Golden Modesto Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff to meet resident needs when medications were given over 60 minutes late to seven out of seven sampled residents (Residents 1-7). This failure had the potential to result in sub therapeutic serum levels (medication levels dropping below the minimum needed to work), microbial resistance (bacteria becoming resistant to antibiotics), sudden metabolic or physiological instability (vital signs or blood chemistry becoming dangerously unbalanced), and complications with medications that have a narrow therapeutic range (where even small delays can make the dose ineffective or dangerous) leading to longer hospital stays, irreversible organ damage, or death. During a concurrent interview and observation on 6/24/26 at 11:22 am with Licensed Vocational Nurse (LVN) 1, LVN 1 was charting at the nurse's station. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from significant medication errors according to their policy and procedure titled, Medication Administration for two of three residents (Resident 2, Resident 4) when on 6/11/26 Licensed Vocational Nurse (LVN) 1 did not administer scheduled medication Insulin (used to manage blood sugar by lowering the glucose) for diabetes mellitus (disorder that causes high blood sugar levels and body cannot produce or use insulin) as ordered by the physician. This failure had the potential for delayed medication effects, causing adverse reactions such as high or low blood sugar, dizziness, increased thirst, shakiness and medication ineffectiveness.

Inspectors wroteBased on interview and record review the facility failed to ensure therapeutic diets were followed according to physician orders for one of five sampled residents (Resident 1) when on 6/11/26, the facility staff served Resident 1 a meal tray with a regular consistency (diet with no alterations) and Resident 1 had a physician diet order for soft and bite sized textured meals. This failure resulted in Resident 1 experiencing episode of inability to chew his food and had the potential to cause malnutrition, choking, aspiration and death.

Inspectors wroteBased on interview and record review the facility failed to follow and document recommended dietary changes according to professional standards of practice and the facility's policy and procedure titled Diet Change, for one of three sampled residents (Resident 1) when the facility nursing staff did not notify the physician of speech therapy recommendations to change Resident 1's diet order 0n 12/6/25. This failure placed Resident 1 at risk for inadequate food consumption, choking, coughing and inability to swallow food.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from significant med errors according to its policy and procedure titled Medication Administration for nine of 10 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9) when on 12/26/25 Registered Nurse (RN) 1 did not administer scheduled medications as ordered by the physician. This failure had the potential for delayed medication effects, cause adverse reactions, medication ineffectiveness and placed Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8 and Resident 9 at increased risk for life and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for one of five sampled residents (Resident 1), when Resident 1 had one documented weight on 6/6/25 since being admitted to the facility on [DATE]. Staff did not complete a weight on admission and weekly as ordered by the physician, Resident 1 was not consuming meals to its entirety or refused meals, the facility was aware of Resident 1's refusal to be weighed and the Restorative Nursing Assistant (RNA) did not follow up with the licensed nurses. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents' rights to be treated with respect and dignity were followed for one of seven sampled residents (Resident 7), when Resident 7 did not receive scheduled showers on 7/18/25, 7/25/25, and 7/29/25 while in the facility. This failure placed Resident 7 at risk for an undignified existence that could have resulted in poor hygiene and cleanliness. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan (included initial goals based on admission orders, physician orders, summary of residents medication, services and treatments to be administered by the facility, and conditions and risks affecting the residents health and safety) within 48 hours of residents admission according to the facility's policy and procedure (P&P) titled, Baseline Care Plan, for one of seven sampled residents (Resident 7) when Resident 7 did not have a baseline care plan for diagnosis and treatment for Chronic Kidney failure (a condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), heart failure (condition where the heart muscle cannot pump blood effectively enough to meet the body's needs) and hypertension (condition characterized by persistently [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents' rights to access and obtain medical records was honored for one of four sampled residents (Resident 1), when Resident 1' s representative requested medical records on 1/8/25 and the facility did not provided records within 30-60 days according to their policy and procedure (P&P). This failure resulted in Resident 1's representative not being provided medical records needed and not respecting Resident 1's right to access and obtain medical records.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from accidents for one of five sampled residents (Resident 1) when on 2/20/25, Resident 1 was served a meal tray with a regular consistency (diet with no alterations) and was ordered a full liquid diet with nectar thick consistency. This failure resulted in Resident 1 experiencing episode of coughing and emesis (vomit) and had the potential to cause choking, aspiration and death.

Inspectors wroteBased on interview and record review the facility failed to ensure therapeutic diets were followed according to physician orders for one of five sampled residents (Resident 1) when on 2/20/25, Resident 1 was served a meal tray with a regular consistency (diet with no alterations) and had physician orders for a full liquid diet with nectar thick consistency (liquid slightly thicker than water). This failure resulted in Resident 1 experiencing an episode of coughing and emesis (vomit) and had the potential to cause choking, aspiration, and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of three residents, (Resident 1), when Resident 1 was admitted on [DATE] with history of abnormalities of gait and mobility, assessed with severe cognitive impairment and the need for assistance with mobility, and experienced falls on 11/7/24, 11/8/24, 11/11/24, 11/14/24 and 11/15/24 and did not provide supervision and effective interventions to prevent falls in accordance with policies and procedures and professional standards of practice. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of significant medication error for one of four sampled residents (Resident 1), when Resident 1 was administered the Insulin (a hormone that helps regulate blood sugar level) without a physician order and diagnosis. This failure had the potential to result in Resident 1 experiencing a hypoglycemic event (occurs when the body ' s sugar levels drop too low) causing trembling or shaking, weakness, sweating or chills, dizziness or lightheadedness, confusion or trouble concentrating, irritability, tingling or numbness of the lips, tongue or cheeks and had the potential to result in death.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure residents were free from abuse and neglect for one of three sampled residents (Resident 2) when Resident 2 did not receive assistance to go to the restroom and was told by CNA 1 to soil herself while in bed. This failure resulted in Resident 2 feeling humiliated and neglected by CNA 1 when Resident 2 held her urine until her stomach was in pain and urinated on herself.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received adequate supervision to prevent accidents according to the facility' s policy and procedure (P&P) for one of three sampled residents (Resident 1), when the facility had knowledge of Resident 1' s history of falls and Parkinson's disease (brain disorder that causes uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) on admission and did not provide interventions and supervision to prevent an unwitnessed fall with injury on [DATE] and an unwitnessed fall with injury on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to follow facility's policies and procedures and meet professional standards of quality for one of three sampled Residents (Resident 1), when staff did not document Resident 1's change of condition and post fall assessment for unwitnessed fall with injury on 9/26/24. This failure had the potential to result in the inaccurate assessment of Resident 1 and had the potential for falls and delay in care.

Inspectors wrote2. An admission Record indicated the facility admitted Resident #22 on 04/28/2021. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/20/2024, revealed Resident #22 had severe impairment in cognitive skills for daily decision making and had short-term and long-term memory problems per a staff assessment of mental status (SAMS). Resident #22's care plan included a focus area revised on 08/01/2024 that indicated the resident had the potential for impairment in skin integrity. Resident #22's Order Summary Report, with active orders as of 09/18/2024, contained an order dated 08/24/2024 for betadine-soaked gauze and dry gauze over the left big toe daily until resolved. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to submit a status change to a Level I Pre-admission Screening and Resident Review (PASARR) following a new mental health diagnosis for 1 (Resident #62) of 3 residents reviewed for PASARR. Specifically, Resident #62 had a positive Level I PASARR and was later diagnosed with a new mental health disorder and the facility failed to submit a status change to the resident's Level 1 PASARR evaluation.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a Level I Pre-admission Screening and Resident Review (PASARR) was complete and accurate for 2 (Resident #62 and Resident #12) of 3 residents reviewed for PASARR. Specifically, Resident #62 and Resident #12 had a Level I PASARR completed that did not capture all their mental health diagnoses.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to follow pharmacy recommendations for 1 (Resident #19) of 5 residents reviewed for unnecessary medications. Specifically, the facility failed to respond to May and June 2024 pharmacy recommendations for an AIMS (abnormal involuntary movement scale) assessment for Resident #19.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate less than 5 percent (%). There were 2 errors out of 32 opportunities, which resulted in a 6.25% medication error rate for 2 (Resident #5 and Resident #86) of 4 residents observed for medication administration.

Inspectors wroteBased on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure 1 (Resident #86) of 4 residents observed for medication administration was free from a significant medication error and failed to follow vital sign parameters when administering medications for 1 (Resident #62) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision and services for the prevention of accidents for two of five sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 were both admitted with diagnoses that included dysphagia (difficulty swallowing or chewing) and were not evaluated or treated in accordance with professional standards of practice and the comprehensive care plan. Speech Therapy was not consulted, swallow evaluations (to determine the presence and severity of dysphagia as well as to determine the need for further testing) not conducted, meals were not supervised, modified meals to prevent the risk of choking and risk of aspiration (sucking food into the airway) were not served. These failures resulted in the risk of choking and aspiration for both Residents 1 and 2; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was written and implemented within 48 hours for 1 of 3 sampled residents (Resident 9) when Resident 9 was admitted to the facility with a broken left hip on 12/16/23 with no documented care plan for Resident 9 ' s broken left hip. This failure had the potential for Resident 9 to have unmet care needs for her broken left hip.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services which meet professional standards of quality for one of three sampled residents (Resident 1) when the facility did not provide Resident 1 ' s Metformin (medication used to control blood sugar) for 17 days. This failure placed Resident 1 at risk for a hyperglycemic (too much sugar in the blood) event which could lead to serious medical conditions including kidney damage, vision loss, nerve problems, loss of limbs, coma, and possibly death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal privacy and confidentiality rights was honored for one of three sampled resident (Resident 2) when CNA 1 used her personal phone on video, while providing bathing care and turned her phone to show Resident 1 ' s face during a bed bath. This failure resulted in the violation of the Resident 1 ' s right to privacy and confidentiality.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure safe and orderly discharge from the facility for one of five sampled residents (Resident 1) when Resident 1 was discharged home with no discharge orders, no discharge summary, no home health referral set up, no Durable Medical Equipment (DME) and no medications were sent home with Resident 1. This failure had the potential to cause health complications for Resident 1 from the lack of equipment, follow up care and experience difficulties in managing their condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality for one of five sampled residents (Resident 2) when One of the medication for Resident 2 was left un-attended on top of a medication cart. This failure had the potential for Resident 2's medication being stolen or taken by another resident who may take it accidentally leading to harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of four residents (Resident 1, 2, 3, and 4) received therapeutic diets when Resident 1, 2, 3, and 4's diets were altered without consulting with the prescribing physician or registered dietitian (RD). This failure was not the standard of practice according to the facility's policy and procedure (P&P), titled Therapeutic Diets and had the potential to negatively affect the nutritional health of Resident 1, 2, 3, and 4.

Inspectors wroteBased on observation, interview and record review the facility failed to provide services inside and outside the facility for one of three sampled residents (Resident 2) when multiple physician ' s orders for Resident 2 were not completed. This failure caused Resident 2 to feel frustrated and helpless and not receive services per physician ' s orders.

Inspectors wroteBased on observation, interview and record review the facility failed to keep residents safe from verbal abuse for one of three sampled residents (Resident 1), when Resident 1 was placed in a room with Resident 3 who was a known verbal abuser of staff and residents. This failure placed Resident 1 and any other residents that would be placed with Resident 3 in the future at risk of verbal abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow Policy and Procedure and provide adequate training for Misappropriation of Resident Property for one of three sampled residents (Resident 1), when Certified Nursing Assistant (CNA) 1 did not report suspected misappropriation of resident property and agreed to be a witness in the signing of legal documents while Resident 1 was sedated and unable to consent to changes to her financial assets on [DATE]. This failure had potential for Resident 1's financial assets to go unprotected.

Inspectors wrote3. During a review of the clinical record for Resident 101, the Nursing Progress Note dated [DATE], at 3:14 p.m., indicated, Around [1:45p.m.] was notified by CNA that Resident [101] had fell out of his wheelchair in the hallway while being taken to his dialysis [appointment]. When went to assess, saw Resident [101] laying [sic] face down in the hallway wheelchair. Upon assessment noted Resident [101] bleeding from a laceration [A torn or jagged wound] to left forehead. Pressure to forehead applied. Resident awake but was not responding to writer. When asked what happened, transportation driver [TD] stated, He leaned forward and fell, I tried to grab him from his sweater but couldn't. The record indicated Resident 101 was sent to the hospital emergency room (ER) for evaluation and treatment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision and assistive devices were provided to prevent accidents for three of nine sampled residents (Residents 46, 29, and 101) when: 1. Resident 46 who was assessed with impaired cognitive function, poor safety awareness, impulsivity, impaired balance, and unsteady gait was not provided with two-person assistance with transfers, extensive assistance of one staff with toileting, and limited assistance of one person with ambulation and had a total of 24 falls between 1/3/18 and 5/13/19. The facility staff did not ensure adequate supervision was maintained to prevent ongoing falls. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management measures were maintained and implemented for one of three sampled residents (Resident 454) when Resident 454 yelled and moaned in pain and staff did not respond when he was calling for help; pain medication was not available upon his admission. This failure resulted in Resident 454 experiencing pain and suffering for prolonged periods of time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven residents (Resident 960) did not develop pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) when preventive measures were not put into place when Resident 960 was assessed as a high risk for developing pressure ulcers and he was not turned and repositioned for more than two hours. Resident 960 was not provided a pressure relief cushion and ongoing skin assessments were not conducted. These failures resulted in Resident 960 developing a preventable Stage 2 (partial-thickness skin loss into but no deeper than the dermis) pressure ulcer to the coccyx (tailbone) area.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the resident transfer and discharge notification to a representative of the Office of the State Long-Term Care Ombudsman (an official appointed to represent the elderly and frail's rights under public authorities) for 10 of 10 sampled residents (Residents 463, 53, 357, 72, 16, 8, 62, 87, 34, and 506). These failures had the potential to result in inappropriate resident transfer and discharge practices for Residents 463, 53, 357, 72, 16, 8, 62, 87, 34, and 506.

Inspectors wroteBased on interview and record review, the facility failed to ensure the food services staff had appropriate competencies for food safety and to effectively carry out the functions of food services when [NAME] 1, [NAME] 2, and dietary aide (DA)1 were unable to verbalize the cool down food process (a safe way to cool down food safely). This failure had the potential for untrained staff to place residents at risk for exposure to foodborne illness (food poisoning).

Inspectors wroteBased on interview and record review, the facility failed to have an effective Quality Assessment and Performance Improvement (QAPI- a program that enables the facility to evaluate and improve the quality of Resident care and services through data collection, staff input, and other information) program when care planning issues were not identified with appropriate plans of actions developed to correct the identified deficient practice (cross reference F 656). This failure resulted in an ineffective QAPI program necessary to improve implementation of individualized resident centered care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen equipment was safely maintained when excess ice build-up was found inside the walk-in freezer. This failure had the potential to impact the ability of dietary staff to prepare, store, and serve food in a safe and sanitary manner for all resident, staff and visitors who were served meals from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, and sanitary environment in the kitchen when staff left the floor near the dishwasher area saturated with water. This failure had potential to create an unsanitary, and unsafe environment for, residents who receive meals from the kitchen, dietary staff and interfere with food services to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- evaluation of memory recall, mood and functional abilities) assessment accurately reflected the resident's current hearing status for one of five sampled residents (Resident 26) when Resident 26's hearing loss was not accurately documented on the MDS assessment. This failure resulted in Resident 26's hearing needs going unmet.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receiving hemodialysis (medical procedure of removing waste products and excess fluid from the blood through an artificial kidney) treatment received care consistent with professional standards for one of two sampled residents (Resident 53) when licensed nurses did not monitor Resident 53's arteriovenous fistula (AV- is a catheter inserted into the artery and vein to provide dialysis treatment) site in the left upper arm for bruit (a sound heard through a stethoscope generated by turbulent flow of blood in an artery indicating patency) and thrill (vascular thrill) every shift. This failure had the potential to result in Resident 53's AV fistula to clog and malfunction and placed Resident 53 at risk of delay in his dialysis treatment in the event his AV fistula could not be accessed for patency.

Inspectors wroteBased on interview and record review, the facility failed to ensure dietary staff followed their food thermometer (instrument for measuring and indicating temperature) calibration (check or standardize a measuring instrument) policy and procedure when the kitchen staff did not document the food thermometer temperature calibrations. This failure had the potential to result in inaccurate food temperature and potentially result in food borne illness (food poisoning) for all residents, staff and visitors who were served meals from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to identify discharge needs and develop a discharge care plan for one of 31 sampled residents, (Resident 565) when Resident 565 was discharged to a board and care home without ensuring the board and care home was capable of meeting Resident 565's needs. The facility Interdisciplinary Team (IDT, a team of healthcare providers who meet to plan resident care) did not meet to evaluate Resident 565's need for a safe discharge. Resident 565 was discharged to the board and care home which could not provide Resident 565 with required assistance for bathing and grooming. Resident 565 was transferred without adequate discharge planning, discharge teaching or emotional preparation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Registered Dietitian (RD) provided frequently scheduled consultations to the Dietary Supervisor when a lapse in the delivery of food services associated with diet provision (Cross Reference F800), following of menus (Cross Reference F803), meal temperatures (Cross Reference F804), accommodating resident allergies (Cross reference F806) and food safety (Cross Reference F812 and F925)occurred. This failure to ensure food and nutrition services systems are accurately and effectively delivered have the potential to result in compromising the nutritional status of residents through the potential transmission of foodborne illness, incorrect plating of physician ordered diets, and/or decreased nutritional intake due to residents' poor acceptance of meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their policy regarding food brought by family and visitors when: 1. Residents, family, and visitors were not provided a copy of the facility policy on food brought by Family/Visitors. 2. Staff was not aware that there was a policy and was not trained in safe food handling practices. This failure resulted in the residents, family, and visitors not being aware of the facility's policy and staff not aware of the process of handling resident's food from home safely which had the potential to result in foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect consistent with enhancing each resident's quality of life for two of 31 sampled residents (Residents 20 and 417) and four random residents (Residents 122, 11, 85 and 53) when: 1. On 5/16/18 staff dressed a cognitively impaired resident, Resident 20, in mismatched colored shoelaces on her shoes against the facility policy to care for vulnerable and cognitively impaired residents with dignity and respect. 2. Staff did not respond in a timely manner to Resident 417's request for assistance to the bathroom and as a consequence urinated in the bed. Resident 417 expressed extreme frustration and felt disrespected because of this occurrence. 3. Staff did not address Resident 122's need for assistance with her breakfast tray and did not remove the plastic wrapping. [...]

Inspectors wroteBased on interview, and record review, the facility failed to make prompt efforts to resolve the residents grievances and to keep the residents informed of progress towards a resolution through the facility designated Grievance Officer for six of 15 random residents(Resident 14, Resident 31, Resident 55, Resident 79, Resident 81 and Resident 86) and two of 31 sampled residents (Resident 29 and Resident 77) when resident Council members complained regarding the facility food, soup was cold, food coming out cold to the social dining room, and hot food not being served hot enough. For Resident 14, Resident 29, Resident 31, Resident 55, Resident 77, Resident 79, Resident 81 and Resident 86, these failures placed the residents at risk of not having their grievances resolved that could of improved the residents' quality of life and services received from the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an orderly environment for four of 52 bedrooms (Rooms 42, 43, 44 and 45) when: 1. room [ROOM NUMBER]'s bedroom trash can was without a liner. 2. Peri Wipes laid on top of the bedside table and the residents bed in Rooms 42, 43, 44 and 45. These failures resulted in a disorderly and un-homelike environment for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four of 31 sampled residents (Resident 29, Resident 89, Resident 42 and Resident 71) and one of 15 random residents (Resident 4) were free from physical restraints when: 1. Resident 29, Resident 89, Resident 42, Resident 71, and Resident 4 had a position change alarm (wheelchair alarm) (alerting devices intended to monitor a resident's movement that emits an audible loud sound when the resident moves) in place without a physician's order, no medical justification, no consent was obtained from the resident or resident's responsible party and no assessment or evaluation was done to determine the need for the wheelchair alarm. These failures resulted in: 1. Resident 29 felt angry when the position change alarm [wheelchair alarm] emitted a loud audible sound every time she moved which restricted her movement. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person centered care plan for two of 31 sampled residents (Resident 33 and Resident 89) when: 1. Resident 33 did not have an individualized activities care plan to identify listening to music as his activity preference. 2. Resident 89's wheelchair alarm was not identified in the care plan. These failures placed Resident 33 at risk of inappropriate activities resulting in possible decreased psychosocial well being and Resident 89's care needs to not be met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely revise and implement a person centered comprehensive care plan for two of 31 sampled residents (Resident 71 and Resident 72) when: 1. Resident 72's enteral nutrition (nutrition provided through a feeding tube into the stomach) care plan interventions indicating the feeding times did not match the physician's order. 2. Resident 71 sustained a fall and no new interventions were documented in the care plan. These failures had the potential to result in Resident 72 to receive inaccurate doses of his enteral nutrition and for Resident 71 to sustain reoccurring falls and at risk for not having her care needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services which met professional standards of quality when Licensed Nurse (LN) 13 did not follow the facility's Administering Medications policy and procedure, when LN 13 stored the medication inside the medication cart after Resident 77 refused the medications and documented in the medication administration record that Resident 77 took the medications. This failure had the potential to result in medications being administered to the wrong resident and the medications not being administered in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper hydration for two of 31 sampled residents (Resident 16 and Resident 29) when: 1. Resident 29 did not have a water pitcher at her bedside table. 2. Resident 16's water pitcher was not within reach. Resident 29 did not have a water pitcher at her bedside table. These failures placed residents at risk of not having sufficient fluid intake to maintain proper hydration and placed Resident 29 and Resident 16 at risk of dehydration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menus were followed when the pork loin was cooked for four hours instead of the indicated [NAME] Time of - 1-1 ½ Hrs (hours) and incorrect portion size was served. These failures had the potential for residents to receive inadequate protein and nutrients in their meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food is palatable and served at an appetizing temperature when residents complained of food being bland and being served cold. This failure had the potential to result in residents not eating their food which could compromise their nutritional status and result in weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the food allergies for one of 31 sampled residents (Resident 417) when Resident 417 was allergic to tangerines and was served tangerines on her meal tray. This failure had the potential to result in an allergic reaction and negative outcome to Resident 417.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare and serve food safely when: 1. Half a tray of bread got contaminated by a drain fly. 2. There was a 15 day old opened bag of spinach in the walk-in refrigerator. 3. One (8 pounds) and a half of turkey breast was found submerged in a basin of water. 4. Unlabeled sandwiches were laying on two food prep (preparation) tables. 5. Three frozen boxes of dough had the wrong dates (date received) on them. These failures had the potential to result in unsafe food storage and handling practices that could lead to negative outcomes to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility infection control practices were followed and implemented when: 1. Licensed Nurse (LN)1 did not perform handwashing after resident direct contact. 2. Certified Nursing Assistant (CNA) 5 did not perform proper hand hygiene before, in between, and after resident care and failed to follow transmission-based precaution when handling a resident with a diagnosis of MRSA (Methicillin-resistant staphylococcus aureus) and after disposal of soiled linens for sampled residents (Resident 16 and 56), and one of 15 random residents (Resident 87). 3. Two of 31 sampled residents (Resident 34 and Resident 45) oxygen tubing was not properly stored after use. 4. Resident 121's oxygen tubing was laying on the floor. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were within reach for three of 31 sampled residents (Resident 76, Resident 29 and Resident 420) when: 1. Resident 420's call light lay on the floor and was out of reach. 2. Resident 76's call light lay on top of the bed while resident was sitting on her wheelchair and was out of reach. 3. Resident 29's call light lay on top of the bed while resident was sitting on her wheelchair and was out of reach. These failures resulted in the potential harm of Resident 122, Resident 76 and Resident 29 to not be able to call for assistance by using the call light in the event of need or in an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment free of pest when drain flies were seen flying in the kitchen and landed on a tray of bread. This failure had the potential to result in foodborne illness to the residents from drain flies contaminating the food.

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident's change of condition (COC), transfer to the hospital and death was immediately informed to the attending physician for 1 of 31 sampled resident (Resident 115). When Resident 115 was seen at 2 a.m. in his wheelchair, unresponsive, no palpable pulse and not breathing. This failure resulted in Resident 115's physician not being fully informed of his resident's medication condition.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to ensure the facility did not violate the right of the resident to personal privacy of his physical body and during the provision of his personal care for 1 of 10 random sampled residents (Resident 64) when: 1. Certified Nurse Assistant ( CNA) 5 exposed Resident 64's uncovered body in the hallway after his shower and dressing resident in front of the staff, residents passing by and a visitor watching. For Resident 64 , the facility failed to respect the resident's right to privacy during the provision of care and services which had resulted in the violation of the resident's right to be cared for in a manner and in an environment that honors the resident's privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's status for one of 31 sampled residents (Resident 89) when the use of a wheelchair alarm was not coded in Section P (section for alarms and restraint use) of Resident 89's admission and quarterly assessment. This failure resulted in an inaccurate assessment of Resident 89's MDS assessment and had the potential to result in Resident 89's care needs to not be met.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that the resident's Discharge Summary was documented by the attending physician and included in the resident's clinical record after the resident's death for one of 15 sampled residents (Resident 115). The facility failed to provide a recapitulation of Resident 115's stay at the facility and a final summary of Resident 115's status at the time of the discharge in the closed record which had the potential to result in the inavailability of the Discharge Summary information.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and assistance to maintain continency of urine to one of 31 sampled residents (Resident 417) when there was no staff available timely to assist Resident 417 to use the restroom. This failure resulted to Resident 417 urinating in bed two times in one day. Findngs: On 5/15/18 at 11:32 a.m., during an interview, Resident 417 stated, I came in on Friday . and I think it was Sunday night . I kept pushing my buzzer [call light] and no one came to my room . I had to pee in my bed, it is very upsetting . I am an independent person, I got so frustrated I wanted to scream. Resident 417's husband stated, I came in Monday the 14th and she told me she had to pee in bed because no one can answer the call light to take her to the bathroom and it all happened in the same night . [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff supported the nutritional well-being for one of 31 sampled residents (Resident 417) when the admitting staff did not fill out and submit a Diet Requisition (meal ticket) for Resident 417. This failure resulted in (Resident 417) not receiving meal trays for five (5) meals which had the potential to compromise her nutritional status and result in weight loss.

Inspectors wroteBased on interview and record review, the facility failed to accurately document the physician order for life-sustaining treatment (POLST, a medical order for the specific medical treatments for a resident during a medical emergency form) in the medical records for one of 31 sampled residents (Resident 56). This failure had the potential risk for Resident 56's life-sustaining orders not being followed.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the results of the most recent abbreviated survey document titled, Statement of Deficiencies in a place readily accessible to residents and their representatives. This failure had the potential to violate the rights of the residents and their representatives to be informed of abbreviated survey deficiencies and the facility's plan of correction.