Glendora Canyon Transitional Care Unit

Inspectors wroteBased on interview and record review, the facility staff failed to document the amount of meal intake on the resident's medical record for one of four sampled residents (Resident 1). This deficient practice had the potential to result in lack of communication between staff and delay and interrupt the provision of care needed to maintain the resident's highest practicable, physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to provide medically related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) to one of nine sampled residents (Resident 1) when the Social Services Director (SSD) did not assist Resident 1 to apply for health insurance before Resident 1's Medicare (federal health insurance for anyone age [AGE] and older) coverage ended on 11/10/2025. This deficient practice resulted in Resident 1 having no health insurance after 11/10/2025 and resulted in Resident 1 having to shoulder the cost of skilled nursing services Resident 1 received after 11/10/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were called by their legal (official name recognized by government on documents), proper and preferred names for three of three sampled residents (Residents 14, 96, and 132). These failures had the potential for Residents 14, 96, and 132 to lose their dignity and individuality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:a. The call lights were accessible for residents in four of four private shower areas.b. The call light was accessible for one of one visually impaired resident (Resident 92). These deficient practices had the potential to result in a delay in meeting the residents' needs for assistance and could lead to falls and accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement specific and resident-centered care plans (CP) for four of four sampled residents (Residents 3, 48, 49, and 95). These deficient practices had the potential for Residents 3, 48, 49 to not receive appropriate care, treatment, and/or services related to their needs and the potential to result in burns or injuries to Resident 95 during smoking breaks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers/injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) was set accurately for two of three sampled residents (Residents 48 and 117). These failures had the potential to worsen and impede healing of both residents' wounds and cause further skin injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for residents with indwelling catheter (a catheter inserted into the bladder to drain urine) and suprapubic catheter (a soft tube inserted directly into the bladder through a small incision in the lower belly [just above the pubic bone] to drain urine into a bag) for two of four sampled residents (Residents 132 and 33) by failing to: a. Ensure Resident 132's foley catheter (FC - a common type of indwelling catheter, a soft, plastic or rubber tube that is inserted into the bladder to drain urine) was secured to the resident's thigh. b. Ensure Resident 33's suprapubic catheter site was monitored for signs and symptoms of skin breakdown as indicated in residents plan of care and facility's policy and procedure (P&P) titled Suprapubic Catheter Care, Urinary. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for residents receiving oxygen therapy (treatment that provides supplemental, or extra oxygen) in accordance with professional standards of practice for five of the five sampled residents (Residents 33, 68, 76, 131 and 117) by failing to: a. Ensure Resident 33's nasal cannula tubing (flexible plastic tubing used to deliver oxygen through the nostrils and the tubing is fitted over the patient's ears) was stored appropriately when not in use, there was a physician's order for the use of oxygen at two liters per minute through nasal cannula and there was a cautionary sign posted on Resident 33's door indicating oxygen was in use. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt the use of appropriate alternatives to bedrails (a bar that runs along the side of a bed) or siderails (adjustable metal or rigid plastic bars attached to bed) and did not meet the residents' needs before its installation for two of two sampled residents (Residents 76 and 94). These failures placed Residents 76 and 94 at risk for entrapment (an event in which residents were caught, trapped, or entangled in the tight spaces around the bed) and injury from the use of bedrails or side rails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation for one of one facility kitchen. This deficient practice has the potential to result in pathogen (germ) exposure to residents and places them at risk for developing foodborne illness.

Inspectors wroteBased on interview and record review, the facility licensed nurses failed to document the intravenous (IV, directly into a vein) antibiotic (a medicine that killed bacteria) medication administrations on the Medication Administrative Record (MAR) for two of two sampled residents (Residents 42 and 48). These deficient practices had the potential to result in lack of communication between staff and delay and interruption of care needed to maintain the residents' highest practicable, physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for two of five sampled residents (Residents 33 and 132) by failing to:a. Wear required personal protective equipment (PPE, equipment that protects people from injury or illness ) while providing care to Resident 33 who was placed on Enhanced Barrier Precaution (EBP, precautions that involve using a glove and gown during high-contact resident care activity for residents who are colonized or infected with an multidrug-resistant organisms [MDRO, bacteria that is resistant to many types of antibiotics] and those at a higher risk of developing a MDRO, such as, residents with wounds or indwelling medical devices).b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen dry storage area was free of fruit flies on 1/13/2026 and 1/14/2026 for one of one kitchen dry storage area. This deficient practice had the potential to result in pathogen (germ) exposure to residents and placed the residents at risk for developing foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure (P&P) on Informed Consent for Physical Restraint, for the use of bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) for one of one sampled resident (Resident 76). This failure violated Resident 76's rights and placed Resident 76 at risk for psychological distress from hearing the alarm sound.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Advance Directive (AD, a written instruction, recognized under State law relating to the provision of health care when the individual is incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care]) for one of eight sampled residents (Resident 10) was readily accessible in accordance with the facility's Policy and Procedure (P&P) titled Advance Healthcare Directives/POLST. This failure had the potential for facility staff to provide medical treatment and services against Resident 10's will.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise a plan of care for one of one sampled resident (Resident 96), as indicated in the facility's policy Care Plans, Comprehensive Person-Centered. This deficient practice had the potential for Resident 96 to not receive appropriate care, treatment and/or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure policies and procedures (P&P) on Smoking were implemented for one of one sampled resident (Resident 95) when Resident 95 did not receive direct supervision and was not offered a smoking apron during smoking break. This failure had the potential to place Resident 95 at risk for burns and accidents during smoking break.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition/medication directly into the stomach) site as ordered by the physician and as indicated in the plan of care for one of one sampled resident (Resident 10). This failure had the potential for complications related to tube feedings for Resident 10.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 2) from physical abuse (aggressive or violent behavior with the intention to cause physical harm) as indicated in the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program to be free from abuse. As a result, on 8/23/2025 Resident 1 pushed Resident 2 and Resident 2 fell to the floor. Resident 2 was transferred to General Acute Care Hospital (GACH) 1 for an assessment and evaluation due to an unwitnessed fall. Resident 2 sustained an acute (sudden) comminuted (the bone breaks into multiple small fragments) fracture (partial or complete break of the bone) of the right 5th metacarpal (the bone in the hand that connects the little finger to the wrist).

Inspectors wroteBased on interview and record review, the facility failed to report and a physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) incident to the California Department of Public Health (CDPH, State Agency) for one of three sampled residents (Resident 2) as indicated in the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program. This deficient practice resulted in the delay of notification to the State Agency and had the potential to result in residents residing at the facility to be subjected to further abuse. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe and comfortable room temperature in 2 of 2 resident shower rooms observed. This deficient practice had the potential to cause discomfort and unsafe conditions for residents who used the shower rooms. During a concurrent observation and interview on 8/26/25 at 11:27 AM, with Certified Nurse Assistant 1 (CNA 1) the thermostat of the third-floor shower room showed 82 F. CNA 1 stated, It is hot and stuffy, not usually like this. During a concurrent observation and interview on 8/26/25 at 11:31 AM with Licensed Vocational Nurse 1 (LVN 1) the thermostat of the second-floor shower room, showed 85 F. LVN 1 stated the room feels hot and stuffy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by failing to ensure:1. Resident 1's responsible party (RP, a person who is responsible for guiding, informing, assisting, and advocating for residents in the healthcare system) was informed when Resident 1's blood sugar level was 480 and Resident 1 had to be given additional dose of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) on 5/17/2025 at 12:23 pm.2. Resident 1's blood sugar level of 480 on 5/17/2025 was documented in Resident 1's medical record.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policies and procedures (P&P) titled, Hand Hygiene (procedures that included the use of alcohol-based hand rubs (ABHR- containing 60%-95% alcohol) and hand washing with soap and water), and Standard Precautions (SP- a set of evidence-based infection control practices designed to prevent the transmission of infectious diseases in healthcare settings), Enhanced Barrier Precautions (EBP- set of infection control measures that use personal protective equipment [PPE- equipment worn to minimize exposure to hazards] to reduce the spread of multidrug-resistant organisms [MDRO- organism that is resistant to most antibiotics] by wearing a gown and gloves) and Transmission-Based Precautions (TBP- extra measures, used in addition to standard precautions, to prevent the spread of specific infectious agents that can [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the right of one of three sampled residents (Resident 1) to participate in the resident's treatment when the facility failed to give Resident 1's Pramipexole Dihydrochloride (medication used to treat Parkinson's disease [a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination]) at Resident 1's requested time. This failure had the potential for Resident 1 to experience an increase in tremors (involuntary, rhythmic shaking movements that can affect various parts of the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications for one of three sampled residents (Resident 2) were kept locked in secure storage when Resident 2's morning medications were observed to be unattended at Resident 2's bedside. This failure had the potential for Resident 2 to not receive Resident 2's scheduled medications and had the potential to cause harm to other residents who could access and swallow the unattended medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for three of three sampled residents (Residents 14, 211 and 251) as indicated in the facility's Policy and Procedure (P&P) titled Call System, Resident. These deficient practices had the potential for the residents to receive delayed services and placed the residents at risk for falls/accidents.

Inspectors wroteBased on interview and record review, the facility failed to implement its Policy and Procedure (P&P) on Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) for four of four sampled residents (Residents 47, 82, 89 and 92) by failing to: a. Ensure a copy of Resident 47's AD was in the resident's medical record/chart. b. Ensure a copy of Resident 89's Advance Directive Acknowledgement (ADA) Form was in the medical record/chart. c. Complete the ADA Form on admission for Resident 82. d. Ensure a copy of Resident 92's AD was in the medical record/chart. These deficient practices had the potential for the facility staff to provide medical treatment and services against the will of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an effective communication method for two of two non-English speaking sampled residents (Residents 17 and 92). This failure had the potential for Residents 17 and 92 not to receive necessary care and services affecting their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two of two sampled residents (Residents 82 and 301) by failing to: a. Implement Resident 82's care plan (CP), when Resident 82's bilateral (both) feet with arterial ulcers (open wounds that form when there was not enough blood flowing to the bilateral extremities) were not offloaded (elevating an extremity to relieve pressure). This failure had the potential to result in worsening or delayed wound healing. b. To provide transportation for one of one sampled resident (Resident 301) to the resident's scheduled physician's appointment. This failure resulted in the delay of Resident 301's diagnostic exam.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide wound care treatments as ordered by the Medical Doctor (MD) for an unstageable pressure ulcer (PU, pressure ulcer [injuries to the skin and underlying tissue that are result of pressure on the skin for long periods of time] that was not stageable due to coverage of the wound by slough [white, yellow, tan, gray, or green in color that consist of dead tissue] and or eschar [thick, dry, black or brown scab like covering that forms over the wound]) on the right midback from 10/30/2024 to 11/7/2024 (eight days) for one of two sampled residents (Resident 82). This failure had the potential to result in worsening of Resident 82's right midback unstageable PU.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's Policy and Procedure (P&P) on the use of siderails for two of two sampled residents (Residents 26 and 28) by failing to: a. Ensure Resident 26 had a doctor's order for siderails, siderail use was consented and appropriate alternative interventions were attempted and did not meet the resident's needs before the installation of side rails. b. Ensure Resident 28 was assessed for the use of siderails and appropriate alternative interventions were attempted and did not meet the resident's needs before the installation of side rails. These deficient practices placed Residents 26 and 28 at risk for entrapment and injury from the use of siderails.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's Policy and Procedure (P&P) on psychotropic (medications that alter brain function) and antipsychotic (medications that reduce delusions or hallucinations) medication use, for two of five sampled residents (Residents 82 and 96) by failing to: a. Ensure as needed (PRN) psychotropic medication was ordered with a stop date of 14 days when Resident 82 was receiving Lorazepam (medication to treat anxiety) 0.25 milliliters (mL, unit of measurement for volume) every four hours PRN for restlessness and or agitation. b. Ensure Resident 96's target behavior and adverse side effects (unwanted or undesirable effect) was monitored, and the order included a specific indication for the use of Haloperidol (antipsychotic). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices by: a. Placing a staff's personal lunch bag inside the facility's one of one walk-in refrigerator used to store residents' food. b. Failing to ensure one of one dome drying rack was free from rust and dirt. These deficient practices had the potential to result in food-borne illnesses to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated resident assessment tool) was accurately coded for language preference for one of one sampled resident (Resident 17). This failure had the potential risk for Resident 17 not to receive necessary care services.

Inspectors wroteBased on interview and record review, the facility failed to create a baseline care plan (CP) for one of one sampled resident (Resident 82) upon admission on [DATE]. This failure had the potential for delayed provision of necessary care and services for Resident 82.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized/person- centered care plan for one of five sampled residents (Resident 96) who was on Haloperidol (antipsychotic medication to treat serious mental disorder in which people interpret reality abnormally) in accordance with the facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person - Centered. This deficient practice had the potential for Resident 96 to not receive appropriate treatment and/or services related to the use of Haloperidol.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents' indwelling catheter (foley catheter, a tube that allows urine to drain from the bladder into a bag) was assessed and monitored for the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria) in the urine in accordance with the facility's Policy and Procedure (P&P) titled Catheter Care, Urinary and the resident's care plan (Resident 44). This deficient practice had the potential for Resident 44 to receive delayed care and treatment to prevent urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Policy and Procedure (P&P) to post actual nursing hours within two hours of the start of each shift. During a tour of the facility, the posted nursing hours for one of one sampled day (11/7/24) was not updated and did not reflect the current date. This deficient practice had the potential to inaccurately reflect the actual nursing staff providing direct care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of three sampled residents (Resident 301) who signed the Resident-Facility Arbitration Agreement (AA, a Binding Arbitration Agreement requires the person who signed it resolve any dispute by binding arbitration, rather than in court) on 10/31/2024, had the capacity to understand and make decisions. This failure had the potential risk to result in Resident 301 to not be able to make an informed decision and/or his rights to be denied.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Policy and Procedures (P&P) titled Isolation - Categories of Transmission - Based Precautions for one of five sampled resident (Resident 89) when Licensed Vocational Nurse 1 (LVN 1) did not wear the required personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection) while administering medication to Resident 89 inside a Contact (precautions used for infections, diseases, or germs that are spread by touching the patient or items in the room) Precaution room. This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a call light device (a means of communication for patients to their care providers that are outside of the patient's room) was functioning for one of one sampled resident (Resident 17). This failure had the potential to result in the delay of the provision of needed care and services to Resident 17.

Inspectors wroteBased on interview and record review, the facility failed to include in its written Policy and Procedure (P&P) titled Abuse Prevention specific information and guideline on how the facility staff would identify, intervene, and manage resident's property including handling of resident's money for one of four sampled residents (Resident 1). This deficiency violated Resident 1's right. Certified Nursing Assistant 1 (CNA 1) and Activity Aide 1 (AA 1) received and encashed multiple personal check from Resident 1. This violation placed Resident 1 at risk for financial abuse (withholding, stealing, or restricting money).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Fingernails/Toenails, Care of, for one of nine sampled residents (Resident 4) and failed to follow Resident 4's untitled care plan by failing to: Ensure assigned Licensed Vocational Nurses (LVNs) notified the Social Services Director (SSD) that Resident 4 needed to be referred and seen by a podiatrist (medical doctor who help with problems that effect the lower legs and feet) for cleaning and trimming of Resident 4's long and overgrown toenails. This failure had the potential to cause injuries and infection to Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision according to the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, for one of nine sampled residents (Resident 1) by failing to: Ensure Licensed Vocational Nurse (LVN) 1 and LVN 2 obtained an order for a sitter (one-to-one supervision) after Resident 1 sustained a fall (move downward, typically rapidly and freely without control, from a higher to a lower level), was assessed to be confused, and needed a sitter on 8/15/2024. This failure placed Resident 1 at risk for further falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 7 reassessed the pain level of one of nine sampled residents (Resident 4) after 30 minutes to one hour of receiving acetaminophen (pain medication used to relieve mild or chronic pain and to reduce fever) for complaint of mild pain on 8/16/2024 at 9:44 am as indicated in the facility's policy and procedure (P&P) titled, Pain- Clinical Protocol. This deficient practice resulted in unrelieved pain for Resident 4 and placed Resident 4 at risk for psychosocial (mental, emotional, social, and spiritual effects) harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled certified nursing assistants (CNA 1) had an active CNA certification to perform resident care while employed at the facility. This deficient practice had the potential for a knowledge, training, and certification deficit for CNA 1 which could lead to inadequate and unsafe resident care.

Inspectors wroteBased on interview and record review, the facility failed to notify one of two sampled residents (Resident 1) and the resident's responsible party (RP 1) prior to room/bed change in accordance with the facility's policy and procedure (P&P) titled, Room Change/Roommate Assignment. This deficient practice had the potential to violate Resident 1 and RP's rights and affect Resident 1's sense of self-worth and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) received care and the necessary services to prevent pressure ulcers (localized damage to the skin usually over a bony prominence) and promote healing by failing to: 1. Ensure licensed nurses set Resident 3's low air loss (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) mattress settings accurately based on comfort or Resident 3's weight. 2. Ensure nursing staff turned and repositioned Resident 3 every two hours as indicated in Resident 3's plan of care. 3. Ensure nursing staff provided timely incontinent care to Resident 3 after a bowel movement. These deficient practices had the potential to lead to further skin breakdown, worsening and/or delayed wound healing for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with dignity and respect for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 not being respected in a manner to maintain dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the meals provided to one of four sampled residents (Resident 1) was in accordance with the resident's meal tray ticket (menu based on the resident's diet order, standing orders and food preferences) for one of four sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to not receive adequate nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide needed care and services in accordance with the physician's order and facility's policy and procedure for three of three sampled residents (Residents 35, Resident 305 and Resident 60) by failing to; a. Provide nectar thickened liquid in accordance to the physician's order for Residents 35 and 305. b. Provide Resident 60 an arm sling (device to support an injured upper arm, forearm, and wrist) for the left shoulder as ordered by the physician.

Inspectors wroteDuring an observation, interview, and record review the facility failed to ensure food delivered to the residents were within recommended temperature range as indicated in the facility's policy for Meal Service for three of seven sampled residents who attended the resident council meeting (Residents 44, 59 and 66). This deficient practice had the potential to affect the resident's appetite to eat.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow it's Policy and Procedure on storing, preparing, distributing and serving food in accordance with professional standards for food service safety, proper sanitation and food handling practices by failing to ensure: a. Stored food items were dated when it was first opened, in one of two kitchen freezers. b. One box of potatoes was not placed directly on the floor in one of one dry storage area. c. One of one facility staff (Housekeeping 1 [HKP 1]) performed hand hygiene before entering the kitchen and not place personal item on top of the food preparation area. These deficient practices had the potential for residents to be at risk for food borne illnesses (infections caused by ingesting contaminated food or beverages)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and sanitary environment to help prevent the development and transmission of communicable diseases (one that is spread from one person to another through contact with blood and bodily fluids, or breathing in an airborne virus) for four of five sampled residents ( Residents 23, 38, 77 and 155), by failing to: a. Ensure Resident 155's peripheral IV site (a site where a thin, flexible tube was inserted through the skin into a small vein in the periphery such as the hand, elbow, or foot) was labeled to indicate the date of insertion. b. Ensure Resident 38's unused and unlabeled nasal cannula with nasal prongs did not touch the back of the resident's wheelchair. c. Ensure Resident 23's unused breathing treatment tubing was not hanging inside the trash bin. d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's suprapubic catheter (a hollow, flexible tube that is used to drain urine from the bladder through a cut in the abdomen) was secured and the nephrostomy (a tube that drains urine from the kidney through an opening in the skin on the back) tube bag was covered with a privacy bag for one of six sampled residents. This deficient practice resulted in the violation of Resident 1's privacy and had the potential to affect Resident 1's self-esteem, self-worth, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for one of one sampled resident (Resident 38) who was at risk for fall, by failing to ensure the resident's call light was within reach as indicated in the facility's Policy and Procedure, titled Answering the Cal Light and resident's Care Plan titled Risk for Falls and/or Injuries. This deficient practice had the potential for Resident 38 not to receive or received delayed care to meet the necessary services that could result in falls and accidents.

Inspectors wroteBased on interview and record review for two of four sampled residents (Residents 69 and 65), the facility failed to: a. Provide information on advance care planning (a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) to Resident 69. b. Ensure Resident 65's AD (AD, a written instruction, such as a living will or durable power of attorney for health care relating to the provision of health care when the individual is incapacitated) was in Resident 65's medical record. These deficient practices had the potential to result in failure to provide treatment and services in accordance with the resident's will.

Inspectors wroteBased on interview and record review, the facility staff failed to notify the attending physician of a change of condition for one of one sampled resident (Resident 104). This deficient practice resulted in Resident 104 not getting the treatment and services needed in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 102)'s Minimum Data Set (MDS, a resident assessment and care-screening tool) dated 9/2/2023 accurately assessed to reflect the resident's discharge destination. Resident 102, who was discharged home, was coded in the MDS assessment as discharged to a general acute care hospital. This deficient practice resulted to inaccurate reporting to the Centers for Medicare & Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential to result in Resident 102 not to receive interventions to address specific care concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 19) wore hearing aid (device used to increase the volume of a sound) as ordered by the physician. This deficient practice had the potential to result in Resident 19's decline or loss of the ability to communicate with others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure chair alarm was connected to the chair pad and the chair alarm was turned on in accordance to the physician's order, for one of five sampled residents (Resident 19). This deficient practice had the potential for accidents for Resident 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen therapy (treatment that provides supplemental, or extra, oxygen) in accordance with accepted standards of clinical practice and with the facility's Policy and Procedure on Oxygen Administration, for two of five sampled residents (Resident 13 and 23). These deficient practices placed Residents 13 and 23 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which can lead into serious complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe administering a medication, Mesalamine (a drug that treats symptoms of ulcerative colitis [an inflammatory bowel disease]) Delayed Release (DR, a drug which should not be crushed, that do not immediately release the active ingredients into the body) by crushing the medication, for one of four sampled residents (Resident 307). This deficient practice had the potential to result in the drug being released too early, destroyed by stomach acid, or irritating the stomach lining, and causing harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one opened bottle of Firvanq (Vancomycin Hydrochloride - antibiotic used to treat bacterial infections) 50 milligrams per milliliter (mg/ml, a unit of measurement) 150 ml solution was labeled with the date opened as indicated in the facility policy on Medications Requiring Notation of Date Opened, for one of one medication refrigerator inspected. This deficient practice had the potential to result in the loss of efficacy and unsafe storage of the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure meal was provided according to resident's meal ticket (a slip of paper on the meal tray with detailed food information) for one of six sampled residents (Resident 14). This deficient practice had the potential to affect the resident's dietary intake which may cause inadequate nutrition for Resident 14.

Inspectors wroteBased on interview and record review, the facility failed to designate a member of the facility's Interdisciplinary Team (IDT- a group of health care professionals who work together toward the goals of their patients) who was responsible for working with Hospice (a program designed to provide comfort care and emotional support to the terminally ill) representatives to coordinate care to the resident for one of one sampled resident (Resident 77). This deficient practice had the potential to affect Resident 77's quality of life during Hospice Care.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standard infection control practices during a Coronavirus (COVID 19, a mild to severe respiratory illness that spread from person to person) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) in accordance with the Department of Public Health's (DPH) guidelines and the facility's policy and procedures (P&P) by failing to: 1. Ensure Resident 1 who was exposed to Resident 2 with confirmed positive for COVID 19 wore facemask during group activities . 2. Ensure Housekeeping 1 (HKP 1) kept and monitored the log for cleaning and disinfecting of high touch areas (surfaces that are frequently touched) in the facility's red zone (an area dedicated for residents who are Corona Virus 19 positive). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Interdisciplinary Team (IDT- a coordinated group of experts from several different fields who work together) was involved in developing a discharge plan that reflected the resident's discharge needs, goals, and treatment preferences) as indicated on the facility's policy and procedure, titled Discharge Summary and Plan, for one of one sampled residents (Resident 5). This failure had the potential to result in incomplete or ineffective discharge planning and could have led to lack of necessary care for Resident 5 after discharge.