Glendale Post Acute Center

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop a resident centered care plan for one of three sampled residents (Resident 1), who routinely refused showers due to a preference for bed baths. This deficient practice had the potential for Resident 1 continuous refusal of and missed opportunities for the facility to provide care in accordance with the resident's choices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Treatment Nurse (TXN) 1 observed the facility's Enhanced Barrier Precautions (EBP, an infection control strategy used in nursing homes to prevent the spread of multi-drug resistant organisms [MRDO, hard to treat, drug resistant germs]) policy and procedure and the facility's Infection Control policy and procedure when TXN 1 failed to wear a personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while providing wound care for one of three sample residents (Resident 3). [...]

Inspectors wroteBased on interview and record review, the facility failed to identify resident's needs and care for one of four sampled residents (Resident 1) in accordance with the resident's preferences, goals of care and professional standards of practice as indicated on facility's Policy and Procedure (P&P) when, 1)Resident 1 was admitted on [DATE] had Moisture-Associated Skin Damage (MASD- an inflammatory skin condition caused by prolonged exposure to moisture, such as sweat, urine, or wound exudate) in the groin area extended to the gluteal fold and there was no care plan (CP) to care for MASD. Resident 1 was discharged home on 4/21/2026 with MASD in the groin area extended to the gluteal fold. [...]

Inspectors wroteThe facility failed to ensure care and services were provided to one of two sampled residents (Resident 1) as ordered by the physician by failing to: 1. Document Resident 1's high blood pressure (when the force of the blood pushing against the artery walls is too high) on 5/17/20262. Notify the physician of Resident 1's high blood pressure This deficient practice had the potential to delay assessment and treatment of uncontrolled hypertension

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure effective pain management was provided for one out of three sample residents (Resident 1) by failing to: Re-evaluate the effectiveness of nonpharmacological interventions (non-chemical, and non-invasive health interventions that treat conditions without medication). Ensure Resident 1 received pain medications as ordered. This deficient practice had the potential to result in unmanaged pain which could delay recovery, decrease mobility, and reduce the quality of life. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of six sampled residents (Resident 59, 72, and 84) could hold the Resident Council meeting (an independent group of nursing home residents that convenes at least once a month to discuss their concerns, offer suggestions, and plan activities) independently, without staff presence. This failure violated the resident's rights from exercising their right to hold Resident Council meetings privately without the presence of the facility staffs, as well as participating in and voicing grievances without fear of retaliation.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain the low air loss (LAL - specialized air mattress with tiny holes that constantly released air, creating a gentle airflow to keep skin dry, manage moisture, and prevent painful pressure ulcers (a skin injury due to prolonged unrelieved pressure and friction]) for people who could not move much) mattress at the proper inflation, weight, and therapy settings, and did not follow the care plan for Resident 40, one of two sampled residents identified as high risk for developing pressure ulcers and reviewed for pressure ulcer prevention. The facility failed to: Ensure the LAL mattress was correctly set at an inflation level consistent with Resident 40's weight and clinical needs. Implement Resident 40's care plan interventions to adjust the LAL mattress according to the resident's weight and comfort level. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and accident-free environment for three of 3 sampled residents (Resident 23, 135 and Resident 10) by failing to: 1. Post the required No Smoking/Oxygen in Use signage in the resident's doorway in the presence of supplemental oxygen for Residents 23 and 101 in accordance with the facility's policy and procedure (P&P) titled Oxygen Administration. 2. Supervise and implement safety measures for Resident 10 during a smoking break. These deficient practices had the potential to result in a significant fire hazard and compromise the safety and life of the residents, staffs and visitors in the facility.

Inspectors wroteBased on observation and interview and record review, the facility failed to label a used by date for the following food items in accordance with the facility's policy and procedure Food Receiving and Storage and with the professional standards for food service safety by failing to: 1. Indicate the used by date of an opened box with five pieces of pie shell 2. Indicate the used by date of an opened plastic container of dill pickle relish 3. Indicate the used by date of an opened bag of brownie powder and the facility staff failed to perform hand hygiene after engaging in activities that contaminate the hands and prior to dispensing meal trays to residents for three of ten sampled residents (Resident 64, Resident 119, and Resident 134) in accordance with the facility's policy and procedure (P&P) titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose garbage and refuse (food waste, scraps) by having the lids of two of three metal dumpsters (large trash container designed to be emptied into a truck) to closed completely and did not contain excess garbage bags, the garbage area was clear of litters, used opened boxes on the ground and used wooden pallet in accordance with the facility's policy and procedure titled, Food- Related Garbage and Refuse Disposal. This deficient practice had a potential to attract birds, flies, insects, pest, rodents, and possibly spread infection to residents, visitors and staffs in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices in accordance with facility policy and procedures and professional standards for two of four sampled residents (Resident 3 and Resident 135) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 2 wore an isolation gown when providing care one of one sampled residents (Resident 3) who was placed on Enhanced Barrier Precautions (EBP-an infection prevention and control intervention to reduce the spread multidrug resistant organisms [MDRO- disease causing organism resistant to medication used to treat infection]) due to the resident having gastrostomy tube (GT-tube inserted through the abdominal wall directly into the stomach used to deliver nutritional formula, fluid and medications). 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 2 sampled residents (Resident 23 and 101) were provided care in a manner that maintained dignity and respect when: 1. Licensed Vocational Nurse (LVN) 6 left Resident 23 was lying in bed uncovered and exposed without replacing the blanket or gown to maintain the resident's privacy after care was provided. 2. The Treatment Nurse (TN1) was standing next to Resident 101 while assisting the resident to eat during dinner. This failure had potential to negatively affect the residents sense of dignity and respect during the care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents call lights (a device used by residents to signal his or her needs for assistance) were within reach for two of two sampled Residents (Resident 88 and 127) for reasonable accommodation of needs. Resident 88 who was legally blind and Resident 127 were at risk for accident and fall. This deficient practice had the potential for Residents to be unable to call for assistance in an emergency which could lead to a fall and/or injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment for two of two sampled residents (Residents 100 and Resident 42) by ensuring Resident 100 and 42's wall clock in the room displays the accurate time of the day at all times. This deficient practice had the potential to cause disorientation, that could negatively affect Resident 100 and Resident 42's quality of life.

Inspectors wroteBased on Interview and record review, the facility failed to ensure that the facility informed one of eight residents (Resident 129) reviewed for resident's rights. Resident 129 and/or the representatives were not informed in writing the facility's policy on bed hold and return ( the facility keeps the resident's bed/room saved for up to 7 days while the resident is temporarily out of the facility) and keeps the document in the resident's clinical record that the resident was placed on bed hold at the time of transfer to the General Acute Care Hospital (GACH) on 9/9/2025 in accordance with the facility's policy and procedure (P&P) titled Bed-Holds and Returns, This deficient practice had the potential for residents' bed not to be appropriately held during hospitalization and to lose their room or their right to return to the same bed.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP) for two of seven residents (Resident 55 and 35) reviewed for comprehensive care plan by failing to: 1. Develop a CP to ensure Resident 55 received necessary care and interventions while receiving Ambien (a medication used to treat insomnia (a sleep disorder that can make it hard to fall asleep or stay asleep). 2. Develop a CP to ensure Resident 35 received necessary care and intervention while on hospice care (an end-of-life care). These deficient practices placed Resident 55 at risk of not receiving appropriate interventions to prevent the unnecessary use of psychoactive medications, which could result in adverse side effects (undesired effects). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the peripheral Intravenous (IV-small catheters inserted into a vein used to administer fluids, blood and medications) sites for one of eight (Resident 52) on the right and left arms peripheral IV dressings were dated and initialed by the staff who changed the dressing in accordance with the facility's policy and procedure titled Peripheral and Midline intravenous and the physician's order. This deficient practice had the potential to increase the risk for result IV infection, IV site skin breakdown, IV infiltration (IV fluid leaking out from the veins and into the tissues causing swollenness, pain and tissue damage)

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident 102 was free from significant medication error by failing to administer the correct dose of Retacrit ( a stimulating agent used to increase red blood cell production used to treat anemia (not enough healthy red blood cells that carry oxygenated blood to the tissues) reducing the need for blood transfusions) as ordered by the physician. This deficient practice had the potential to further worsened Resident 102's anemia and compromise resident's well-being and that may lead to the need for urgent blood transfusion and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for one of four sampled residents (Resident 55) as evidenced by having dust with white debris, a drinking cup, a medication cup, a piece of cotton swab, a pack of food condiments, and old dry liquid stains on the floor under the resident's bed. This deficient practice had the potential to result in Residents 55's non homelike environment that affects the resident's quality of life and self-image. During a review of Resident 55's admission Record (AR), the AR indicated the facility admitted Resident 55 on 1/16/2025 with diagnoses that included type II diabetes mellites (a condition that happens when your blood sugar is too high) and hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide the required minimum of 80 square feet (sq. ft., unit of measurement) per resident in 34 out of 45 resident bedrooms. Specifically, Resident Bedrooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 18, 19, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 41, 42, 43, 44, 45, 46, and 47 were measured and found to provide less than 80 square feet per resident. These rooms consisted of 31 three-bed capacity bedrooms and three two-bed capacity bedrooms. This deficient practice had the potential to negatively impact residents by limiting adequate space for safe nursing care, reducing privacy, and potentially increasing the risk of accidents or compromised care delivery due to overcrowded conditions.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the medical doctor (MD 1) of clinical issues for one of two sampled residents (Resident 1) when Registered Nurse (RN) 2 and RN 3 did not inform MD 1 when they were unable to initiate an intravenous (IV) line (a thin, flexible tube inserted into a vein to deliver fluids, medications, blood, or nutrition directly into the bloodstream) and were therefore unable to administer Dextrose (sugar) 5% in Water (D5W - a fluid used to provide hydration through an IV line) ordered by MD 1 on 10/31/2025 for hydration. These failures had the potential to result in serious harm, including cardiac arrhythmias (when the heart beats too fast, too slow, or in an uneven way), worsening of Resident 1's condition, or death due to untreated low potassium levels and delayed fluid therapy. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide care in accordance with professional standards of practice for one of two residents sampled for quality of care (Resident 1) when:1. Licensed Vocational Nurse (LVN) 1 did not notify Resident 1's medical doctor (Medical Doctor [MD] 1) or assess Resident 1 for a change in condition when LVN 1 was informed of Resident 1's low blood potassium (an electrolyte that is essential to the normal functioning of muscles such as the heart) level of 2.7 mEq/L (milliequivalent per liter- a unit of measure; normal levels between 3.5 to 5.2 mEq/L) on [DATE] from 1:57 pm to 5:00 pm.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident specific care plan was initiated for one of three sampled resident (Resident 1), when Resident 1 verbalized feelings of being upset, angry and threatened during an incident that occurred on 9/7/25 after Responsible Party 1 told Resident 1 to lower the telephone volume. This deficient practice had the potential to result in Resident 1 not being monitored adequately by facility staff and not meeting Resident 1's specific needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to :1-Provide adequate Certified Nursing Assistant (CNA) staff to respond to requests for assistance with toileting and activities of daily living (ADL) in a timely manner , for three of four sampled residents (Resident 2, Resident 3,and Resident 4).2- Implement the Facility Assessment and All facility Letter (AFL) 21-11 to meet requirement Direct Care Service Hours Per Patient Day (DHPPD) for CNA for minimum of 2.4 hours. This deficient practice resulted in Resident 2 sustaining a fall on 7/27/25 in the facility hallway, Resident 4 stated feeling helpless after facility staff did not address the call light timely to assist Resident 4 with his wheelchair, and Resident 3 waiting for two hours to assist with ADL's. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2) who were at risk for falls, were provided supervision to prevent further fall instances, by failing to: 1. Ensure Resident 1, who had severely impaired cognition (thought process) was frequently monitored as indicated on Resident 1's Care Plan.2. Accurately document and assess Resident 2's Fall Risk Assessment after Resident 2 fell on 5/25/25 and 7/27/25. This deficient practice resulted in Resident 1 sustaining a fall on 7/27/2025. This deficient practice resulted in Resident 2 sustaining a fall on 5/25/2025 and 7/27/2025 and Resident 2 not receiving appropriate preventative measures to prevent future falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and the responsible party (RP) for one of five sampled residents (Resident 1) when Resident 1 had a change of condition of new skin redness between the skin folds of the lower abdomen (belly). This deficient practice had the potential to result in worsening of Resident 1's skin condition and delayed provision of necessary care and services to maintain skin integrity and prevention of infection. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 5/15/2023 and readmitted her on 7/3/2023 with diagnoses that include dementia (A group of thinking and social symptoms that interferes with daily functioning) and difficulty in walking. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 1)'s was provided with a safe and functional wheelchair with brakes that prevented the wheelchair from moving when activated. This deficient practice had the potential to result in falls or injuries for Resident 1 f during transfers and while stationary. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 5/15/2023 and readmitted her on 7/3/2023 with diagnoses that include dementia (A group of thinking and social symptoms that interferes with daily functioning) and difficulty in walking. During a review of a Minimum Data Set (MDS, a resident assessment tool), dated 4/24/2025, indicated Resident 1 had severely impaired cognition (ability to understand and make decisions) and memory. [...]

Inspectors wroteBased on interview and record review, the facility failed to document medications administered for three of five sampled residents (Resident 1, 3, and 4) onto the Medication Administration Record (MAR) on 6/15/2025 during the 3 PM to 11 PM. This deficient practice had the potential to result in medication errors for Resident 1, 3 and 4 and negatively impact the delivery of services for the residents. 1. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 5/15/2023 and readmitted her on 7/3/2023 with diagnoses that include dementia (A group of thinking and social symptoms that interferes with daily functioning) and seizure (a sudden, uncontrolled surge of electrical activity in the brain that can cause changes in behavior, movements, sensations, or levels of awareness). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a sanitary environment for one of the five sampled residents (Resident 2) by not ensuring the wheelchair for Resident 2 was clean. This deficient practice had the potential to result in Resident 2' discomfort and the spread of infection. During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 12/17/2018 and readmitted her on 1/15/2019 with diagnoses that include Alzheimer's Disease (a progressive brain disorder that gradually destroys memory and thinking skills) and hypertension (high blood pressure). During a review of a Minimum Data Set (MDS, a resident assessment tool), dated 6/3/2025, indicated Resident 2 had severely impaired cognitive (ability to understand and make decisions) skills for daily decision making. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify the provision of monitoring and supervision to prevent abuse and intoxication of illicit/recreational drugs ([street drugs] refers to the use and misuse of illegal and controlled drugs) for one of two sampled residents (Resident 1) reviewed for substance abuse, and with a recent history of taking recreational drugs by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for controlled medications (medications with a high potential for abuse) affecting six out of seven residents (Residents 2, 3, 4, 5, 6 and 7) in one of two inspected medication carts (Station 2 Cart 3) in accordance with the facility's policy and procedures for controlled medications by failing to: 1. Document in the Controlled Medication Count Sheet (CMCS, a log signed by the nurse with the date and time each time a controlled substance was administered to a resident) when the medication was removed from the medication supply of the residents and administered to Residents 2, 3, 4, 5, 6 and 7. 2. Remove and securely store the medications in the medication cart of Resident 3 who was transferred to the hospital and Resident 7 who had expired. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) received Restorative Nursing Assistant (RNA) services to increase, maintain, or prevent a decline in range of motion (ROM - the extent of movement of a joint) mobility per physician ' s orders, by failing to: 1. Initiate RNA services until 1/26/2025 (16 days after RNA services were ordered) as indicated on the physician ' s order dated 1/10/2025 for Resident 1 ' s left upper extremity (UE) elbow extension (a device, like a brace or splint, that helped extend or straighten the elbow joint after an injury, surgery, or to assist with recovery or rehabilitation) and left hand-roll. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to prevent weight loss for one of three sampled residents (Resident 1) who was fed via gastrostomy tube (G-tube, a surgically placed feeding tube that delivers nutrition directly into the stomach through a small opening in the abdomen, used when someone could not eat or swallow safely or adequately) by failing to: 1. Perform weekly weights upon admission and on 1/18/2025 when recommended on Resident 1 ' s Registered Dietician (RD) Nutrition Care Recommendation. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for Laboratory Services and implemented fall care plan interventions for one of three sampled residents (Resident 1), who has a diagnosis of dementia (mental decline of memory, thinking and reasoning) and assessed at high risk for falls, by failing to: 1. Ensure to have a Fall Protocol (a system of rules that explain the correct conduct and procedures to be followed in formal situations) and Fall Prevention Program in place, as indicated in the facility ' s Fall Care Plan Interventions developed for Resident 1 on 2/4/2025 and 2/15/2025, and physician orders on 2/17/2025 and 2/18/2025. In an interview, the Assistant Director of Nurses (ADON) stated the facility did not have a fall protocol or fall prevention program in place. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident's right to be free from sexual abuse (a non-consensual sexual contact of any type with a resident) by Certified Nurse Assistant (CNA) 1 on 2/21/2025, as evidenced by a video recording showing, CNA 1 pull his penis out and used Resident 1's hand, stroke his (CNA 1) penis. CNA 1 stated he stroked Resident 1's penis until he (Resident 1) ejaculated (the release of semen through the penis during orgasm [the height or peak of sexual arousal]) then used Resident 1's blanket to clean the resident. This deficient practice resulted in Resident 1 being sexually abused by CNA 1 on 2/21/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the management of Resident 1 ' s psychotropic medications met the psychotropic medication requirements, in accordance with the facility ' s policy and procedures (P&P) titled Medication Utilization and Prescribing - Clinical Protocol, Psychotropic Medication use, and Appendix 3: Medication Issues Of Particular, Relevance In Older Adults by failing to: 1. Ensure Resident 1 ' s Depakote (brand name as divalproex sodium, used to treat epilepsy and bipolar disorder, medication works by affecting chemicals in the brain) use from 12/11/2024 to 12/18/2024 was given only when necessary to treat a specific diagnosed and documented clinical condition, that was based upon a clinical assessment of the resident ' s condition and consistent with clinical standards of practice. [...]

Inspectors wroteDuring observations, interviews, and record reviews, the facility failed to implement an ongoing infection prevention and control program (IPCP) to prevent, control the onset and spread of gastrointestinal (GI, the organs of the body that play a part in food digestion) infection, for 26 of 106 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ,11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, and 26),and 16 of 150 facility staff (CNAs 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, LVNs 1, 3, 4, and Ancillary Staff 1, who presented with GI illness (conditions affecting the digestive system) from 12/5/2024 to 12/18/2024 (14 days) by failing to: 1. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure the facility ' s Quality Assurance Performance Improvement ([QAPI] takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes) committee failed to identify facility and resident care issues, develop, and implement appropriate plans of action to implement the facility ' s infection prevention and control program (IPCP), in accordance with the facility ' s policy and procedures on Continuous Quality Improvement Program (QAPI), by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was specific for one of two sampled residents (Resident 1) who had diagnosis of anxiety. This failure had a potential to result in Resident 1 ' s inadequate and incomplete provision of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure by failing to administer Resident 1 ' s medications on 11/4/24, 11/5/24, and 11/12/2024 at 9am as ordered by the physician. This deficient practice had the potential for Resident 1 to experience high blood pressure (when your blood pressure is consistently higher than normal), high blood sugar and decline in overall health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 who was transferred to a General Acute Care Hospital (GACH) via 911 emergency services for a change in condition, was provided written information regarding the facility ' s bed-hold policies and permitted to be readmitted back to the facility on the first available bed, in accordance with the facility ' s policy and procedure titled Bed-Holds and Return, and the California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities for one of three sampled residents (Resident 1). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of two licensed nurses (Registered Nurse [RN] 3 and Licensed Vocational Nurse [LVN] 3) in the facility completed their annual competency assessment and evaluation (a process that assess and evaluates an employees skills, knowledge and performance) for the appropriate job category, in accordance with the facility ' s policy and procedure. This deficient practice placed the residents at risk for receiving care and services that was not within the standard of practice appropriate and safe which could result in abuse and decline in the resident's quality of life and care.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedure guidelines to prevent food contamination and the spread of foodborne illness for one of one kitchen when: 1. Multiple opened dry food items in the kitchen ' s dry goods storage area were not sealed and labeled. 2. Two boxes containing 229 unpasteurized eggs were found in the kitchen and were being used as ingredients to foods served to residents. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility ' s policy and procedure for infection control related to Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, Bacteria that resist treatment with more than one antibiotic]) due to presence of multiple wounds and use of a foley catheter (an indwelling medical device that consists of a hollow tube inserted into the bladder to drain or collect urine) for one of eight sampled residents (Resident 13). Certified Nursing Assistant (CNA) 1 was observed providing care to Resident 13 without wearing the proper personal protective equipment (PPE). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 103) was treated in a dignified and respectful manner when a certified nursing assistant (CNA 2) did not provide body coverage when transporting Resident 103 through the hallway in a shower chair, in accordance with the facility ' s policy and procedure titled Dignity. This deficient practice had the potential to cause psychosocial (mental and emotional well-being) decline, resident ' s individuality, self-esteem, and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility IDT (Interdisciplinary Team- team of facility staff that plans the care for the residents) did not accurately assess on of one resident (Resident 90) to ensure safely self-administer 17 bottles of medications that were stored the bedside which were not prescribed or ordered by the physician to self administer by failing to: Conduct an Interdisciplinary Team (IDT) meeting to assess if Resident 90 had the cognitive and physical abilities to self-administer medications. Review if any of the medications were expired, discontinued, or recalled. Document time when Resident 90 self-administered her medications. Ensure the medications were stored in a secure place, and not easily accessible to other residents besides Resident 90. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of three sampled residents (Residents 26, 83, and 314) by ensuring the residents call light (a device used to alert staff to the resident ' s room) within their reach (within arm ' s reach). This deficient practice had the potential for the residents not to receive or receive delayed care and services that could result in accidents and falls.

Inspectors wroteBased on interview and record review the facility failed to ensure that a current copy of a resident ' s advance directive was in the resident ' s medical record for two of three sampled residents (Resident 21 and 53). This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident ' s wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions.

Inspectors wroteBased on interview and record review the facility failed to notify the resident ' s physician and resident representative(s) for one of two sampled residents (Resident 21) with significant weight loss (when you lose more than 5% of your body weight over a period of six to 12 months) of 23 pounds (lbs.) in a period of 15 days. These deficient practices had the potential for the resident not to receive the necessary interventions to prevent further weight loss and negatively affect the provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility initiated facility initiated discharges on two of four sampled residents (Resident 320 and 111) when: 1. Resident 320 was informed by the Social Services Director [SSD] that she did not meet the criteria to stay admitted at the facility on 7/25/2024, after being admitted to the facility on [DATE]. Resident 320 was provided an option to pay out of pocket for Rehabilitation Services or sign the Against Medical Advice [AMA] on 7/25/2024. The facility did not provide adequate discharge planning for Resident 320, resulting in an unsafe discharge against medical advice [AMA] on 7/25/2024. Resident 320 was not provided with the information of the resident's rights to appeal and stay at the facility while an appeal is pending. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and revise the resident ' s care plan for one (1) of 3 residents, (Resident 38) by failing to revise Resident 38 ' s care plan for pain management when the resident continued to complain of pain everyday to indicate alternative interventions to relieve the resident ' s pain experience. This deficient practice resulted in Resident 38 to continue experiencing pain everyday that affected her quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to assist Resident 72 in receiving proper treatment and assistive devices to maintain vision when Resident 72 reported his prescription glasses (glasses prescribed by a doctor based on the resident ' s ability to see or vision) were broken by facility Certified Nursing Assistant (CNA). This deficient practice could lead to Resident 72 experiencing a decline in his everyday quality of life while at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen therapy (treatment that provides supplemental, or extra, oxygen) with a physician order of the amount of oxygen and with the parameter to when or when not to administer oxygen in accordance to acceptable standards of clinical practice and accordance with the facility ' s policy and procedure for one of two sampled residents (Resident 47). This deficient practice could result in Resident 47 to receive too much or not sufficient oxygen to meet the body ' s demand and place the resident at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which can lead into serious injury or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a Medication Regimen Review (MRR- a thorough evaluation of a patient's medications to identify and resolve issues, and to promote positive outcomes) to one of three sample residents (Resident 90) who consumed 17 bottles of medications kept at bedside that were not prescribed by the physician. This deficient practice put Resident 90 and other residents in the facility that could access the medications to be at risk for potentially harmful side effects (undesirable effect of medication) and adverse reaction (an untoward reaction to a medication) of the drug to the current drug regimen of the resident that could result in hospitalization and death.

Inspectors wroteBased on interview and record review the facility failed to maintain complete and accurate documentation of medical records for one (1) of 11 sampled residents (Resident 80) by failing to update the contact phone number of the representative of Resident 80 in the admission Record. The contact number listed in Resident 80 ' s chart was out of service. This deficient practice had the potential to interrupt provision of care and services for Resident 80 that could lead to delayed interventions to the resident especially during an emergency.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain to keep the electric wheelchair of one of one sampled resident (Resident 40) in safe and functional condition. Resident 40 stated her electric wheelchair (a battery-powered device that helps people with mobility challenges move around) had been broken for two years and was waiting for the facility to fix the electric wheelchair. Resident 40 stated she was very frustrated that the electric wheelchair was broken and needs the electric wheelchair to go outside and be able to do things. This deficient practice resulted in the resident ' s feeling frustration that limits her ability to mobilize in and out of the room to socialize and do outside activities which negatively affected her quality of life that could affect her mental/emotional/psychological state.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident for 33 out of 44 resident ' s rooms (Rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 18, 19, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 41, 42, 43, 44, 45, 46). The 33 resident rooms consisted of 31- three (3) bed capacity rooms and two (2)- 2 bed capacity rooms. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a sufficient preparation and orientation (sufficient preparation and orientation means the facility informs the resident where he or she is going and takes steps under its control to minimize anxiety) to a safe and orderly discharge was conducted for one of four sampled residents (Resident 1), who had fluctuating capacity to understand and make decisions and required continuous use of oxygen due to chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems). The facility did not provide adequate discharge planning for Resident 1, resulting in an unsafe discharge against medical advice on 9/25/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 3 sampled residents (Residents 2, 6, and 7) residing at the facility were free from sexual abuse (non- consensual [something is not agreed to by one or more of the people involved] sexual contact) from Resident 1, who had a diagnosis of Alzheimer ' s disease ((a brain condition that causes a progressive decline in memory, thinking, learning and organizing skills), by failing to: 1. Protect Resident 6 from nonconsensual sexual contact (any physical contact with another person of a sexual nature without effective consent) when Resident 1 grabbed Resident 6 ' s left arm and pulled down Resident 6 ' s sleeve on [DATE]. 2. [...]

Inspectors wroteBased on interview and record review the facility failed toensure one of three sampled residents (Resident 3) was free from misappropriation of property (the unauthorized, improper, or unlawful use of funds or other property for purposes other than for which intended) by failing to: 1. Protect Resident 3 ' s personal belonging/ valuables. Resident 3 ' s wallet was not accounted for on the Residents ' Clothing and Possession Form (inventory list), and Resident 3 was missing debit cards, two hundred dollars cash and a watch. 2. Accurately document on Resident 3 ' s Clothing and Possession Form personal belongings and valuables brought into the facility by Resident 3 and revise the form upon readmission and as needed. 3. Immediately report and investigate Familymember2 ' s (FM2) allegation of abuse of Resident 3 ' s missing personal belongings/valuables. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report an allegation of misappropriation of property ( the illegal use of the property or funds of another person for one ' s own use unauthorized purpose) for one of three sampled residents (Resident 3) to the California Department of Public Health (CDPH), within two hours by telephone and written report, in accordance with the facility ' s Policy and procedure titled Abuse investigation and reporting - Investigation Incidents of theft and or misappropriation of resident Property. This deficient practice had the potential to result in unidentified abuse in the facility and the risk of further abuse to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safety to one of two sample residents (Resident 1) who was at high risk for injury as indicated in the facility ' s policy and procedure titled Falls and Fall Risk, Managing and resident ' s care plan by failing to: 1. Ensure Resident 1 was assisted by two persons while performing activities of daily living (ADL). While Certified Nursing Assistant (CNA) 3 assisted Resident 1 to change clothes, Resident 1 turned to scratch the back and started to slide down the bed. CNA 1 grabbed Resident 1 under the neck and back and eased Resident 1 to the floor. 2. Implement fall precautions immediately by monitoring the resident for low bed position and safety after Resident 1 ' s fall on 8/20/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents were kept clean and assisted with activities of daily living, when the facility failed to provide incontinent care and ADL assistance for 5 of 6 sampled residents (Resident 1, 2, 3, 4 and 5). These deficient practices resulted in the residents feeling frustrated, embarrassed, and angry due to lack of or delay in receiving sufficient services to maintain incontinent care and had the potential to lead to skin breakdown and psychosocial distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide sufficient nursing staff to provide nursing care and related services to assure resident safety, assist residents in activities of daily living (ADL) and prevent falls for 6 out of 6 sampled residents (Residents 1, 2, 3, 4, 5, and 6) who required staff assistance for ADLs. This deficient practice resulted in a delay in response to resident needs and resulted in the increased of fall in the facility for the month of July 2024. The facility had a total of 11 falls for July 2024. Three residents falls resulted with injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment free of environmental hazards and provide adequate supervision to prevent accidents for one of three sampled residents (Resident 1). These deficient practices resulted in Resident 1 sustaining repeated falls, a total of two falls from 3/30/2024 to 7/10/2024 and was identified with injuries on one fall as follows: On 7/10/2024, Resident 1 fell in Shower room [ROOM NUMBER] and sustained 2 centimeters (cm) vertically X 0.5 cm head wound laceration (a deep cut or tear in skin or flesh). Resident 1 was transferred to the General Acute Care Hospital (GACH) via 911 emergency services on 7/10/2-24 and came back on the same day with five staples in the head.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled resident ' s representative (Resident Representative 1 [RP 1]) whose a family member of Resident 1, that did not have capacity to understand and make decisions, was informed and involved during Resident 1 ' s admission in the facility, including review and signing of facility required admission paperwork, that included consents for the following: -MDS Transmission Notification -Consent to Treat -Advanced Healthcare Directive Acknowledgement form This deficient practice had the potential for Resident 1 ' s rights to be violated and not have sufficient knowledge of documents before signing, and RP 1 not to be informed of Resident 1 ' s care and documents signed in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility ' s policy and procedure titled Abuse Prevention Program and Abuse Investigation and Reporting by failing to protect Resident 1 during an abuse investigation when Certified Nursing Assistant (CNA) 1, who matched the description of an alleged abuser as described by one of three sampled residents (Resident 1), was not prevented from coming in physical contact with Resident 1 after Licensed Vocational Nurse (LVN) 1 was already informed of the allegation of abuse on 5/31/24 at 7:30 PM. This deficient practice had the potential to cause further abuse and negatively affect the psychosocial well-being of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide Resident 1 ' s responsible party/representative (RP 1) access to Resident 1 ' s records within 48 hours (excluding weekends and holidays) of the initial request for one of two sampled residents (Resident 1), in accordance with the facility ' s policy and procedure titled Release of Information dated November 2009. This deficient practice caused a delay in releasing Resident 1 ' s records in a timely manner.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement individualized person-centered care plans with measurable objectives, timeframes and interventions for one of two sampled residents (Resident 1) by failing to: 1. Develop a comprehensive, resident centered care plan for Resident 1 when a DTI was found by Treatment Nurse 2 on 1/9/2024. On 2/17/2024, Physician Assistant (PA) 1 indicated DTI to Resident 1 ' s right heel. There was no documented evidence that care plan was developed for Resident 1 ' s right heel skin concern. 2. Develop care plan interventions for peripheral vascular disease (PVD - a circulatory condition characterized by the narrowing or blockage of blood vessels outside the heart and brain. [...]

Inspectors wroteBased on interview, observation and record review the facility failed to: 1. Ensure Resident 1 ' s skin was reassessed by the treatment nurse 24 to 48 hours after being newly admitted to the facility on [DATE]. Resident 1 ' s skin was reassessed by the treatment nurse on 1/9/2024 and found a right heel deep tissue injury (DTI- a pressure-related injury to subcutaneous tissues under intact skin), six days after admission. 2. Develop a comprehensive, resident centered care plan for Resident 1 when a DTI was found by Treatment Nurse 2 on 1/9/2024. 3. Follow and notify the physician of the interdisciplinary team (IDT) treatment recommendations made on 1/9/2024 to put in physician order to treat Resident 1 ' s DTI to the right heel with betadine everyday. The treatment order to apply betadine daily to the right heel was not started, until 1/15/2024 (6 days after IDT recommendation). 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy for one of three sampled residents (Resident 1) while treatment nurse (TN)1 provided wound care treatment. This failure had the potential for Resident 1 to be in view of passerby ' s in the facility hallway and affecting Resident 1 ' s self-worth and dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was assessed for pain before, during, and after wound care treatment for one of 3 sampled residents (Resident 1). This deficient practice resulted to Resident 1 experiencing unnecessary pain during wound care treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one out of nine residents (Resident 1) from potentially developing a wound infection when Treatment Nurse (TN) 1 failed to stop and restart a wound treatment after Resident 1 ' s right heel deep tissue injury (a serious form of pressure injuries [localized damage to the skin as well as underlying soft tissue, usually occurring over a bony prominence or related to medical devices]) wound touched her wheelchair ' s footrest. This failure placed Resident 1 at risk of developing an infection on her right heel wound.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of sexual abuse made by the resident ' s family member (FM 1) on 3/31/24, that alleged two men, came during the night shift of 3/30/24 and rubbed the resident ' s private part that caused bleeding for one of four sampled residents, in accordance with the facility ' s policy and procedure titled, Abuse Investigation and Reporting. In addition, the facility failed to suspend Certified Nurse Assistant (CNA) 2 and Licensed Vocational Nurse (LVN) 2, who performed perineal care to Resident 1 during the night shift of 3/30/24, when the facility administrator and the director of nurses (DON) was notified of the sexual abuse allegation on 3/31/2024, pending the completion of the investigation. These deficient practices had the potential to place Resident 1 at risk for further abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to allow one sampled resident (Resident 1) to return to the facility after hospitalization leave as outlined in the facility ' s policy and procedure. In addition, the facility failed to show evidence that the facility made efforts to provide reason of what services they are not be able to provide Resident 1. As a result, Resident 1 remained at the General Acute Care Hospital (GACH) Emergency Department from 3/9/24 to 3/18/24, for nine days while waiting for acceptance from Recuperative Care Center (facility that provides short-term residential care for individuals who need to heal from injury or illness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper use of bed side rails (adjustable metal or rigid plastic bars that attach to the sides of the bed) for one of six sampled residents (Resident 4), as indicated in the facility's policy and procedure titled Bed Safety and Bed Rails, by failing to: -Assess Resident 4 for risk of entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail). -Obtain an informed consent from Resident 4 or Resident 4 ' s representative and review the risks and benefits prior to installing bed rails. These deficient practices had the potential to result in inappropriate use of bed rails for Resident 4 and can lead to accidents such as strangulation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a system was in place to provide a safe resident environment for one of three sampled residents in the facility, identified as active smokers (Resident 1, 2, and 3), and to ensure non-smoking residents of the facility were kept safe, comfortable and free from the hazards of second hand smoke, as indicated in the resident ' s written plans of care and the facility ' s policy and procedure on Smoking. These deficient practices had the potential for residents to acquire unexpected burns, fire hazard and /or injuries caused by unsafe smoking and exposed non-smoking residents and visitors to secondhand smoke.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the resident's choice and preference for one of three sampled residents (Resident 1) rights by assigning a male CNA and having a male CNA assist Resident 1 after Resident 1 and Resident 1's Family Member (FAM) 1 requested a female CNA to be assigned to Resident 1, in accordance with the facility's policy on Dignity. This deficient practice violated Resident 1's rights to have a female CNA care for her and has the potential to negatively affect Resident 1's psychosocial well-being, self worth and self-esteem.

Inspectors wroteBased on observation, interview and record review the facility failed to put measures in place to ensure the safety of two of two sampled residents (Residents 1 and 2) who were assessed as elopement (an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment) risk. The facility staff failed to supervise Resident 1 who eloped from the facility on 10/21/2023, by failing to ensure: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse when Resident 1, who had a behavior of randomly grabbing things and staff was not monitored for behavior to identify risk factors for abuse for one of two sampled Residents (Resident 1). This deficient practice resulted in Resident 1 being physically abused by Resident 2 during a resident -to-resident altercation on 10/22/23. Resident 1 sustained a bruising (bluish-dark discoloration) under the left eye, when Resident 2 (Resident 1's roommate) hit Resident 1, after Resident 1 grabbed Resident 2's jacket, as he walked away.

Inspectors wroteBased on interview, observation, record review, the facility failed to report immediately within two hours, in accordance with the facility's policy on abuse reporting, a suspicion of physical abuse for one of two sampled residents (Resident 1). Resident 1 was physically abused by Resident 2 during a resident -to-resident altercation on 10/22/23. Resident 1 sustained a bruising (bluish-dark discoloration) under the left eye, when Resident 2 (Resident 1's roommate) hit Resident 1, after Resident 1 grabbed Resident 2's jacket, as he walked away. Certified Nurse Assistant (CNA) 1 observed Resident 1's left eye discoloration on 10/22/23 at around 8 AM and did not report it immediately to the Abuse Coordinator. Licensed Vocational Nurse (LVN) 1 observed Resident 1's left eye discoloration on 10/22/23 at around 10: 30 AM and did not report it immediately to the Abuse Coordinator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy and procedure titled Preparation and General Guidelines to ensure the systems of records in disposing expired medications and accurate accounting of controlled drugs (drugs that are subject to high levels of regulation because of government decisions about those drugs that are especially addictive and harmful) for four of four residents (Resident 16, 29, 30 and 80). The facility failed to ensure: 1. The medication cart drawer for controlled drugs did contain Morphine Sulfate (a controlled drug used for pain relief) belonging to Resident 16, who passed away on 10/14/23. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility's policies & procedures on food storage by: 1. Not unpacking the contents of 24 of 24 corrugated (a material shaped into alternate ridges and grooves) shipping boxes and placing those boxes directly onto the shelf in the dry storage room. This failure had the potential to introduce insects such as cockroaches (small insects that cause spread of bacterial infection) into the food storage environment from the corrugated cardboard shipping boxes, which may result in vector-borne diseases (diseases that result from an infection transmitted to human by insects and cockroaches). 2. Not labeling and covering food items in two of two cool storage areas (freezer and walk-in refrigerator). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy and procedure for infection control for five of five sampled residents (Residents 43, 45, 58, 165 and 264) by failing to ensure: 1. The Certified Nursing Assistant 2 (CNA 2) followed the Enhanced Standard Precautions guideline (precautions that require the use of PPE [equipment such as isolation gown, gloves, face mask and/or shield worn to minimize exposure to hazardous fluids that cause serious illnesses] and hand washing or use Alcohol Based Hand Rub (ABHR) during high-contact resident care activities) when providing care to Resident 264 with wound and Foley Catheter (Foley catheter [brand name] for urinary indwelling catheter a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's clinical records were updated for one out of 2 sampled residents (Resident 66) by failing to maintain a current copy of the resident's advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) in Resident 66's clinical record. This deficient practice had the potential to cause conflict with Resident 66's wishes regarding health care treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASARR- The State is required to ensure that every person entering a Medicaid Certified Nursing Facility (NF) receives a Level I Screening and if necessary a Level II Evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) recommendation to obtain a PASARR Level II Evaluation for one of 2 residents (Resident 81). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 81.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess comprehensively, develop a care plan and evaluate one or two residents (Resident 64) with the ability to smoke cigarette safely with or without supervision when smoking in the facility premises. This deficient practice had the potential to result in accidental burn or injuries and fire hazard or harm in the facility that affects Resident 64, other residents, staffs and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy and procedure for pain management titled Pain Assessment and Management and Pain-Clinical Protocol, to ensure one of two residents (Resident 52), was assessed for pain and provided interventions for pain relief or control in a timely manner. This failure resulted in Resident 52 experiencing delayed pain management and control of pain that could affect the inability to maintain the highest practicable level of well-being and healing process.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the hemodialysis (a process of removing toxins and excess fluid in the blood using a machine) emergency kit (kit used in the event bleeding was observed in the hemodialysis site) for two of three residents (Residents 53 and 64 who received hemodialysis. This deficient practice had the potential to delay or unable to immediately provide interventions in an event of emergency to Resident 53 and Resident 64 for complications such as trauma, and bleeding on the dialysis access site (a surgically created vein used to remove and return blood to the body during hemodialysis) that could lead to a significant blood loss and decline in the resident's wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a dental follow up appointment for one of two sampled residents (Resident 39) as per doctor's order. This failure had the potential to result in Resident 39 developing an infection from not receiving a dental assessment after being diagnosed from the hospital with dental caries (permanently damaged areas in teeth that develop into tiny holes cause by bacteria, snacking, sipping sugary drinks and poor teeth cleaning).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two outside garbage dumpster lids were fully closed per facility policy and procedure (P&P), titled Food-Related Garbage and Refuse Disposal . This failure had the potential to attract pests and insects to the facility and cause a wide spread of diseases and infection to the faciltity that affects the residents, staffs and visitors.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the hospice agency documented and coordinated with the facility staffs regarding the plan of care, the interventions implemented and if the interventions were effective to meet the care needed by one of two residents (Resident 112) under hospice care (a specialized care for people whose prognosis is poor and reaching end of life with the focus on providing comfort care). Resident 112 had a fall incident and noted with discoloration on the forehead on [DATE], after three days Resident 112 expired on [DATE] without a documentation from the hospice care agency the plan of care provided after the resident fall. This deficient practice resulted in Resident 112 not to receive the care and interventions necessary under hospice care and services related to the residents change of health conditions after a fall.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's bedroom measured at least 80 square feet (sq. ft.-a unit of measurement) per resident in multiple resident bedrooms for 33 out of 44 rooms. Rooms 2, 3, 4, 5, 6, 7, 8, 9,10,11,12,14,15,16,17,18,19, 20,21 23,24,25,26,27,28,29,30,31,33, 34, 41, 42, 46 and 48 measured less than 80 sq. ft. per resident. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.