesses for one final sampled resident (Resident 159) and one nonsampled resident (Resident 37) who had peripheral IV access. * The facility failed to ensure Resident 37's peripheral IV access was labeled with the date, time, and licensed nurse's initials when it was inserted and discontinue when not in used. *The facility failed to ensure Resident's 159's peripheral IV access was assessed after the completion of intravenous therapy and discontinued when not in use. These failures posed the risk of the residents developing complications related to the use of the peripheral IV catheter.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary pharmaceutical services to ensure for an accurate reconciliation of the controlled medications in one of two medication carts reviewed for controlled medication reconciliation. * The facility failed to ensure the controlled medication count during the change of shift was completed and the Controlled Drugs - Count Record was signed by two licensed nurses. These failures had the potential for inaccurate reconciliation, and drug diversion of the controlled medications.

Inspectors wroteBased on observations, interviews, and facility P&P review, the facility failed to ensure the facility food was appetizing and palatable for two of 155 residents (Residents 138 and 139) who received food prepared in the facility kitchen. * The facility failed to ensure Residents 138 and 139 received food that was appetizing and palatable. This deficient practice had the potential to impact the residents' nutritional status, and not meet the residents' desires to be served food they felt was palatable and attractive.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to accommodate the drink preferences for one of one resident (Resident 49) reviewed for hydration. * The facility failed to ensure Resident 49 was provided with 120 ml of cranberry juice as listed in Resident 49's meal ticket. This failure had the potential to affect Resident 49's overall meal intake and hydration status.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 35 final sampled residents (Resident 49) and one nonsampled resident (Resident 97) were complete and accurately documented. * The facility failed to ensure Resident 49's blood pressure access site was accurately documented in the resident's medical record. * The facility failed to ensure Resident 97 's blood pressure access site was accurately documented in the medical record. These failures have the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure two of two posted daily nursing Direct Care Service Hours Per Patient Day reviewed had accurate information. * The facility failed the posted daily nursing PPD had the current date and PPD information. This failure had the potential for the residents and visitors to not be informed about the facility's staffing.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary services related the resident discharge for one of seven sampled residents (Resident 1). * The facility failed to ensure Resident 1 was assessed by the physician and deemed safe to be discharged to a board and care facility. In addition, the facility failed to ensure Resident 1 had an order for discharge. This failure posed a risk for unsafe discharge and had the potential to negatively affect the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure documentation for one of three sampled residents (Resident 1) was accurate and maintained within accepted professional standards and practices. * Multiple entries in Resident 1's nursing progress notes incorrectly indicated he was able to verbalize, communicate his needs, and was oriented, despite Resident 1 being nonverbal and having severe cognitive impairment. * Nursing care was documented as being provided to Resident 1 after he had been discharged from the facility. This failure posed the risk for changes in Resident 1's condition to be missed, miscommunication between care providers, and for Resident 1 to receive incorrect treatment.

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 three sampled residents (Resident 1). * The facility failed to develop and implement a baseline care plan that addressed pressure injuries and wounds for Resident 1, who was admitted with pressure ulcers and other wounds. * The facility incorrectly created a baseline nutritional care plan that included interventions to feed Resident 1 who was not able to take in nutrition or liquids by mouth and was dependent on enteral tube feedings for his nutritional and hydration needs. These failures posed the risk for Resident 1 not to receive the necessary treatment and services to meet Resident 1's individualized care needs and for Resident 1 to potentially suffer harm due to incorrectly rendered care.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record was accurate for one of six sampled residents (Resident 1). * Resident 1's social services notes were not accurate related to the hours the resident went on a temporary out on pass from the facility. This failure had the potential to negatively impact the delivery of services as the medical information was not accurate.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmaceutical services for one of six sampled residents (Resident 2). * Resident 2 did not receive the medication as ordered by the physician. This failure posed the risk of Resident 2 receiving unnecessary medication and negative health consequences.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the social worker was qualified to fulfill the job responsibilities and role. * The facility social worker did not have a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, gerontology, special education, rehabilitation counseling, and psychology. This failure has the potential to jeopardize the health and well-being of 196 residents who required care and psychosocial needs in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the identification, reporting, and investigation was completed when one of three sampled residents (Resident 1) reviewed for abuse, reported two abuse allegations against another resident. * On 11/16/25, Resident 1 alleged Resident 2 was going to hit her, resulting in Resident 1 feeling threatened, scared, and unsafe. Resident 1 reported the alleged incident to facility staff. * On 11/26/25, Resident 1 alleged Resident 2 threatened to cut her into pieces, resulting in Resident 1 feeling threatened and unsafe. Resident 1 reported the alleged incident to facility staff. These failures of the facility to identify, report, and investigate Resident 1's allegations of abuse posed the risk for resident-to-resident abuse to occur in a highly vulnerable population.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide reasonable care for the protection of resident's personal property from loss or theft for one of seven sampled residents (Resident 4). * Resident 4's personal belongings form was not signed by Resident 4, and the form was not accurately completed. This failure had the potential for the resident's property to get lost or stolen.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the discharge process was properly followed for one of tree sampled residents (Resident 1). * The failed to ensure Resident 1's medical record showed the physician's documentation indicating the resident's health improved sufficiently and ready to be discharged from the facility. This failure had the potential for Resident 1 to unsafely discharge from the facility.

Inspectors wroteBased on observation, interview, and manufacturer document review, the facility failed to maintain the essential equipment in the safe operating conditions when:* The facility failed to maintain three of three ice machines in sanitary working condition.* The facility failed to ensure the manufacture specifications were followed for one of three ice machines. These failures had the potential to cause contamination of ice in a highly vulnerable population of 145 residents who received ice from the ice machines.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete, and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for seven of 10 final sampled residents (Residents 35, 36, 49, 51, 85, 122, and 153) and one nonsampled resident (Resident 146) reviewed for siderails. * The facility failed to ensure the residents' entrapment assessments were accurately completed for Residents 35, 36, 49, 51, 122, and 153. * The facility failed to ensure Residents 85 and 146 's bilateral grab bars bed entrapment assessment was accurate and completed. These failures had the potential to negatively impact the residents, resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 89) was free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior).* The facility failed to ensure non-pharmacological interventions were implemented for the depression and behaviors exhibited by Resident 89. This failure had the potential to place the residents at risk of receiving unnecessary medications and an increased risk of serious medication adverse reactions.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to send a copy of the notice of discharge to the representative of the Office of the State Long Term Care Ombudsman for one of three sampled residents (Resident 194) reviewed for closed records. This failure posed the risk of the LTC (Long term Care) Ombudsman not being aware of the circumstances of the resident's transfer/discharge should the resident and their representative believe the transfer or discharge was inappropriate or involuntary.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure a comprehensive care plan was developed for one of 35 final sampled residents (Resident 86).* Resident 86's care plan specific to oxygen administration failed to include the oxygen administration parameters. The nursing staff failed to attempt to administer the lowest amount of oxygen required to maintain Resident 86's oxygen saturation level at 92 % or greater, in accordance with the physician's order. This failure placed the resident at risk for not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure necessary care and services were provided to two out of 35 final sampled residents (Residents 85 and 195). * The facility failed to ensure Resident 85's Infectious Disease Physician's recommendation dated 5/17/25, for an urgent MRI of the right hip was communicated to the ordering Physician and arranged in a timely manner. * The facility failed to ensure Resident 195's Intake and Output (I&O) were documented. These failures had the potential to affect Resident 85 and 195's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure injuries and promote the healing of existing pressure injuries four of five final sampled residents (Residents 28, 98, 122, and 131) reviewed for pressure injuries. * The facility failed to ensure the low air loss (LAL) mattress setting was consistent with the residents' weight. This had the potential for the residents to not receive the appropriate care and services to promote healing or prevent the development and worsening of pressure injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided to prevent the decline in the ROM functions for one of six final sampled residents (Resident 5) reviewed for ROM functions.* The facility failed to ensure the physician's orders to apply the left AFO and bilateral elbow splints to Resident 5's extremities were followed. In addition, Resident 5's skin was not assessed when the left AFO and bilateral elbow splints were applied. This failure had the potential for Resident 5 to sustain a decline in ROM functions, leading to muscle atrophy (loss of muscle mass and strength) and decrease in functioning.

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 an accidents for one of four final sampled residents (Resident 4) reviewed for prevention of accident hazards. The facility failed to implement the floor mats on both sides of Resident 4's bed for safety, in accordance with the physician's order. This failure put the resident at high risk of serious injuries from a fall.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent UTIs for three of three final sampled residents (Residents 12, 63, and 89) reviewed for the use of indwelling urinary catheter (thin, flexible tube inserted into the bladder through the urethra to drain urine). * The facility failed to ensure the urinary catheter tubing was not touching the floor for Residents 12 and 63. * The facility failed to ensure indwelling urinary catheter care was provided as per the care plan to Resident 89. These failures had the potential for the residents to develop UTIs.

Inspectors wroteBased on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure the respiratory care and services were provided for six of nine final sampled residents (Residents 36, 54, 86, 89, 104, and 122) and two nonsampled residents (Residents 69 and 80).* The facility failed to ensure the oxygen was administered as per the physician's order for Resident 89. In addition, there was no documentation for the PRN administration of the oxygen and the reason why the oxygen was administered to Resident 89.* Resident 86 had a physician's order to administer continuous oxygen via a nasal cannula and to titrate the oxygen rate to maintain an oxygen saturation level of 92% or greater. Resident 86 received continuous oxygen therapy at a rate of six liters per minute via nasal cannula for approximately five hours. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure dialysis care was provided for one of 35 final sampled residents (Resident 9).* The facility failed to assess Resident 9's dialysis access site (AV shunt) for a bruit and thrill every shift in accordance with the facility's P&P. This failure had the potential for the facility staff failing to identify impaired functionality of Resident 9's AV shunt, and posed the risk for negative health outcomes in the event Resident 9's dialysis access site was to become inoperable.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmacy services in accordance with the physician's orders and the facility's P&P for one of six residents (Resident 9) reviewed for unnecessary medications and three of four medication carts observed.* The facility failed to ensure Resident 9's scheduled morning medications were administered after Resident 9 had returned to the facility from his dialysis appointment.* The facility failed to ensure the narcotic log sheets were signed by the licensed nurses during the controlled medication reconciliation for Medication Carts A, B, and C.These failures had the potential for negative health outcomes and posed the risk for diversion of controlled medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and labeling of the residents' medications, for one of four medication rooms, two of eight medication carts, and one of 35 final sampled residents (Resident 1) and one nonsampled resident (Resident 171).* Resident 171's olanzapine (antipsychotic medication) medication bottle was labeled with the incorrect administration time. * The physician's order for ferrous sulfate liquid and the ferrous sulfate liquid supplement medication bottle label failed to show the prescribed dose to be administered to Resident 171.* The facility failed to ensure the orally administered medications were kept separate from externally used medications, e.g., eye drops and suppositories (medication given, inserted rectally or vaginally). [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one sampled resident (Resident 93) received the appropriate consistent carbohydrate diet as ordered by the physician. This failure had the potential to cause elevation of the resident's blood sugar.

Inspectors wroteBased on observation and interview, the facility failed to ensure sanitary requirements were met in the kitchen as evidenced by: 1. Two of three ice scoop holders were not clean and one of three ice scoop holders contained standing water. 2. The plate cover rack was not clean. 3. More than ten plate covers did not have a smooth and cleanable surface. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population of 145 who consumed food prepared in the kitchen and ice from the ice machines.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to implement a safe food handling policy to ensure outside foods brought into the facility for residents by visitors were properly prepared and stored for safe consumption. * The facility failed to ensure the residents' foods inside Refrigerator A were labeled with the residents' names. * The facility failed to provide specific documentation on Resident 49's care plan addressing the problem of risk on storage of food in Resident 49's restroom bathtub. * The facility failed to ensure the facility's P&P for the use and storage of foods brought in by the family or visitors included any food safety related concerns such as time and temperature control and safe food handling and preparation. [...]

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment;2. A plan to maximize recruitment and retention of direct care staff; and3. A contingency plan for staffing needs. This failure 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 observation, interview, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections.* The facility failed to ensure the soiled laundry was not stored in the clean laundry area.* The facility failed to ensure the facility staff performed hand hygiene before and after wearing gloves during the wound treatment observation for one nonsampled resident (Resident 120).* The facility failed to ensure the appropriate transmission-based precaution door signage was placed for one final sampled resident (Resident 162). These failures had the potential for cross-contamination and spread of infectious organisms in the facility.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to accurately monitor and address the use of the antibiotics when the resident's condition did not meet the McGeer's criteria (a set of criteria used in long term care facilities to identify if residents' symptoms meet the criteria of a true infection) or Loeb minimum criteria (a set of minimum clinical criteria used to guide the initiation of antibiotic therapy for suspected infections in residents of long term care facilities) for one of five final sampled residents (Resident 89) reviewed for antibiotic stewardship. This failure had the potential risk for continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for one of 35 final sampled residents (Resident 63). The facility failed to ensure the call light for Resident 63 was within the residents' reach. This failure had the potential to negatively impact the resident's physical and psychosocial well-being or would result in delayed provision of care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the copy of the advance directive was maintained in the resident's medical record for one of 35 final sampled residents (Resident 51). This had the potential for the facility to provide treatment and services against the resident's wishes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of 35 final sampled residents (Resident 104) was revised to reflect the resident's current care needs and interventions. The facility failed to ensure Resident 104's plan of care was revised to address Resident 104's breathing treatment. This posed the risk of not providing Resident 104 with individualized and person-centered care.

Inspectors wroteBased on observation and interview, the facility failed to comply with CA State law SB 1383 dated 1/1/22, which mandated the facilities to separate the organic waste from their waste stream. This failure had the potential to increase the environmental impact of the facility thus adversely impacting the residents' health and well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure complete and accurate resident medical records and facility records were maintained for one of three sampled residents reviewed for closed records (Resident 195), one nonsampled resident (Resident 171), and the Resident Council record. * Resident 171's scheduling details for the administration of olanzapine zydis (antipsychotic medication) showed conflicting information specific to the medication administration time. * The facility failed to ensure complete and accurate documentation on the Resident Council Agenda/ Minutes record for the months of March, April, May, and June 2025. * The facility failed to ensure the Notice Proposed Transfer/Discharge form was accurately completed and signed for Resident 195. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary pharmacy services were provided to 16 of 16 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16) when the medications were not provided within their prescribed time. This failure had the potential for negative health outcomes to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1's IV and oral fluid intakes were monitored and recorded. This failure had the potential for Resident 1 to have fluid overload, which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of seven sampled residents (Resident 6) attained and maintained the highest practicable physical well-being. * The facility failed to ensure the physician was timely notified of Resident 6's change in condition. This failure posed the risk for Resident 6 to not receive the necessary care and services to maintain the resident's highest physical well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for two of seven sampled residents (Residents 4 and 6). * The licensed nurse failed to assess and manage Resident 4's pain when providing the wound care treatment. * The facility failed to develop a care plan problem to address Resident 6's MASD to the bilateral buttocks extending to sacrococcyx (base of the spine and tailbone), which had deteriorated to a sacrococcyx unstageable pressure injury. In addition, there was no care plan problem developed to address Resident 6's purplish nonblanchable (skin abnormality when the skin does not turn white when pressed) area to the right heel. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control program and practices designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections as evidenced by: * The facility failed to ensure Resident 5 had a physician's order for contact precautions related to Klebsiella pneumoniae ESBL (Extended-Spectrum Beta-Lactamase, a bacterium that produces enzymes that make it resistant to many antibiotic). In addition, the facility failed to ensure the facility staff were informed of the resident's contact precautions. * The facility failed to ensure Room B (EBP room) had a trash can inside the resident room and near the exit for discarding PPE after removal as per the facility's policy. [...]

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 failed to immediately report an allegation of sexual abuse to the CDPH, L&C Program, Long Term Care (LTC) Ombudsman office, and local law enforcement agency within two hours after the allegation was made for one of three sampled residents (Resident 1). This failure had the potential to delay the investigation of the alleged abuse and for staff to no take prompt and appropriate corrective actions to prevent the abuse.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide a safe environment free from potentially serious accident hazards for one of three sampled residents (Resident 4). * The facility failed to ensure a portable space heater was not in use in Resident 4's room. This failure posed the risk of fire and serious injuries to the resident and to the other residents who resided in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of two of 12 sampled residents (Residents 9 and 12). * Resident 12 was observed lying in bed without his call light in reach. * Resident 9 was observed lying in bed callingout repeatedly for water and without his call light in reach. These failures had the potential for their care needs to go unmet.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for two of 12 sampled residents (Residents 1 and 10). * The facility failed to ensure Resident 1 did not exceed the maximum hours for her therapeutic leave as ordered by the physician. In addition, the facility failed to notify the physician that Resident 1 was staying out longer than ordered during her therapeutic leave. * The facility failed to ensure Resident 1 was assessed upon leaving and/or returning to the facility and the Release for Temporary Absence sign-in and sign-out sheets were completed each time Resident 1 left and returned from her therapeutic leave. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment were followed for three of 12 sampled residents (Resident 5, 6, and 7). * The facility failed to ensure the ESP was practiced related to the PICC line for Resident 6 and GT for Residents 5, and 7. This failure had the potential to result in the spread of infection to the residents in the facility.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were maintained. * The staff failed to perform hand hygiene during care provided to two of two sampled residents (Residents 1 and 3). * The facility failed to ensure proper handling, storing, processing, and transporting of the linens to prevent the spread of infection. * CNA 5 failed to perform hand hygiene when leaving an Enhanced Precaution room and touched clean linen with their soiled gloves. These failures had the potential to result in the spread of infection to the residents.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the safe and sanitary handling of the residents' foods brought in from the outside, as per the facility's P&P and standards of practice. * Two bottles of drinks and muffins were found near the window and air conditioner. This failure had the potential to expose the residents to food contamination.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain the complete and accurate medical record for one of eight sampled residents (Resident 1). * The facility failed to ensure the completion of Resident 1's ADL- Bed Mobility Intervention/Task. This failure had the potential for the resident care needs not being met as the medical information was incomplete and inaccurate.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain an accurate and complete medical record for one of seven sampled residents (Resident 1). This failure posed the risk for changes in Resident 1's health condition not being identified and delay in necessary care and treatment.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's family was informed promptly of the transfer and admission to the acute care hospital as per the facility's P&P for one of seven sampled residents (Resident 1). This failure had the potential for the resident's family to not be aware of the resident's changes in condition.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the transmission of diseases and infections. * The facility failed to ensure the housekeeping staff performed hand hygiene practices after removing the gown and glove and leaving room [ROOM NUMBER] (a Covid isolation room). * The facility failed to ensure CNA 4 wore the appropriate PPE when providing care for one of 11 nonsampled residents (Resident 9) who was on the enhanced barrier precautions. These failures posed the risk of infection and the transmission of disease-causing microorganisms.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the resident and/or resident representative the written notification before the residents' room was changed for one of four sampled residents (Residents 1). Resident 1 was moved to another unit without the written notification provided to Resident 1 and/or resident representative, including the reason for the move. This failure had the potential for Resident 1 and/or his responsible party to not receive the necessary information regarding the need for a room change.

Inspectors wroteBased on observation, interview, the facility failed to implement and maintain their infection control as evidenced by: * The facility failed to ensure the staff performed hand hygiene between trays during the meal pass observation for Resident 2, A, and B. This failure posed the risk for the potential transmission of communicable diseases to other residents throughout the facility.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store the drugs, biologicals, and medical supplies in a safe manner as evidenced by: * The facility failed to ensure one of 11 medication carts (Medication Cart 3) were properly locked when left unattended. This failure had the potential for unauthorized personnel access to the residents' medications. * The facility failed to ensure the expired medications and opened IV medical supplies in Medication rooms [ROOM NUMBERS] and Medication Carts 1, 5, 6, 7, 8, 9, 10, and 11 were disposed of. This failure had the potential for the medications to be accidentally administered and/or used and the IV medical supplies not maintaining sterility (free from germs). * The facility failed to ensure the medication was not left at the resident's bedside for one of 35 final sampled residents (Resident 160). [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the scoops used for food portioning were air dried and clean prior to storing. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good conditions. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. These failures had the potential to cause foodborne illnesses for the residents in the facility.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to implement and maintain their infection control program as evidenced by: - The facility failed to implement their infection control surveillance program from July through September 2023. The facility conducted surveillance of the residents' infections based on whether the residents were prescribed the antimicrobial medications. The facility failed to determine whether the residents who were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria) and thus failed to include these residents in facility's infection control surveillance program. * The facility failed to ensure to practice infection control before giving back the contaminated call light to Resident 61. This failure has the potential to cause infections. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document interview, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete including the measurements during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for seven of 35 final sampled residents (Residents 38, 79, 104, 123, 142, 146, 161, and 528). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 35 final sampled residents (Residents 58 and 152) were assessed to determine if the residents were safe to self-administer their medications prior to self-administering their medications. * The facility failed to ensure Resident 152 was assessed to safely self-administer ProAir HFA Aerosol Solution (Albuterol Sulfate-medication to help control symptoms of lung diseases). * The facility failed to ensure Resident 58 did not have multiple bottles of medications at bedside. These failures had the potential to negatively impact the residents' physiological well-being, and posed the risk of inaccurate medication administration.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for three of 35 final sampled residents (Residents 85, 104, and 109) and one nonsampled residents (Resident 94). * The facility failed to ensure the call lights for Residents 85, 94, 104, and 109 were within the residents' reach. This failure had the potential to negatively impact the residents' physical and psychosocial well-being or would result in delayed provision of care.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the privacy for one of 35 final sampled residents (Resident 109) was provided during care. This failure had the potential to violate the resident's right to privacy.

Inspectors wroteBased on interview and medical record review, the facility failed to protect one nonsampled resident's (Resident 145) right to be free from verbal abuse by another resident (Resident 173). This had the potential for negatively impact Resident 145's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 159) and one nonsampled residents (Resident 83) were free from physical restraints. * The facility failed to conduct an assessment and implement the least restrictive measures prior to applying a mitten (mitten which look like boxing gloves with a Velcro or tie at the wrist to hold them in place and immobilize the resident's fingers) to Resident 159's left hand. In addition, the facility failed to ensure the mitten was released every two hours as per the resident's care plan. * The facility failed to ensure Resident 83's right hand mitten use was monitored and released every two hours as per the resident's care plan. These failures posed the risk of compromising the residents' independence and psychosocial well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to send a copy of the noticed of transfer/discharge to the representation of the Office of the State-Long Term (LTC) Ombudsman for two of 35 final sampled residents (Residents 66 and 144). This failure posed the risk of the LTC Ombudsman not being aware of the circumstances of the resident's transfer/discharge should an appeal be filed or requested by the resident or their representative regarding the transfer.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify two of 35 final sampled residents (Residents 66 and 144) of their rights to a bed hold (holding or reserving a resident's bed while the resident in the acute care hospital) policy upon transfer to the acute care facility. This failure had the potential for Residents 66 and 144 or their representatives to be unaware of his rights to request a bed hold upon transfer.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs of two of 35 final sampled residents (Residents 106 and 120). * The facility failed to develop a care plan problem to address Resident 106's weight loss. * The facility failed to ensure a care plan was developed to address Resident 120's MASD. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure two of 35 final sampled residents (Residents 528 and 146) attained and maintained their highest practicable well-being. * The facility failed to coordinate the care of Resident 528 with the contracted hospice. The hospice calendar and the sign-in/out forms did not show complete skilled nursing and CHHA visits were provided as per the physician's orders. In addition, the medication profile list, nursing clinical notes, and hospice aide notes were not updated. Furthermore, a hospice packet containing the Continuous Care Note, Continuous Care Documentation, Continuous Care Initiation Sheet, Hospice Aide Care Plan/Note, Plan of Care, Pain Inventory Scale, and Medication List was not available. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 161) received appropriate services to meet their nutritional needs and maintain desirable weight. The facility failed ensure the physician was notified of the RD's recommendation for nutrition supplement to address the resident's weight loss. Resident 161 did not receive the nutrition supplement as recommended by the RD. This failure creaed the risk of not providing nutritional needs and poor health outcome for this resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for two of 35 final sampled residents (Residents 527 and 177). * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented in the medical record for Residents 527. * The facility failed to ensure Resident 177's midline IV (a type of peripherally inserted IV catheter) site was labeled with the date and the licensed nurse's initials to show when it was last changed These failures had the potential to delay the identification of catheter related complications for these residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled resident (Resident 61) and three nonsampled residents (Residents 91, 108, and 141) were provided with the appropriate respiratory care when: * The facility failed to follow the physician's order for oxygen for Resident 91. * The facility failed to follow the physician's order for oxygen for Resident 108. In addition, the facility failed to ensure there was a humidifier attached to the oxygen machine, the nasal cannula was dated and labeled, and the nebulizer mask was stored properly. * The facility failed to ensure the oxygen tubing was labeled and oxygen and nebulizer tubing were not touching the floor for Resident 141. * The facility failed to ensure Resident 61's oxygen tubing was not touching the floor. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to accurately record the change in the dialysis (a process of removing excess water solutes and toxins from the blood in people whose kidneys can no longer perform these functions naturally) days for one of 35 final sampled resident (Resident 151). This posed the risk for medical complications if Resident 151 missed the scheduled dialysis services.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to complete the assessments, attempt the least restrictive alternative measures, and obtain the physician's orders, and informed consents prior to the use of side rails for six of 35 final sampled residents (Residents 38, 79, 104, 142, 146, and 528). This failure had the potential to put the residents at risk for serious injuries.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the narcotic disposition bin was securely locked. In addition, the facility failed to ensure the narcotic medication administration was accurately documented for one of 35 final sampled residents (Resident 151) and two of 13 nonsampled residents (Residents 16 and 165). * The facility failed to ensure the narcotic disposition bin was securely locked and sealed by the consultant pharmacist as per the facility's P&P. Furthermore, the narcotic disposition bin included whole pills of disposed narcotic medications not fully diluted. * The facility failed to ensure the narcotic medication administration accurately reflected on the eMAR for Residents 16, 151, and 165. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the lack of non-pharmacological interventions prior to the use of psychotropic medication was identified during the monthly drug regimen review for two of 35 final sampled residents (Residents 85 and 126). This failure put Residents 85 and 126 at risk for receiving the unnecessary medications.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure one of 35 final sampled residents (Resident 85) on anticonvulsant medications was monitored for seizure activity and side effects of the medication. This failure had the potential to cause poor health outcomes for Resident 85.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure five of 35 final sampled residents (Residents 85, 106, 120, 123, and 126) were free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * Resident 85 who had diagnoses including dementia (a disorder which causes a progressive decline in memory and behavior that affects the ability to perform everyday activities) was prescribed quetiapine fumarate (antipsychotic medication) for schizophrenia disorder (mental illness that affects how a person thinks, feels, and behaves) manifested by combative during care and buspirone (mood medication) manifested by episodes of repetitive verbalization of concerns with care. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 10%. * LVN 8 failed to accurately follow a physician's order to flush the G-tube (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) before medication administration and between medications as ordered for Resident 146. * LVN 4 failed to follow a physician's order and provide education to Resident 59 prior to administration of Arnuity Ellipta Aerosol (inhaler medication). LVN 4 also failed to administer Resident 59's lactobacillus (probiotic medication) as ordered. These failures had the potential to cause negative outcomes for the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 106) was offered the pneumococcal vaccine (a vaccine given to protect the resident from pneumococcal disease) when he was eligible to receive, in accordance with current CDC guidelines and recommendations. This failure posed the risk of Resident 106 acquiring pneumonia.

Inspectors wroteBased on observation, interview, facility document review, and the facility's P&P, the facility failed to ensure the Quality Control Record for one Assure Platinum Glucometer (a device used to measure blood sugar levels) (Glucometer A) from one of 21 Medication Carts (Medication Cart 1) was completed accurately. This failure had the potential for residents requiring blood glucose checks to have inaccurate readings.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to inform and provide the written information regarding the rights to formulate the advance directives to two of 35 final sampled residents (Residents 50 and 71) and one nonsampled resident (Resident 10). In addition, the facility failed to ensure the copy of advance directive was maintained in the medical record for one of 35 sampled residents (Resident 123). This had the potential for the facility to provide treatment and services against the resident's wishes.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide a safe, clean, homelike environment for one resident room (Room C). * Room C was observed two blind slats missing from the window. These placed the residents at risk for living in an unkempt environment and had the potential for the residents to not have full privacy.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the baseline care plan for quetiapine fumarate (mood medication) for one of 35 final sampled residents (Resident 126) was initiated upon admission. This failure put Resident 126 at risk of not receiving resident-centered care.

Inspectors wroteBased on observation and interview, the facility failed to ensure four of eight garbage dumpsters were not properly closed with lids. The failure had the potential to attract pest/rodents that carried diseases.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure the medical records for two of final sampled residents (Residents 66 and 106) and one nonsampled resident (Resident 48) were accurately maintained. * The facility failed to ensure Resident 106's H&P examination was completely filled out by the physician to show the reason for the resident not having the capacity to understand and make decisions. * The facility failed to ensure Resident 106's Resident Clothing and Possessions were completely filled out. * The facility failed to ensure Resident 106's water hydration order via G-tube was clarified to reflect the accurate administration order. * The facility failed to ensure Resident 48's change in condition was documented in the medical record after identification of cloudy urine with sediments. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure comfortable sound levels for two of 12 sampled residents (Residents1 and 2). This failure had the potential to impact the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility's P&P review, the facility failed to ensure the medical record was accurate for one of 12 sample residents (Resident 3). Activity Assistant 1 provided the activity services to Resident 3 but did not initial for the activities provided for three days. Another activity staff had signed their initial in place of Activity Assistant 1 for those three dates. This failure had the potential for inaccurate medical record for Resident 3.