Garden Grove Post Acute

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary discharge services was completed for two of four final sampled residents (Residents 6 and 41) reviewed for acute care hospitalization and one of three sampled residents (Resident 5) reviewed for closed records. * The facility failed to ensure the physician signed and dated the physician's discharge summary for Resident 5's transfer to the acute care hospital on 6/20/26. * The facility failed to ensure the physician signed and dated the physician's discharge summary for Resident 6's transfer to the acute care hospital on 4/15/26.* The facility failed to ensure the physician signed and dated the physician's discharge summary for Resident 41's transfer to the acute care hospital on 4/18/26. These failures had the potential for the residents to have an inappropriate discharge.

Inspectors wroteBased on interview, medical record review, facility P&P review, facility document review, and the California Code of Regulations, the facility failed to ensure a staff member was onsite during the night shift, who could provide respiratory services to the residents, in accordance with the residents' plan of care. * On 11/24/25, 11/25/25, 4/6/26, 4/12/26, 4/19/26, 6/8/26, 6/15/26, and 6/22/26, on the night shift, the facility failed to ensure a staff member was on site at the facility, who could provide respiratory services to the residents with oxygen titration orders. This failure had the potential to result in negative health outcomes for the residents.

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. * The facility failed to ensure the cutting boards were maintained in sanitary condition and had smooth, cleanable surfaces. * The facility failed to ensure the heavy-duty blender used for puree preparation and three stainless steel square serving pans were air dried prior to stacking and storage. * The facility failed to maintain the hood over the stove in a clean and sanitary condition. * The facility failed to ensure the kitchen utensils had smooth, cleanable surfaces and were maintained in good repair. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage were properly stored in three of four garbage dumpsters. * The facility failed to ensure the lids of the three garbage dumpsters were fully closed. This failure had the potential to attract pest/rodents that carry diseases.

Inspectors wroteBased on observation, interview, medical record review, and P&P review, the facility failed to ensure the medical record was complete and accurately maintained for six of 22 final sampled residents (Residents 3, 8, 11, 16, 48, and 79). * The facility failed to ensure Resident 3's POLST was completed accurately. * The facility failed to accurately document the administration of midodrine medication (medication used to low blood pressure) to Resident 8. In addition, the facility failed to ensure Resident 8's telephone orders were signed by the physician as per the facility's P&P. * The facility failed to ensure Resident 11's POLST was complete and contained the physician's printed name, phone number, license number, and date. * The facility failed to ensure Resident 16's POLST contained the physician's phone number and license number. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for August 2025 through May 2026. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobial medications. The facility failed to determine whether residents who exhibited signs and symptoms of infection, and were not prescribed antimicrobial medications, met the facility's criteria for infection (McGeer's Criteria) and thus, failed to include these residents in the facility's infection control surveillance program. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to fully inform the resident or responsible party and obtain a completed informed consent prior to the use of the psychotropic medications for one of five final sampled residents (Resident 6) reviewed for unnecessary medications. * The facility failed to ensure Resident 6's consent form for the use of the hydroxyzine (a medication used for anxiety and itching caused by an allergic reaction) and temazepam (sedative medication) included the information about the medications' benefits and side effects. These failures had the potential for Resident 6 and the resident's responsible party to be unaware of the risks associated with the psychotropic medications.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment for one of 22 final sampled residents (Resident 67). * Resident 67 resided in Room A. The wall behind the resident's bed was observed in disrepair as evidenced by several areas of chipped and peeled paint. This failure had the potential to negatively impact the resident's quality of life and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided prior to the transfer to the acute care hospital for one of four residents (Resident 6) reviewed for hospitalizations. * The facility failed to ensure Resident 6 was assessment and/or change in condition documentation was completed prior to Resident 6's transfer to the acute care hospital on 4/15/26. This failure had the potential to result in the resident's change in condition not being assessed thoroughly and addressed in a timely manner.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide the drink preference as per physician's order for one of one resident (Resident 8) reviewed. * The facility failed to provide a health shake with meals to Resident 8 as ordered by the physician. This failure had the potential to not meet the resident's nutritional needs and negatively impact the resident's well-being.

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 access for one of one sampled resident (Resident 16) reviewed for intravenous care. * The facility failed to ensure the peripheral IV line dressing for Resident 16 was labeled and dated. This failure had the potential for the use of the resident's outdated peripheral IV access and posed a risk for IV site complications.

Inspectors wroteBased on interview, medical record, facility document review, and facility P&P review, the facility failed to ensure the pharmacist recommendations identified during the Drug Regimen Review were followed through in two of five residents reviewed for unnecessary medications ( Residents 8 and 31). * The facility failed to ensure Resident 8's Drug pharmacy recommendation for levothyroxine (medication to treat underactive thyroid by replacing missing hormones), and Latanoprost (prescription eye drop used to treat open-angle glaucoma and ocular hypertension by lowering intraocular pressure) and cyclosporine (used to treat chronic dry eye disease by decreasing eye inflammation and increasing your natural tear production) medications were followed through in a timely manner. [...]

Inspectors wroteBased on interview, observation, 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 to one of three medication rooms and one of four medication carts inspected for labeling and storage of drugs and biologicals. * The facility failed to ensure Resident 55's opened vial of lidocaine HCl (medication used to temporarily numb specific areas of the body to block pain) was dated when the vial was opened. * The facility failed to ensure expired COVID-19 testing kits were removed from the medication supply room. These failures posed the risk for the resident's use of outdated medication and inaccurate testing results for the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of 22 final sampled residents (Residents 68 and 88) who received hospice services. * The facility failed to ensure the hospice skilled nurse visit notes and CHHA notes were available and included in Resident 68's medical records. Furthermore, the facility failed to ensure the staff awareness of the facility's hospice designee/coordinator. * The facility failed to ensure the hospice skilled nurse visit notes and CHHA notes were available and included in Resident 88's medical records. Furthermore, the facility failed to ensure staff awareness of the facility's hospice designee/coordinator. These failures posed the risk of delay in communication between the hospice provider and facility which may affect resident care.

Inspectors wroteBased on observation, interview, medical record and facility P&P review, the facility failed to ensure the appropriate respiratory care and services were provided for three of six residents (Residents 3, 7, and 80) reviewed for respiratory care. * The facility failed to ensure Resident 3 and 7's oxygen concentrators were free of dust like particles. * The facility failed to ensure Resident 80's nebulizer machine was maintained in a sanitary condition. These failures had the potential to negatively impact the residents' health outcomes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the physician signed the telephone orders for two out of 22 final sampled residents (Residents 6 and 41). * The physician failed to sign Resident 6's telephone orders on a timely manner. * The physician failed to sign Resident 41's telephone orders on a timely manner. These posed the risks for inaccurate treatment for the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure two of seven sampled residents (Residents 4 and 7) attained and maintained the highest practicable physical well-being. * The facility failed to ensure Resident 4's sling was positioned properly to the resident's left arm as ordered by the physician. Additionally, the facility failed to provide toileting schedule as ordered by the physician for Resident 4. * The facility failed to ensure Resident 7's left thumb had a splint as ordered by the physician. These failures had the potential to negatively impact Residents 4 and 7 physical 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 prevent a fall incident for one of seven sampled residents (Resident 4). * The facility failed to assess and notify the resident's physician and family member when Resident 4 was found on the floor mattress. These failures had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services related to GT were provided for two of seven sampled residents (Residents 2 and 3). * Resident 2 was provided with Glucerna (enteral feeding formula) 1.2 at 65 cc/hour via GT, when the physician's order specified it to be 50 cc/hour. * Resident 3 was provided with water flush at 30 cc/hour via GT, when the physician's order specified it to be 35 c/hour. These failures posed the risk for complications related to the use of GT for Residents 2 and 3.

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 seven sampled residents (Resident 4). * The facility failed to ensure Resident 4's call light was within the resident's reach. This failure had the potential to negatively impact the residents' physical and psychosocial well-being or result in a delay to receive care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident1) was free from the unnecessary medications. * Resident 1 was administered Ozempic (medication used to manage type 2 diabetes) one mg subcutaneously (beneath the skin) for DM. However, Resident 1 had no diagnosis of DM. In addition, the facility failed to ensure Resident 1's plan of care addressed the use of the Ozempic medication and monitored the side effects of the medication. * Resident 1 was administered oxycodone (used to relieve severe pain) 10 mg medication when Resident 1's pain level was below the parameters ordered for the medication. These failures had the potential for Resident 1 to receive unnecessary medications and experience adverse effects from the medications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper safe storage of drugs for one of four sampled residents (Resident 2). * LVN 1 left a medication inside a clear cup unattended on Resident 2's bedside table. This failure posed the risk of other residents, visitors or unauthorized facility staff gaining access to the medication.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) was free from the significant medication errors. * The facility failed to administer Resident 1's ketotifen (an antiallergic medicationto help prevent asthma attacks) as ordered by Resident 1's physician. This failure had the potential to negatively affect the resident's well-being.

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 as evidenced by: * The facility failed to ensure the opened food items in the freezer were properly dated. * The facility failed to ensure the foods in refrigerator were properly labeled and dated, and failed to discard the items in the refrigerator that past the use-by date. * The facility failed to ensure the juice boxes and thickener were properly labeled and dated. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the food preparation equipment was in good condition. * The facility failed to ensure multiple bags of the English muffins did not have ice buildup inside. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to ensure the water management plan was available which addressed and identified where Legionella and other opportunistic waterborne pathogens could grow and spread, control measures to prevent the growth of the pathogens, and how to monitor them. * The facility failed to ensure the Administrator attended the quarterly infection control committee meetings. * The facility failed to ensure the Laundry Attendant performed proper hand hygiene prior to touching the clean linens. In addition, there were dirty items stored with the clean linens. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure one of 19 sampled residents (Resident 745) and one nonsampled resident (Resident 31) attained and maintained their highest practicable physical well-being. * Resident 745's measurements of abdominal girth were not documented. * The licensed nurse did not check Resident 31's last bowel movement prior to administering the stool softener medication to determine if it needed to be hold as per the physician's order. These failures had the potential for delay in providing the necessary care and services to the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided to prevent a decline in ROM functions for one of 19 final sampled residents (Resident 80). * The physician's order to apply an extension splint to Resident 80's left elbow was not followed. In addition, Resident 80's skin was not assessed when the splint was applied. These failures had the potential for Resident 80 to sustain a decline in ROM functions, leading to muscle atrophy and decrease in functioning.

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 prevent accidents for one of 19 final sampled residents (Resident 68). * The facility failed to ensure the floor mats were in place as per Resident 68's physician's order and care plan. This failure put Resident 68 at high risk for falls and serious injuries.

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 access for one of one final sampled resident (Resident 745) reviewed for IV care and failed to ensure the enteral feeding water bag was accurately labeled with the resident's name for one of 19 final sampled residents (Resident 30) reviewed for enteral feeding care. * The facility failed to ensure the baseline measurements of the PICC line external catheter length and arm circumference were confirmed and documented in the medical record prior to the administration of the IV antibiotics for Resident 745. In addition, the facility failed to ensure the PICC line external catheter length and arm circumference were measured and documented during the PICC dressing change as per the facility's P&P and Resident 745's care plan. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the physician's order for oxygen therapy was followed for one of two final sampled residents (Resident 80) and one nonsampled resident (Resident 695) reviewed for oxygen administration. * The facility failed to follow the physician's order for the administration of the oxygen for Resident 695. Additionally, there was no care plan developed for the use of oxygen. * The facility failed to ensure Resident 80's nasal cannula was not touching the floor and the nebulizer tubing was dated and placed on a clear plastic bag when not in use. These failures had the potential to negatively impact the resident's medical condition.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of two final sampled residents (Resident 34) reviewed for dialysis care. * The facility failed to ensure Resident 34 was assessed upon her return to the facility after dialysis treatment. * The facility failed to ensure the accurate documentation for the monitoring of Resident 34's fluid restriction. * The facility failed to ensure the emergency dialysis kit was kept at Resident 34's bedside. * The facility failed to ensure Resident 34's care plan was updated to include the dialysis transportation information as per the facility's P&P. These failures had the potential to negatively affect Resident 34's physical well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services. * The facility failed to ensure the active ingredients for Resident 31's artificial tears medication were the same as the Resident 31's physician's order. * The facility failed to ensure the Controlled Drug Record matched the MAR for Resident 66's oxycodone hcl (a narcotic pain medication). These failures had the potential to negatively affect the resident's well-being and posed the risk of diversion of the controlled medication.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of five sampled residents (final sampled resident, Resident 56) reviewed for the use of psychotropic medications. * Resident 56 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 Seroquel (an antipsychotic medication). There was no documented diagnosis prior to starting the Seroquel medication. * The facility failed to ensure an informed consent was obtained and least restrictive measures were implemented prior to starting Resident 56's Seroquel medication. * The facility failed to ensure a care plan for the use and monitoring of Resident 56's Seroquel medication was created at the time Resident 56 started receiving the medication. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the P&P regarding the outside food for the residents was updated to meet the state regulations and failed to ensure the visitors and staff were educated on safe food handling of outside food. These failures posed the risk for food borne illness to the residents who consumed food from outside sources.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the safe self-administration of medication for one of 19 final sampled residents (Resident 745). * Resident 745 had a bottle of the Glucosamine/Chondroitin (supplement) medication at the bedside. Resident 745 did not have a physician's order to keep the medication at bedside. Resident 745 reported to self-administer the medication despite not being qualified to self-administer. This failure had the potential to negatively impact Resident 745's physiological well-being as well as the potential for the medication interactions and inappropriate use of medications.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS was coded accurately for one of 19 final sampled residents (Resident 34). This failure had the potential for the resident to not receive individualized plans of care to address individual care needs.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to update the care plan regarding removing of oxygen for one of 19 sampled residents (Resident 49). This failure had the potential for not providing necessary care and services to the resident.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage and disposal of the medications. * Medication Cart B had oral medications stored with the externally used medication. * Medication Cart D had two expired skin staple removers. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the enteral feeding water bag was accurately labeled with the resident's name for one of 19 final sampled residents (Resident 30). This failure had the potential for the resident's care needs to not be met as their medical information was not complete and accurate.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the influenza vaccine (a vaccine which provides immunity to a variety of influenza viruses) was consented to be provided to one of five final sampled residents reviewed for vaccinations (Resident 38). * Resident 38 was administered the influenza vaccine on 9/20/24. There was no informed consent from Resident 38's responsible party for the influenza vaccine to be administered to Resident 38. This failure had the potential for violating Resident 38's right to refuse the vaccine.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to thoroughly investigate the allegations of abuse for one of two sampled residents (Resident 1). * Resident 1 claimed he was hit in the head by a staff member. The facility failed to ensure other residents were interviewed by the facility's Abuse Coordinator. This failure had the potential to put Resident 1 and other residents at risk of not being protected against the alleged abuse.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the services to attain or maintain the highest practicable well-being for two of 18 final sampled residents (Residents 4 and 5). * The facility failed to ensure the Xeloda (capecitabine - chemotherapy drug used to treat colorectal cancer) medication was administered as per the physician's orders for Resident 5. * The facility failed to follow up with the physician timely when Resident 4 had a change of condition involving an episode of hypertension (high blood pressure) of 180/100 mmHg. These failures had the potential to negatively affect the resident's health conditions and well-being.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to protect the resident's rights to be free from the physical abuse by the staff. * Resident 3 was hit on the right of the head by CNA 1 with an open hand, which was witnessed by another staff. This failure had the potential to cause injury and physical and/or psychosocial harm to the resident.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * The facility failed to ensure the proper storage temperature of medications in Medication room [ROOM NUMBER]. The temperature of Medication room [ROOM NUMBER] was 81 degrees F; however, the medications stored in Medication room [ROOM NUMBER] showed to store at the controlled room temperature between 68 to 77 degrees F. This failure posed the risk for administration of deteriorated medication. * The facility failed to maintain the acceptable temperature of the medication refrigerator in Medication rooms [ROOM NUMBERS]. The temperatures of the medication refrigerators were below 36 to 46 degrees Fahrenheit. This failure posed the risk for administration of deteriorated medication. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen staff performed hand hygiene during dishwashing. * The facility failed to ensure the heavy-duty blender used for puree preparation was air dried prior to storing. * The facility failed to ensure the microwave oven was clean and free of food particles. * The facility failed to ensure the cutting boards were in sanitary condition and with cleanable surface. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was implemented for one of 20 final sampled residents (Resident 22). * The facility failed to ensure Resident 22's bed was maintained in the lowest possible position in accordance with Resident 22's at risk for fall/injury care plan. 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 provide the necessary care and services to ensure one of 20 final sampled residents (Resident 25) attained and maintained the highest practicable physical well-being. * The facility failed to coordinate with the contracted hospice agency to provide the services to Resident 25 regarding the plan of care. This failure created the risk of not providing the appropriate and consistent care to Resident 25.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 20 final sampled residents (Residents 22 and 72) remained free from accident hazards. * The facility failed to ensure Resident 22's bed was maintained in the lowest possible position as per the physician's order. Resident 22 was assessed to be at risk for falls. * The facility failed to accurately document Resident 72's history of falls on the Fall Risk Evaluation form resulting in an inaccurate fall risk score status post an unwitnessed fall. These failures had the potential to place the residents at risk for serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the equipment utilized to provide the residents with oxygen therapy was labeled and changed in accordance with the facility's P&P, for three of 20 final sampled residents (Residents 22, 23, and 87). * The facility failed to ensure Resident 22's nasal cannula oxygen tubing and oxygen concentrator humidification bottle were labeled with the date when they were changed. * The facility failed to ensure Resident 23's nasal cannula oxygen tubing and oxygen concentrator humidification bottle were changed weekly and labeled with the date when they were changed. * The facility failed to ensure Resident 87's nasal cannula oxygen tubing was changed every seven days and as needed. These failures had the potential to result in negative health outcomes to the residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the nursing staff demonstrated the competencies and skill sets needed to provide safe nursing care to the residents. * CNA 6 failed to perform within their scope of practice when CNA 6 was observed turning off Resident 24's enteral feeding pump prior to performing ADL care. * The blood glucose test strips and control solution were not accurately tested with the Assure Platinum glucometer (device used to measure blood sugar levels). These failures had the potential to result in inadequate care and risk for adverse consequences for the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs of one nonsampled resident (Resident 27) when Resident 27's losartan (blood pressure medication) was not available on 9/15 and 9/16/23. This failure resulted in Resident 27 not receiving the blood pressure medication for two days, which had the potential to result in poor health outcomes to the resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the side effect monitoring of blood thinner medications for two nonsampled residents (Residents 10 and 68). This failure had the potential to cause negative outcomes for Residents 10 and 68.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 43) were free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * Resident 43 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 (Seroquel, an antipsychotic medication) for psychosis manifested by striking out at staff. There was no documented diagnosis of psychosis prior to starting the quetiapine fumarate medication. [...]

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 medication error rate was 13.79%. * The facility failed to administer eyedrops as per the facility's P&P and aspirin (blood thinner) chewable tablets as chewable to Resident 28. * The facility failed to administer aspirin chewable tablets as chewable for Resident 27. * The facility failed to administer Metamucil (fiber supplement) in accordance with the pharmacy label to Resident 94. These failures had the potential to negatively affect the residents' health.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to accurately complete the MDS for one of 20 final sampled residents (Resident 69). This posed the risk of the resident not receiving an individualized plan of care based on the resident's specific needs. * Resident 69 had an order to apply splints to left upper extremity and bilateral knee. The facility failed to code the use of splints in the annual MDS dated [DATE], and quarterly MDS dated [DATE].

Inspectors wroteBased on observation and interview, the facility failed to ensure garbage was properly stored in three of four garbage dumpsters. The failure had the potential to attract pest/rodents that carried diseases.