Golden Rose Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision, conduct a wandering and elopement risk assessment, and to develop and implement an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) for one (1) of three (3) sampled residents (Residents 1) at risk for elopement (a form of unsupervised wandering that leads to the resident leaving the facility) as indicated on the facility's policy and procedure (P&P). These deficient practices resulted in Resident 1 eloping from the facility on 7/17/2026 at 8 PM to 7/18/2026 at 8 AM (12 hours) which posed a significant risk to Resident 1's safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote healing, and prevent development and worsening of pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for two (2) of 2 sampled residents (Resident 19 and 71), reviewed for pressure ulcer and skin condition in accordance with the facility's policy and procedure by: Failing to ensure Resident 19's low air loss mattress (LAL - a specialized medical bed surface featuring inflatable air chambers with tiny, perforated holes with airflows to wick away moisture and regulate skin temperature for preventing and healing the skin and the underlying tissue damage) air pressure setting was set up according to the resident's body weight. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) services and care were provided as indicated on the physician's order and facility policy for two (2) of 2 sampled residents (Residents 9 and 70 ) reviewed for dialysis by failing to ensure:1. Resident received dialysis treatment on 5/7/2026, 6/9/2026, at 6/13/2026.2.a. Resident 70 received dialysis treatment on 6/13/2026 and 6/20/2026.2.b. Resident 70, who was on fluid restrictions, was not provided with a water pitcher at bedside. These deficient practices have the potential for Residents 9 and 70 to experience life threatening complications such as dangerous waste and fluid buildup, resulting to difficulty breathing, heart problems, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error (the observed or identified preparation or administration of medication or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) rate was less than five (5) percent (%). Two (2) medication errors out of 25 opportunities (observed administered medications) for error which yielded a facility medication error rate of 8 % for one (1) of 8 (eight) sampled residents (Resident 56) observed for medication administration (med pass). These deficient practices had the potential to result in harm to Resident 56 by not administering medications as prescribed by the physician in order to meet Resident 56's medication needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly stored as indicated on the facility's policy and procedure (P&P) by failing to ensure: 1. One (1) of four (4) medication carts (MC- med cart) were not left unattended and locked on 7/8/2026 and during medication administration on 7/9/2026. This deficient practice had the potential for unauthorized access to medications by staff and visitors which could lead to medication overdose (taking a toxic or poisonous amount of a drug or medicine), unauthorized use, adverse reactions (any unexpected or dangerous reactions to a drug), or harmful drug interactions (a reaction between two or more drugs or between a drug, and a food, beverage, or supplement). 2. To defrost (become free of accumulated ice) two of three medication refrigerators (Medication Refrigerators 1 and 2). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the dietary menu (a planned food program designed to meet the nutritional needs of residents) and ensure to use the correct measuring scooper (a food serving utensil used to measure even portions) on 7/9/2026 for the lunch meal servings of beans and brown rice provided to 32 of 78 residents. This failure resulted in inconsistent portion sizes and had the potential to cause the 32 affected residents to receive inadequate nutritional intake, placing them at risk for not meeting daily dietary requirements, which could lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the dietary staff failed to ensure food was served at an appetizing and proper temperature on 7/9/2026 during lunch as indicated on the facility Policy & Procedure (P&P). This deficient practice had the potential to result in rapid growth of bacteria that can cause foodborne illness (any illness resulting from eating contaminated/spoiled foods) and had the potential to result in insufficient meal intake and weight loss for 56 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling and food storage practices in accordance with the facility's policy and procedure (P&P) by failing to ensure: 1. Food was stored appropriately in the refrigerator and dry storage. 2. Dietary staff maintained sanitary measures during the preparation and serving of food during tray line. These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place 56 residents consuming food by mouth at risk for developing foodborne illness (caused by food contaminated with bacteria) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage practices in accordance with its policy and procedure (P&P) by failing to ensure one of one resident refrigerator temperature was 41 degrees Fahrenheit (F- a method of measuring temperature) or less. This deficient practice had the potential to result in food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide the necessary infection control measures and services for seven (7) of 7 sampled residents (Residents 56, 32, 88, 73, 82, 2 and 95) reviewed for infection control and oxygen use in accordance with the facility's policy and procedure (P&P) by failing to ensure:Licensed Vocational Nurse 4 (LVN) performed hand hygiene (the process of cleaning the hands to remove germs, dirt, and microorganisms by washing with soap and water or using an alcohol-based hand sanitizer [hand sanitizer]) after removing her soiled gloves during medication administration for Residents 56, 32, 88, and 73. Resident 82, 2, and 95's indwelling catheter (a tube inserted into the bladder to help drain urine) drainage bags (a bag used to collect urine from an indwelling catheter) and/or tubing were not touching the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy for one (1) of 1 sampled resident (Resident 1) reviewed for dignity by failing to keep the curtains drawn on 7/8/2026 while the resident was receiving care as indicated on the facility's policy. This deficient practice resulted in Resident 1 being visible to the other residents and visitors in the room, which had the potential for loss of dignity and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light (a handheld medical device that allows residents to easily contact staff for assistance) was within resident's reach for one (1) of two (2) sampled residents (Resident 2), reviewed for accommodation of needs, as indicated on the care plan and facility policy. This failure had the potential for Resident 2 to have unmet needs unmet and inadequate assistance, which could negatively affect the resident's care and overall wellbeing.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the Notice of Medicare Non-Coverage (a form issued by the facility to indicate Medicare-covered services are ending) for one of three sampled residents (Resident 87) reviewed for Beneficiary Notification was signed by the responsible party. This failure had the potential to result in Resident 87 not being able to exercise the right to file an appeal.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide privacy and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the Resident and/or the individual's surrogate or representative) for two (2) of 25 sampled residents (Resident 88 and 32) when Resident 88 and 32's electronic medical records were left exposed by leaving the computer on and unattended during medication administration on 7/9/2026. This deficient practice violated Resident 88 and 32's right to privacy and confidentiality.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the environment for one (1) of two (2) residents (Resident 56), in the environment task, was clean and free of dirt in accordance with the facility's policy and procedure (P&P) titled, Resident Rooms and Environment. This failure had the potential to negatively affect Resident 56's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 25) reviewed for restraints (any device, medication, or physical method used to restrict a patient's freedom of movement or access to their body) was free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body) in accordance with the facility's policy and procedure (P&P), titled Restraints. This deficient practice had the potential to result in limiting Resident 25's mobility and may cause injury. This also had the potential for Resident 25 not to be treated with respect and dignity with the use of restraints.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate assessment and documentation of the Minimum Data Set (MDS, a resident assessment tool) for three (3) of 25 sampled residents (Resident 13, 25 and 86) in accordance with the facility's policy and procedure (P&P) by failing to ensure the MDS reflected:Resident 13's weight of 103 pounds (lbs) on 3/5/2026 and 101 lbs on 6/5/2026. Resident 25 reflected the resident's active diagnosis of psychiatric/mood disorder (a mental health condition where your persistent emotional state, your mood, is severely disrupted). Resident 86's basal cell carcinoma (BCC- the most common type of skin cancer) skin lesions. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) to address one (1) of 1 resident (Resident 71) pressure ulcers/injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). This failure had the potential for Resident 71 to receive care that was not personalized to meet the specific needs for his pressure injuries, which could negatively affect his overall wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was updated and revised for one (1) of two (2) sampled resident (Resident 81), reviewed for urinary tract infections (UTI- a common bacterial infection occurring in any part of the urinary system which included the kidneys, bladder, uterus, and urethra), after Resident 81 was ordered Ceftriaxone (an antibiotic [a powerful, life-saving medication used to treat and prevent bacterial infections] used to treat severe bacterial infections) on 7/8/2026. This deficient practice had the potential to result in lack of interventions necessary to prevent worsening of UTI and had the potential to affect the provision of necessary care and services for Resident 81.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality for two (2) of two sampled residents (Resident 62 and Resident 33) by failing to:Complete a quarterly smoking assessment for Resident 62 as indicated in the facility's policy and procedure (P&P). Conduct an elopement (unauthorized departure-when a resident with cognitive impairment leaves a safe care facility without notifying staff ) and wandering (aimless or disoriented roaming) assessment for Resident 33 as indicated in the P&PThis deficient practice had the potential to result in Resident 62 and 33 not receiving the necessary interventions which could lead to accidents, elopement, and harm.

Inspectors wroteBased on observation and interview, the facility failed to provide oral care for one (1) of one (1) sampled residents (Residents 19) reviewed for activities of daily living (ADL, basic, routine tasks that individuals perform to maintain daily functioning) as indicated on the facility policy. Resident 19 was observed with white, crusted substance around the mouth on 7/7/2026 and 7/8/2026. This deficient practice had the potential to cause dry mouth, infection mouth soreness, discomfort, and reduction in Resident 19's overall quality of life. During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 86), in the general care area, received:Weekly skin assessments for the resident's basal cell carcinoma (BCC- the most common type of skin cancer) lesions (an area of abnormal or damaged tissue caused by injury, infection, or disease) per facility Policy and Procedure (P&P). A follow up oncology (a branch of medicine dedicated to the diagnosis, treatment, and study of cancer) appointment was carried out in accordance with Resident 86's physician order and the facility and General Acute Hospital 1 (GACH 1) discharge instructions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a one (1) to 1 sitter ( 1:1 sitter- a healthcare worker who provides constant, individualized supervision to a single patient) was provided for 1 of 1 sample resident (Resident 11), reviewed for accidents, as recommended by Resident 11's interdisciplinary team (IDT - a coordinated group of experts from several different fields), indicated in Resident 11's care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) and as ordered by the physician. This failure had the potential for Resident 11 to experience preventable falls, injury or accident hazards.

Inspectors wroteBased on interview and record review, the facility failed to ensure competencies and skills sets to provide nursing and related services were completed for two (2) of five (5) sampled nursing staff in accordance with the facility assessment and policy and procedures (P&P). This deficient practice had the potential to result in an increased risk for improper care provided to the residents which could negatively affect the residents' overall wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for one (1) of eight (8) sampled residents (Resident 56) reviewed and observed for medication administration (med pass) in accordance with the facility's policy and procedure (P&P) by failing to:Correctly check Resident 56's enteral tubing (G-tube a soft, flexible plastic tube used to deliver liquid nutrition, fluids, or medications directly into the stomach) placement when Licensed Vocational Nurse 4 (LVN) instilled approximately 50 ml of water instead of air before administering Resident 56's medications. Mix Resident 56's crushed medications with 10 milliliter (ml- unit of measurement for liquid) of water before administering Resident 56's medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records in accordance with the facility's policy by failing to accurately document the administration of oxygen to one (1) of 1 sampled resident (Resident 56) reviewed for oxygen use, in the Medication Administration Record (MAR - a document used to record the administration of prescribed medications). This deficient practice resulted in incomplete and incorrect clinical information, which had the potential for delayed interventions, or failure to identify changes in Resident 56's condition and put the resident at risk for compromised respiratory status and other adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (a device used by a resident to signal his or her need for assistance) was within reach of one (1) or four (4) sampled residents (Resident 17) reviewed for environment. This deficient practice had the potential to negatively impact on the psychosocial well-being (the individual's mental and emotional health and their social interactions and environment) of Residents 17 due to the delay of provision of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete and document weekly skin assessments for one (1) of two (2) sampled residents (Resident 1) who were assessed to be at high risk for developing pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) from 12/29/2025 to 3/2/2026 in accordance with the facility's policy. This deficient practice may result in failure in identifying the development of Resident 1's pressure ulcer.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) received labetalol (drug used to lower high blood pressure) 200 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) in accordance with the physician's order and the resident's physician was notified of the missed doses scheduled on 2/27/2026 and 2/28/2026 at 6 AM in accordance with the facility's Policy and Procedure (P&P) titled, Medication Administration - General Guidelines. This deficient practice resulted to missed medication doses for Resident 1 and had the potential to create medication - related adverse consequences (an unintended, harmful, or unpleasant reaction to a medication, treatment, or therapy) such as elevation and ineffective blood pressure control.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy to ensure the medical records were complete for one (1) of two (2) sampled residents (Resident 1) by not maintaining the completed Physician Orders for Life-Sustaining Treatment (POLST-a form that allows seriously ill patients to document their end of life care wishes) in the resident's medical record. This deficient practice had the potential to create conflict in carrying out the resident's treatment preferences and health care decisions.

Inspectors wroteBased on interview and record review, the facility failed to obtain and provide continuous wound treatment for one of three sampled residents (Resident 1) in accordance with the facility policy by failing to: 1) Obtain a wound treatment on the right elbow skin tear (a wound where the top layer of the skin separates from the underlying layer, often caused by friction, shearing or a bump that caused the skin to split, often leaving a flap) from 2/6/2026 to 2/14/2026.2) Provide wound treatments for Resident 1's right elbow skin tear on 1/19/2026, 1/27/2026, and from 2/6/2026 to 2/14/2026. These deficient practices had the potential for delayed healing of Resident 1's right elbow skin tear which could result in complications such as infection and worsening of the wound, thereby negatively affecting the resident's physical comfort and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 3) was turned every two hours in accordance with the resident's care plan and the facility's policy and procedure (P&P). This deficient practice had the potential for Resident 3 to have a skin tear and develop a pressure injury (painful wound caused as a result of pressure or friction).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control measures for one (1) of two (2) sampled residents (Residents 4) as indicated on the facility policy by failing to ensure Treatment Nurse 1 (TN 1) performed hand hygiene (washing hands with soap and water for at least 20 seconds, or using alcohol-based sanitizer, to effectively eliminate germs and prevent disease spread) and change gloves after removing a soiled wound dressing for Resident 4. These failures had the potential to result in an increased risk for Resident 4 to develop an infection and spread bacteria, viruses and pathogens (harmful microorganisms) to staff and other residents.

Inspectors wroteBased on interview, and record review the facility failed to notify one (1) out of three (3) sampled residents (Resident 1) of an upcoming scheduled routine dental cleaning appointment. This deficient practice resulted in Resident 1 missing his dental appointment by not receiving routine dental cleaning/mouth care as scheduled. This deficient practice can potentially lead to oral diseases. During a review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to paraplegia (paralysis of the legs and lower body), type 2 Diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), morbid obesity (when a person's weight is more than 80 to 100 pounds above their ideal body weight) and chronic obstructive pulmonary disease (COPD; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a resident-centered comprehensive care plan (a care plan developed and implemented to meet the residents' preferences and goals and addresses the residents' medical, physical, mental, and psychosocial needs) for one of two sampled residents (Resident 1) by failing to:1. Develop a comprehensive care plan addressing Resident 1's history of gastrostomy tube (G-tube- a tube inserted through the abdomen that delivers nutrition directly to the stomach) dislodgement from 3/19/2025 to 9/24/2025. 2. Develop a resident-centered comprehensive care plan with specific interventions to prevent Resident 1 from pulling her G-tube on 9/29/2025 This deficient practice resulted in inconsistent implementation of care and can result in Resident 1's G-tube to dislodge.

Inspectors wroteBased on interview and record review, the facility failed to follow its Bed Hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) policy for one of two sampled residents (Resident 1) by failing to hold Resident 1's bed for up to seven (7) days while the resident was transferred to the General Acute Care Hospital (GACH) on 9/2/2025. This deficient practice resulted in Resident 1 not being readmitted back when the resident was ready to return to the facility from GACH on 9/7/2025. This had the potential to cause psychosocial harm from displacement and incurred unnecessary hospital days (12 days) at the GACH (from 9/6/2025 to 9/18/2025). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided care and services to maintain good grooming and personal hygiene. This deficient practice resulted in Resident 1 not receiving nail care and had the potential to cause an infection and impact Resident 1's self-esteem (confidence in one's worth or abilities, self-respect).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received treatment and care in accordance with professional standards of practice by failing to notify the physician after Resident 2 refused the resident's Advair (an inhaled medication used daily to prevent and control shortness of breath, chest tightness, and wheezing [a high-pitched, whistling, or raspy sound produced during breathing, usually when air moves through narrowed or blocked airways in the lungs]) on three separate occasions as indicated in the facility's policy and procedure (P&P). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) system was functional to alert the staff for three (3) of 3 nursing stations (Stations 1, 2 and 3) from 7/10/2025 until 7/18/2025 based on the facility policy titled, Communication- Call System,. This deficient practice had potential for the delay in care and/or not to meet the residents' needs for assistance and can lead to frustration, falls and accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat resident with respect and dignity, and maintain privacy for three (3) of 18 sampled residents (Residents 1, 62, and 73) in accordance with the facility policy by failing to ensure: 1. Resident 1 was fed by Certified Nursing Assistant 1 (CNA 1) at the resident's eye level on 6/3/2025. 2. Licensed Vocational Nurse 4 (LVN 4) failed to knock on the door before entering Resident 62's room. 3. LVN 4 failed to knock on the door before entering Resident 73's room.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs of five (5) of 18 sampled residents (Residents 24, 69, 6, 42 and 72) by failing to ensure: 1. Resident 24's call light was answered timely. 2. Resident 69's call light was placed on the resident's side that did not have a contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). 3. and 4. Residents 6 and 42's call light was within reach. 5. Resident 72 had a tap call light (specialized nurse call device that is activated by pressure or touch on a soft pad) when the resident has a mitten restraint (a type of physical restraint, specifically a soft, large glove that covers a resident's hand, often used to prevent them from interfering with medical equipment).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean, comfortable and homelike (a place that feels like home) environment for five (5) of 11 sampled residents (Residents 26, 15, 78, 90 and 43) per facility policy by failing to ensure: 1. Resident 26's floor was clean and sanitary without any visible trash, dried brown smears by the commode, and brown clumps under the right side of the bed. 2. to 5. The facility's hot water temperatures were pleasurable and comfortable for Residents 15, 78, 90 and 43 for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). These deficiencies had the potential to negatively impact the quality of care, life and psychosocial well-being for Residents 26, 15, 78, 90 and 43.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper hydration and nutrition maintenance for two (2) of 2 sampled residents (Residents 11 and 40) by failing to: 1. Provide a water pitcher and fluid at bedside for Resident 11. 2. Follow the significant weight loss policy for Resident 40, after an episode of significant weight loss. These failures had the potential to place Resident 11 at risk for dehydration (harmful reduction in the amount of water or fluids in the body) and Resident 40 for continued preventable weight loss, which could affect the residents' overall physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services for three (3) of 11 sampled Residents (Residents 48, 73, and 76) by failing to ensure: 1. Resident 48 received Marinol (a cannabinoid, a man-made form of cannabis [marijuana is an herbal form of cannabis] used to treat loss of appetite in people with acquired immunodeficiency syndrome [disease in which there is a severe loss of the body's immunity, greatly lowering the resistance to infection and malignancy] and to treat severe nausea and vomiting caused by cancer chemotherapy) medication two times daily from 5/6/2025 to 5/13/2025 (8 days, total of 15 missed doses). 2. Resident 73's medications were administered timely in accordance with the physician's order. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: a. Label open foods in the kitchen with item name and 'use by' date (the last date recommended for the use of the product) or open date. b. Discard expired foods in the kitchen. 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 to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage were properly disposed and contained. This deficient practice had the potential to attract pests and rodents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for six (6) of 18 sampled residents (Residents 72, 69, 24, 62, and 73) in accordance with the facility's policy and procedure when: 1. and 2. Certified Nursing Assistant 4 (CNA 4) failed to change gloves and perform hand hygiene (cleaning hands with the use of alcohol-based hand rubs containing 60%-95% alcohol or hand washing with soap and water) after providing incontinence care (assistance provided due to the inability to control the release of urine or stool) to Residents 72 and 69. 3. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder [MD] or intellectual disabilities [ID] are placed in facilities that can provide the appropriate care) Level II was completed for one (1) of three (3) sampled residents (Resident 40), as indicated in facility policy. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 40.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop individualized resident-centered care plans (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions for two (2) of 18 sampled residents (Resident 72, and 40): 1. Resident 72 did not have a care plan to address resident's incontinence (the inability to control the flow of urine or the passage of stool) needs. 2. Resident 40 did not have a care plan to address resident's fluid restriction diet and episode of significant weight loss of eight (8) pounds from 2/1/2025 to 3/2/2025. This deficient practice had the potential to result in delayed necessary care and services for Residents 72 and 40 which could result in harm and affect the residents' overall wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the care plan for one (1) of 18 sampled residents (Resident 24) to address Resident 24's respiratory status for the discontinuance of ventilator (a medical device that provides mechanical ventilation, assisting or replacing a person's breathing when they are unable to do so adequately on their own) and current use of oxygen (a chemical element that is needed to survive) via tracheostomy (a surgical procedure where an opening is created in the neck to directly access the trachea [windpipe] for breathing). This deficient practice has the potential for a delay in the respiratory care and can cause complications associated with oxygen therapy for Resident 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinent care for one (1) of three (3) sampled residents (Resident 69) who was dependent on activities of daily living (ADLs- are activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), in accordance with the facility's policy. This deficient practice had the potential for Resident 69 to develop skin issues/ complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and treatment for two (2) of 18 sampled residents (Resident 6 and 346) by failing to: 1. Reevaluate and treat Resident 6's wounds on her arms and legs. 2. Provide interventions after report of Resident 346'scomplaint of pain and episodes of confusion. These deficient practices had the potential to result to delay in the necessary care and treatment of Resident 6 and 346's which could negatively affect the residents' overall wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an intervention to prevent pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one (1) of 1 resident sampled for pressure ulcer care area (Resident 64) in accordance with the facility's policy and procedure by failing to: 1. Ensure Resident 64's low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was at a correct setting. 2. Develop a care plan to indicate Resident 64's risk for development of pressure ulcer. These deficient practices placed Residents 64 at risk for development of pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the correct foot orthosis (brace or support worn outside the body) was used to support, align, and protect the right foot for one (1) of two (2) residents (Resident 86) in accordance with the physician's order. This deficient practice had the potential for Resident 86 to develop right foot contractures (occurs when the muscles, tendons, joints, or tissues tighten or shorten causing a deformity) and increases the resident's risk of developing a pressure ulcer ( injury to skin and underlying tissue resulting from prolonged pressure on the skin) on the right heel due to improper foot support.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the fluid restriction (a diet which limits the amount of daily fluid consumption) order for one of one resident (Resident 40) who was dependent on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) as indicated on the physician's order. This failure resulted in Resident 40 not receiving fluid restrictions from 5/19/2025 through 6/3/2025, with the potential to cause fluid overload (having too much fluid in the body), or preventable health complications for Resident 40.

Inspectors wroteBased on interview and record review, the facility failed to provide trauma-informed care (TIC, an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of traumas) for one (1) of 1 sampled resident (Resident 83) who was diagnosed with post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) in accordance with the facility's policy. This deficient practice had the potential for Resident 83 to experience re-traumatization, (unintentionally causing harm through practices, policies, and/or activities that are insensitive to the needs of the residents) that could lead to severe psychosocial harm and negatively affecting Resident 83's quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure the Medication Regimen Review (MRR, consists of a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one (1) of five (5) residents (Resident 48) was conducted monthly for the months of February 2025 and March 2025. This deficient practice had the potential for Resident 48 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to their medication therapy possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on interview and record review the facility failed to ensure one (1) of five (5) residents (Resident 48), was free of unnecessary medication by failing to clarify the order indication (a specific reason or medical condition that justifies the use) for Marinol (a cannabinoid, a man-made form of cannabis [marijuana is an herbal form of cannabis] used to treat loss of appetite in people with acquired immunodeficiency syndrome [disease in which there is a severe loss of the body's immunity, greatly lowering the resistance to infection and malignancy] and to treat severe nausea and vomiting caused by cancer chemotherapy). This deficient practice had the potential to result in a lack of monitoring the intended indication for Marinol use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Four (4) medications errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 33 opportunities (observed administered medications) for error and yielded a facility medication rate of 12.12% for one (1) of five (5) sampled residents (Resident 73) observed during medication administration (med pass):. Resident 73 did not receive the following medications timely in accordance with the physician's order: a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one (1) of two (2) sampled residents (Resident 21) with meals that accommodated the resident's food preferences. This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition (a condition that occurs when a person's body doesn't get the right amount of nutrients it needs to function properly).

Inspectors wroteBased on interview and record review, the facility failed to ensure the antibiotic stewardship program protocols for prescribing the appropriate antibiotics (medication used to treat or prevent some types of bacterial infection) was followed for one (1) of two (2) sampled residents (Resident 25) prior to the administration of the resident's antibiotic therapy. This deficient practice had the potential for Resident 25 to be prescribed inappropriate antibiotics and increased the risk for developing antibiotic-resistant organisms (bacteria that are not controlled or killed by antibiotics).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within the resident's reach (arm's length) for two (2) of 18 sampled residents (Resident 23 and 86) as indicated on the facility's call system policy. This deficient practice had the potential for Residents 23 and 86 to be unable to call the facility staff for assistance especially during an emergency, which could lead to an injury or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Posted Nursing Hours for Direct Care Staff (Nurse Staffing Information) on 5/30/2025, 6/2/2025, 6/3/2025 and 6/4/2025 were accurate in accordance with the facility's policy and procedure. This deficient practice had the potential for residents and visitors to not be informed of the actual number of nurses providing direct care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to accurately document records for one (1) of two (2) sampled residents (Resident 2) in accordance with professional standards and practices by failing to document Resident 2's wound treatment in Resident 2's medical record from 5/14/2025 to 5/27/2025. These deficient practices had the potential to affect the accuracy of clinical assessments and medical management for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to implement its facility's advance directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) policy for one of two sampled residents (Resident 1) by failing to honor resident's decision to not prolong his life in accordance with the resident's AD and failing to follow the Physician's do not resuscitate (DNR- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation [CPR- an emergency procedure that combines chest compressions and artificial ventilation] if breathing or the heart stops) order. [...]

Inspectors wroteBased on interview and record review the facility failed to report an allegation of physical abuse (the willful infliction of injury or trauma to another person resulting physical harm, pain or mental anguish) and verbal abuse (type of psychological/mental abuse that involves the use of oral or written language directed to a victim) on 4/5/2025 for two (2) of 2 sampled residents (Residents 1 and 2) within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities) and the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), in accordance with the facility's abuse policy. This deficient practice had the potential to compromise or impede the protection of Resident 1 and 2 from further abuse, which could affect the residents' emotional and mental wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide functioning communication system for one of four sampled residents (Resident 1), by failing to ensure the resident's call light (a string that allows patients in healthcare settings to remotely call for help from a nurse or other medical staff) was working properly. This deficient practice resulted in delayed incontinence care for Resident 1 on 5/2/2025, with the potential to negatively impact the psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to protect the medical records for six (6) of 14 sampled residents (Resident 4, 5, 6, 7, 8, and 9) when Respiratory Therapist 1 (RT 1, healthcare professional trained to evaluate and treat people who have breathing problems or other lung disorders) left the respiratory therapy (healthcare specialty that focuses in the diagnosis, treatment of breathing disorders) notes unattended on top of the therapy cart located in the hallway where other staff, residents, and visitors walk by. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of three (3) of 3 sampled residents (Resident 9, 10 and 11) as indicated on the facility policy when Licensed Vocational Nurse 3 (LVN 3) failed to administer Residents 9, 10 and 11's medications within 60 minutes of scheduled time of 9 AM on 4/16/2025. This deficient practice had the potential for Residents 9, 10 and 11's health and well-being to be negatively impacted due to unintended consequences, such as decreased effectiveness of the medications and adverse reactions (an unwanted effect caused by the administration of a drug) from the medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect when Resident 1 alleged Certified Nursing Assistant 1(CNA1) of throwing the resident's legs on the bed and tossed a pillow at her face on 4/11/2025. This deficient practice resulted in Resident 1 verbalizing feeling humiliated and emotionally distressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 3) allergy to eggs was clearly communicated and accommodated during meal service. This deficient practice had a potential for Resident 3 to suffer complications and to get hospitalized as a result of being served a lunch tray containing mayonnaise (an egg-based product), which potentially caused allergic reaction to Resident 3 on 4/15/2025 and being served breakfast on 4/16/2025 without a lunch tray ticket indicating resident's allergies to eggs.

Inspectors wroteBased on observation, interview, and record review, the Kitchen Aid (KA) failed to perform hand hygiene after opening the trash lid and prior to food preparation. This deficient practice had the potential for the residents to suffer from food borne illness (food poisoning caused by consuming food or beverages that are contaminated with certain infectious or noninfectious agents) which could lead to hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision and a safe environment to prevent accidents for three (3) of 3 sampled residents (Residents 1, 2 and 3) by failing to: 1. Ensure Resident 1 did not obtain and consume alcohol on facility grounds on 3/9/2025. 2. Ensure Residents 1, 2 and 3 were supervised while spending time outside by the parking lot and in the smoking area to either smoke or relax on 3/9/2025 and 3/12/2025. 3. Implement their facility's policy and procedure (P&P) titled, Smoking regarding non-compliance and Resident 1's interdisciplinary team meeting (IDT; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a current copy of the advance directives (a legal document indicating resident preference on end-of-life treatment decisions) were placed in the resident's chart with the Physician Orders for Life-Sustaining Treatment (POLST, a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency, taking the patient's current medical condition into consideration) and failed implement the resident's advance directives for one (1) of two (2) sampled residents (Resident 1). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's Physician Orders for Life-Sustaining Treatment (POLST, a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency, taking the patient's current medical condition into consideration) that confirmed the residents/resident's representatives wishes for do not resuscitate [DNR, a medical order written by a doctor to instruct healthcare providers NOT to do cardiopulmonary resuscitation {CPR- a lifesaving technique used when someone's heart stops beating, or they stopped breathing}] if breathing stops or the heart stops beating) for 1 of 2 sampled residents (Resident 1) was complete with the doctor's signature This deficient practice resulted in conflict in carrying out Resident 1's wishes for medical [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the Resident 1's risk of elopment (the act of leaving a facility unsupervised and without prior authorization). This deficient practice has put Resident 1 at risk of elop from safe enviroment without supervision and care and may result in injury.

Inspectors wroteBased on interview and record review, the facility failed to provide ensure a neurological assessment (neuro check, a group of questions and tests to check for disorders of the nervous system [sends messages back and forth between the brain and the body]) was completed for one (1) of two (2) sampled residents (Resident 1) who had an unwitnessed fall, in accordance with the facility's policy and procedure (P&P) titled, Neurological Assessment,. This deficient practice had the potential to result in a delay of care and services, which could negatively affect Residents 1's overall wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to note, document and report to the resident's primary physician the irregularities ( includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) with regards to the Lorazepam order, on the medication regimen review (MRR, or Drug Regimen Review, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) done on 11/29/2024 to 11/30/2024 for one of two sampled Residents (Resident 1) in accordance with the facility policy titled Psychotherapeutic (the practice of prescribing, monitoring, and [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure (P&P) titled Psychotherapeutic Drug Management, by failing to ensure: A. Resident 1 have a specific indication for a specific diagnosis in the physician's order for the use of Lorazepam (medication used to treat anxiety [persistent and excessive worry that interferes with daily activities]). B. Resident 1 have indication for a specific target behavior such as trying to get up of bed without assistance and fidgeting (small movements especially of hands and feet when a person is nervous) indicated in the physician's order for the use of Lorazepam. C. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services to promote healing of pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time) and deep tissue injury (DTI, purple or maroon localized area of discolored intact skin or blood-filled painful swelling on the surface of the skin due to damage of underlying soft tissue from pressure) for two (2) of three (3) sampled residents (Resident 1 and 2) in accordance with the facility ' s policy when: 1. Resident 1, facility did not implement a consistent wound care treatment as ordered by physician and develop a care plan for care and management of resident 1 ' s pressure ulcers and DTI. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure safe and secure method of disposal of lorazepam (a controlled [a medication with high potential for abuse] medication used to treat anxiety [a feeling of fear, dread, or uneasiness]) one milliliters (mL - a unit of measurement for volume) vial and other discontinued medications in one of two inspected medication rooms (East Station Medication Room) 2. Ensure availability of Protonix (a medication used to reduce acid in the stomach and prevent and/or treat acid-reflux) packet for Resident 3 in one of four sampled residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two single dose unopened vials of Retacrit (a medication used to treat anemia [a condition where the body does not have enough healthy red blood cells] were labeled with expiration date, and stored in accordance with manufacturer's specifications and facility's policy and procedure (P&P) titled, Storage of Medications, dated 01/2022 affecting one resident (Resident 3) in one of three sampled medication carts (West Station Medication Cart 2). This deficient practice had the potential to result in Resident 3 receiving medication that had become ineffective or toxic due to improper storage and labeling possibly leading to anemia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from sexual abuse (non-consensual sexual contact of any type with a resident) for one of two sampled residents (Resident 1) who has a diagnoses of aphasia (a disorder that makes it difficult to speak), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition that causes weakness or an inability to move on one side of the body) was free from sexual abuse (non-consensual sexual contact of any time with a resident) by Certified Nurse Assistant 1 (CNA 1). This deficient practice resulted in Resident 1 subjected to sexual abuse by CNA 1 on 7/20/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the comprehensive care plan related to menstruation cycle (a term to describe the sequence of events that occur in a female body as it prepares for the possibility of pregnancy each month) for one of one sampled resident (Resident 1). This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to delay or lack of delivery of care and services and had the potential to missed diagnosed pregnancy for Resident 1 who was a victim of sexual abuse on 7/20/2024.

Inspectors wroteBased on observation, interview, and record review the facility: 1. Failed to provide education and informed consent regarding the benefits and risks of immunization of influenza (Flu; a contagious respiratory illness) vaccine (medications used to prevent diseases usually given by injection or by mouth) prior to administration flu vaccine for one (1) of two (2) sampled residents (Resident 1). 2. Did not administer the flu vaccine on the day it was delivered (10/30/2024) until 11/5/2024. These deficient practices resulted in violated Resident 1 ' s rights to make an informed decision before received vaccine, delayed administration of the flu vaccine and incompletion of Resident 1 ' s medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1), from physical abuse (intentional act causing injury or trauma to another person) by Resident 2. On 10/25/2024, Resident 2 hit Resident 1 with a cane. This deficient practice resulted in pain, redness and swelling to Resident 1's left wrist, as well as anxiety (anticipation of future danger accompanied by a feeling of distress, sadness, hype-vigilance, and tension).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 2) was supervised by a one to one (1:1) sitter (is a trained caregiver who provides supervision and support to patients who need close monitoring) as ordered by the physician. This deficient practice had the potential to result in Resident 2 verbally and/or physically abusing (intentional act causing injury or trauma to another person) other residents in the facility while he was under a 5150 hold (is the number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled).

Inspectors wroteBase on interview and record review the facility failed to provide dignity to one (1) of three (3) sampled residents (Resident 1) by letting Resident 1 wait for transportation from 12:20 PM to 8:20 PM (8 hours). This failure had resulted to Resident 1's to experience loss of dignity and self-esteem.

Inspectors wroteBase on interview and record review the facility failed to document one of three sample residents (Resident 1), regarding Resident 1 leaving the facility to go to pulmonologist (healthcare provider that specializes in conditions that affect your respiratory system, including your airways and lungs) appointment and failed to ensure there was no inconsistency with the documentation when Resident 1 returned to the facility from his appointment on 9/25/2024. This deficient practice can prohibit appropriate communication between the staff and can result in a lack of or delay in provision of care/intervention to the resident.

Inspectors wroteBased on interview and record review, the facility failed to provide continuity of respiratory care and treatment to three (3) of 38 sampled residents (Residents 1, 2 and 3). 1. Resident 1, who was diagnosed with chronic respiratory failure (a long term condition that makes it difficult to breathe because the lungs cannot exchange air properly), chronic obstructive pulmonary disease (COPD; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmaceutical services were provided to one of 36 sampled residents (Resident 1) who had a diagnoses of chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), asthma (a chronic inflammatory disease of the lungs), sleep apnea (a sleep disorder that causes breathing to repeatedly stop or become very shallow during sleep), and shortness of breath (SOB) by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement interventions to prevent an accident for one of two sampled residents (Resident 1) in accordance with the facility's policy by failing to: 1. Provide proper assistance during incontinent/toileting care, keep the resident's bed in low position, and ensuring side rails were up before leaving the resident in bed on 9/19/2024. 2. Complete a Fall risk assessment in April 2024 and July 2024. 3. Develop a care plan specific to resident's need with interventions to reduce the risk of falls. These deficient practices resulted in Resident 1 falling off the bed during a brief (protective underwear to prevent leakage) change (incontinent/toileting care) and resulted in Resident 1 sustaining multiple open areas on the body from the fall and a broken left thigh bone.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident was free from verbal abuse (using words to name call, bully, demean, frighten, intimidate, or control another person) for one of two sampled residents (Resident 2). On 9/12/2024, Resident 1 had verbal aggression towards roommate (Resident 2). This deficient practice violated Resident 2's right to be free from abuse and can cause emotional trauma to Resident 2. Cross reference with F740.

Inspectors wroteBased on interview and record review, the facility failed provide necessary behavioral care services for one of two sampled residents (Resident 1) by: 1. Failing to monitor and document Resident 1's behavior of restlessness and agitation after admission at the facility on 9/4/2024. 2. Failing to monitor and/ or document for side effects and effectiveness of Reisdent 1's medication (Caplyta [lumateperone tosylate] antipsychotic medication used to manage and treat schizophrenia [a chronic and severe mental disorder that affects how a person thinks, feels, and behaves] and other neuropsychiatric disorders [condition that affects both the nervous system and mental health]), and to monitor behaviors and document observed behavior as indicated in the resident's care plan dated 9/13/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Narcotics (drug that produces analgesia [pain relief] count sheet contained two Licensed Nurses' signatures for one (1) of four (4) medication carts (Station 1 Medication [Med] Cart) in accordance with the facility's policy and procedure. This deficient practice had the potential for the diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled substance (medications with a likelihood for physical and mental dependence) medications.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to prevent an accident for one (1) of three sampled residents (Resident 1) by failing to perform a Fall Risk Assessment (a procedure that helps determine how likely someone is to fall which includes a series of questions about overall health, balance, standing, and walking, and whether there have been any previous falls) in accordance with the facility's policy and procedure (P&P). These deficient practices resulted in Resident 1's unwitnessed fall on 8/22/2024 which resulted in a two (2) centimeter (cm- unit of measurement) x 0.2 cm laceration (a cut or break in the skin's surface to expose underlying soft tissue) at the back of Resident 1's head and transferred to General Acute Care Hospital (GACH).

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive and resident-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to monitor the side effects of prescribed narcotics (a drug that produces numbness and reduces pain) for one out of three sampled residents (Resident 1). This deficient practice had the potential to cause inappropriate care of Resident 1's which can potentially result in adverse reaction (harmful effect) of narcotics such as respiratory depression, lethargy (state of sleepiness or deep unresponsiveness) and can lead to the resident's hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to provide effective pain management that met professional standards of practice for one out of three sampled residents (Resident 1) as evidenced by: 1. Failing to do follow up call to Resident 1's attending doctor (MD 1) after the first the first call on 8/21/24 at 4:34 PM until 8/22/2024 at 7 AM to obtain an order for Norco (a controlled medication [A drug or other substance that is tightly controlled by the government because it may be abused or cause addiction] used to reduce moderate to severe pain) authorized. 2. Failing to give Resident 1 appropriate pain medication (Norco) for a pain level of 8/10 (very strong pain/ severe pain; based on a 0 to 10 numerical scale where 0 means no pain and 10 is the worst pain ever felt) when Resident 1 requested for Norco on 8/22/24 at 1:30 AM. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide treatments and services to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) for two (2) of two (2) sampled residents (Residents 1, and 2) as ordered by the physician when: 1. Resident 1 was not provided restorative nursing services (a program available in nursing homes that helps residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) as ordered by the physician. 2. Resident 2 was not provided restorative nursing services as ordered by the physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their facility's abuse policy for one of two sampled resident (Resident 1) by: 1. Facility failed to report an alleged abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) to California Department of Public Health (CDPH), Law enforcement and Ombudsman (advocates for residents of nursing homes) within 2 hours from when the allegation of abuse was made by Resident 1 against Certified Nurse Assistant (CNA) on 7/28/2024 at 1:20 PM. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an alleged abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) to California Department of Public Health (CDPH), Law enforcement and Ombudsman (advocates for residents of nursing homes) within 2 hours from when the allegation was made for one of two sampled resident (Resident 1). This deficient practice resulted in delay of an onsite investigation by the law enforcement.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality for three (3) of four (4) sampled residents (Resident 1, 3 and 4) by: 1. Failing to follow their policy when Resident 1 had a Change of Condition (COC; a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) of coughing which started on 7/21/2024. 2. Failed to develop a Care Plan and implement interventions when resident was non-compliant with Coronavirus Disease 2019 (Covid- 19; a contagious respiratory virus caused by SARS-CoV-2) interventions and when Resident 1 refused to be tested for Covid- 19. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for Coronavirus 2019 (Covid- 19, a respiratory virus caused by SARS-CoV-2) by: 1. The facility did not post a signage indicating the facility was currently with Covid- 19 outbreak (the occurrence of cases of disease or condition above the expected or baseline level, usually over a given period, in a specific population group). 2. The facility did not report Covid- 19 outbreak to California Department of Public Health (CDPH). 3. The facility failed to ensure that the six (6) trashcans was not overflowing with used personal protective equipment (PPE, is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) on six (6) of 35 rooms. 4. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to set one out of two sampled residents (Resident 1) low air loss mattress (LALM; pressure relieving mattress that is filled with air) at the correct weight setting. This deficient practice had the potential to result in Resident 1's pressure ulcers (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) to worsen and/ or develop new pressure ulcer.

Inspectors wroteBased observation, interview and record review, the facility failed to answer the call light (a device used by residents to call for assistance from the facility staff) in a timely manner for two of three sampled residents (Residents 1 and 2) in accordance with the facility's policy and procedure. This deficient practice has the potential to delay in the necessary care and services for Resident 1 and 2.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify and provide treatment and services to attain the highest practicable mental and psychosocial wellbeing for one of three sampled residents (Resident 1) who was diagnosed with major depressive disorder (a constant feeling of sadness and loss of interest, which stops you doing your normal activities) and anxiety disorder (persistent and excessive worry that interferes with daily activities) by facility staff failed to: 1. Identify, determine possible causal factors, monitor, and document Resident 1's behavior of falsely accusing staff members. 2. Contact the attending physician regarding Resident 1's new behavior of falsely accusing staff members. 3. Create a comprehensive resident centered care plan and implement interventions to address Resident 1's behavior of falsely accusing staff members. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain complete medical records for one of three sampled residents (Resident 1) who was diagnosed with major depressive disorder and anxiety disorder by failure to monitor and document Resident 1's menstruation cycle. This deficient practice resulted in staff not knowing if blood found on Resident 1's brief was from menstruation or sexual assault (when a person knowingly causes another person to engage in a sex act by threatening or placing the other person in fear, or if someone engages in a sexual act with a person who is incapable of or unable to give consent) when Resident 1 alleged Certified Nursing Attendant (CNA), CNA 1 of sexual abuse on 7/20/24 and delay in treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent an abuse for two of seven sampled residents (Residents 162 and 260) by failing to: 1. Prevent physical (any intentional act causing injury or trauma to another person by way of bodily contact) and verbal abuse (a range of words or behaviors used to manipulate, intimidate, and maintain power and control over someone) to Resident 162 when Resident 53 hit Resident 162 on the face and threatened to kill Resident 162 on 6/23/2024. This deficient practice resulted in Resident 162 to get a cut on the bridge of his nose and a swollen bottom lip and with the potential for emotional and psychological (affecting the mind. Related to mental and emotional state of a person) trauma. 2. Ensure Resident 260 was free from verbal abuse from Resident 50. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate treatment and services for two of three sampled residents (Resident 167 and 108) who were incontinent of bladder and/ or bowel in accordance with the facility's policy and procedure. 1. Facility failed to ensure Resident 167's indwelling catheter (foley - a tube inserted into the bladder to help drain urine) collection bag (designed to collect urine drained from the bladder via a catheter or sheath) was not touching the floor per facility policy for and to ensure Resident 167's indwelling catheter collection bag (designed to collect urine drained from the bladder via a catheter or sheath) was covered with a dignity bag (a bag used to cover and hold the catheter drainage/collection bag so the urine is not visible). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory services for three (5) of five (5) sampled residents (Residents 260, 161, and 54) as indicated in the facility's policy by failing to: 1. Obtain a doctor's order before administering oxygen therapy to Resident 260. 2. Ensure Resident 161 received the amount of oxygen as ordered by the physician. 3. Obtain a physician's order before administering oxygen therapy to Resident 54 This deficient practice had the potential to cause complications or adverse effects (an undesired harmful effect resulting from a medication or other intervention) to Residents 260, 161, and 54 associated with oxygen therapy.

Inspectors wroteCross reference: F759 Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of seven (7) sampled residents (Resident 208 and 3) as indicated on the facility policy by: 1. During a Medication Pass observation on 7/10/2024, Licensed Vocational Nurse 3 (LVN 3) failed to administer Resident 208's 12 medications within 60 minutes of scheduled time of 7:30 AM and 9 AM. LVN 3 did not indicate the actual time of medication administration in the medication administration record (MAR). This deficient practice had the potential for Resident 208's health and well-being to be negatively impacted due to unintended consequences, such as decreased effectiveness of the medications and adverse reactions (an unwanted effect caused by the administration of a drug) from the medications. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). 12 medication errors out of 27 total opportunities for error, to yield an overall medication error rate of 44.44 % for on (1) of six (6) residents observed for medication administration (Resident 208). The medication errors were as follows: A. During a Medication Pass observation, Licensed Vocational Nurse 3 (LVN 3) failed to administer Resident 208's medications within 60 minutes of scheduled time of 7:30 AM on 7/10/2024. B. During a Medication Pass observation, LVN 3 failed to administer Resident 208's medications within 60 minutes of scheduled time of 9 AM on 7/10/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its policy by failing to: 1. Remove six (6) vials of Epogen (drug used to treat anemia [lack of blood]) of a resident who has been discharged from Medication Refrigerator 3. This deficient practice had the potential for this medication to be mistakenly given to other residents that can lead to a medication error. 2. Defrost (become free of accumulated ice) Medication Refrigerator 1 and 2. This deficient practice had the potential to affect the temperature quality of Medication Refrigerator 1 and 2, which might affect the efficacy of the refrigerated medications for the residents. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with the facility's policy and procedure by failing to: 1. Ensure a box of raw porkchops were stored and labeled per protocol once opened. 2. Ensure plastic containers of flour and dry pasta were tightly sealed while in storage. 3. Boxed juice concentrates were labeled. 4. Walk in refrigerator temperature was below 41 degrees Fahrenheit (°F: a scale of temperature). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items placed in the resident refrigerator (used to store residents' perishable foods brought from outside the facility) were stored and labeled with resident's name and date as indicated in the facility policy. This failure had the potential for residents to consume expired and/or contaminated foods resulting in food-borne illnesses (food poisoning) with symptoms including stomach cramps, nausea, vomiting, diarrhea and fever.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care in a manner that maintained or enhanced a Resident's dignity and respect in full recognition of their individuality for one of 24 sampled residents (Resident 167) by failing to ensure Resident 167's indwelling catheter (foley - a tube inserted into the bladder to help drain urine) collection bag (designed to collect urine drained from the bladder via a catheter or sheath) was covered with a dignity bag (a bag used to cover and hold the catheter drainage/collection bag so the urine is not visible). This deficient practice violated Resident 167's right for privacy and had the potential to affect Resident 167's self-worth, self-esteem, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of two (2) of 24 sampled residents (Resident 159 and 212) by failing to: 1. Provide Resident 159 with a fully functional wheelchair. This deficient practice resulted in Resident 159 having to use the wheelchair tire to wheel himself around the facility resulting in dirt accumulating on his hand and placing him at risk for infection. 2. Ensure Resident 212's call light device (an alerting device for nurses or other personnel to assist a resident when in need) was maintained within easy reach. This deficient practice had the potential to cause a delay in resident care and for Resident 212's needs to remain unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 110) was free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body) when the facility failed to: a. Conduct an assessment for the use of geriatric chair (Geri chair, a large, padded, and mobile reclining chair that prevents a resident from rising). b. Obtain a physician's order for the use of Geri chair. This deficient practice had the potential to result in limiting Resident 110's mobility and cause injury. This also had the potential for Resident 110 not to be being treated with respect and dignity with the use of restraints.

Inspectors wroteBased on interview and record review, the facility failed to implement the abuse policy and procedure by not thoroughly investigating an allegation of abuse and not providing a complete follow up report of the outcome of the investigation to California Department of Public Health (CDPH) for one of seven sampled resident (Resident 19's) who sustained a thigh bruise (injury of unknown origin). These deficient practices resulted in an incomplete investigation of an allegation of abuse from Resident 19 and the facility's lack in communicating the outcomes to appropriate agencies (CDPH) regarding abuse investigations.

Inspectors wroteBased on interview and record review, the facility failed to transmit a Minimum Data Set (MDS, a standardized assessment and care screening tool) Discharge Tracking Form (DTF, an assessment submitted when a resident has been discharged from the facility) within 14 days after completion for five (5) of 11 sampled residents (Residents 1, 14, 46, 47, and 48) in accordance with the facility policy. This failure had the potential to result in inaccurate information to identify and track the movement of residents in and out of the facility.

Inspectors wroteBased on interview, and record review, the facility failed to complete resident-centered baseline care plan (a form that summarizes a person's health conditions and current treatments for their care) with 48 hours of admission to meet the immediate needs that included interventions for safety and preferences for two of 24 sampled residents (Resident 108 and 110). This deficient practice had the potential to delay necessary care and services based on the specific needs of Resident 108 and 110.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a Resident-centered comprehensive care plan (a care plan developed and implemented to meet the resident's preferences, goals, and addressed the resident's medical, physical, mental, and psychosocial needs) for three (3) of 24 sampled residents (Resident 26, 9, and 50) as indicated on the care plan by failing: 1. Implement the care plan interventions for Resident 26, who was on contact isolation (used when a resident has an infectious disease that may be spread by touching either the resident or other objects the resident has handled) for Candida auris (C. auris- a type of yeast that can cause severe illness and spreads among residents with weakened immune systems in healthcare facilities). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the care plan for one (1) of 24 sampled residents (Resident 167) who had a history of pulling out the gastrostomy tube (g-tube - a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration). This deficient practice resulted in multiple incidences of Resident 167 pulling out her g-tube potentially causing further injury and/or pain to Resident 167's g-tube site.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 24 sampled residents (Residents 207) was provided one to one (1:1, one staff to one resident) feeding assistance (the action of a person feeding another person who cannot otherwise feed themselves) during mealtime (lunch) on 7/11/2024. This deficient practice had the potential to result in Resident 207 not being supervised during mealtime, with Resident 207 potentially experiencing a change in condition or weight loss.

Inspectors wroteBased observation, interview, and record review, the facility failed to provide the necessary care and treatment for three (3) of 24 sampled residents (Residents 161, 260 and 3) by failing to: 1. Implement the physician's order for fluid restriction (limiting the amount of liquid consumed daily) for Resident 161who has diagnosis of congestive heart failure (CHF- a serious condition in which the heart does not pump blood as efficiently as it should). This deficient practice had the potential to place Resident 161 at risk for fluid overload (too much fluid in the body which can raise the blood pressure (the pressure of circulating blood against the walls of the blood vessels, cause swelling, and impact organ function), which can lead to health complications, harm, hospitalization, and death. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) feeding was labeled with a date and time for one of two residents (Resident 52) as indicated in the facility's policy. This failure had the potential for Resident 52 to be administered an expired GT feeding, causing preventable gastric complications like nausea, vomiting and/or diarrhea.

Inspectors wroteBased on interview and record review, the facility failed to provide trauma-informed care (an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of traumas) to one of 24 sampled resident (Resident 9) who was diagnosed with post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). This deficient practice had the potential for Resident 9 to experience re-traumatization, (unintentionally causing harm through practices, policies, and/or activities that are insensitive to the needs of the residents) that could lead to severe psychosocial harm and negatively affecting his quality of life.

Inspectors wroteBased on interview and record review, the facility failed to relay the recommendations of pharmacist in Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to the doctor and to take action to address the recommendation/ irregularities for the month of June 2024's MRR for two of five sampled residents (Resident 11and 19) for unnecessary medications review. This deficient practice had the potential to result in adverse medication outcome for potential unnecessary medications to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of six (6) sampled residents (Residents 208) was free from significant medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications [not recommendations] regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services) by failing to administer two (2) medications due to be given at 7:30 AM with meals in accordance with the physician's order and four (4) medications due to be given at 9 AM in accordance with the physician's order. The following medications for Resident 208 were administered more than one (1) hour from the scheduled administration time: 1. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to administer the influenza (flu- a common but sometimes deadly viral infection of the nose, throat, and lungs) vaccine (a preparation that used to stimulate the body's immune response against diseases) for one (1) of five (5) sampled residents (Resident 34) after the responsible party signed the consent form on 2/2/2024. This deficient practice placed Resident 34 at a higher risk of acquiring and transmitting the flu virus to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility remains free of pests (a general term for organisms [rats, insects, cockroaches, etc.] which may cause illnesses) for two (2) of 24 sampled residents (Resident 36 and Resident 165) in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to affect residents when the flies that carry bacteria land on the food that the residents eat, which could result to illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed for three of eight sampled residents (Residents 1, 3, and 4) by Certified Nurse Assistant 1 (CNA 1) failed to: 1. a. Perform hand hygiene (action of hand cleansing, could be through hand washing with soap and water or hand sanitizing with and antibacterial sanitizer solution) after providing a brief (protective underwear to prevent leakage) change for Resident 1 who had signs and symptoms of diarrhea. b. Remove dirty gloves and perform hand hygiene before getting a clean gown from linen cart to bring to Resident 4 (resident without signs and symptoms of vomiting and diarrhea) in Room B. c. Properly discard Resident 1's trash and linen. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to provide supervision for one of three sampled residents (Resident 1) in accordance with the facility policy when Certified Nursing Assistant 1 (CNA 1) left Resident 1, who was assessed as high risk for fall, sitting in a shower chair inside the resident's room unattended. This failure resulted in Resident 1 getting up out of his wheelchair to go to the restroom which resulted in Resident 1's fall on 5/17/2024.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three residents (Resident 1) from further abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) after Resident 2 hit Resident 1 on 3/4/2024 and 5/8/2024, per facility's policy and procedure. This deficient practice resulted in two counts of physical abuse (intentional bodily injury such as pinching, slapping and hitting) and psychosocial (combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) harm for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs - activities related to personal care which include bathing/showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) when Resident 1 requested to get ready to participate in a scheduled activity. This deficient practice placed Resident at risk for psychosocial harm such as feeling depressed or lonely.

Inspectors wroteBased on interview and record review, the facility failed to report to the resident's primary physician the irregularities ( includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) with regards to the Depakote (used to treat seizure [temporary abnormalities in muscle tone or movements {stiffness, twitching or limpness}] disorders) order, on the medication regimen review (MRR, or Drug Regimen Review, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) since October 2023 for one of two sampled Residents (Resident 1) in accordance with the [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of two sampled resident (Residents 1) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure: 1. Resident 1 have a specific indication for the use of Depakote (used to treat seizure disorders, extended release (ER) oral tablet once a day ordered on 9/12/2023. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent one of four sampled residents (Resident 1) from falling by failing to provide adequate supervision when resident's care plan to move resident to a room closer to the nurse's station was not implemented. This deficient practice resulted in Resident's 1 fall (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force ) and transfer to General Acute Care Hospital (GACH) on 2/14/24 for evaluation.

Inspectors wroteBased on observation, interview, and record review the facility failed to practice infection control measures to prevent scabies (a contagious, intensely itchy skin condition marked by itching and small raised red spots caused by a tiny, burrowing [to make a hole or tunnel] mite) for two (2) of 2 residents (Residents 1 and 2) by failing to: 1. Detect symptoms of scabies (severe itching, pimple-like itchy rash) and provide treatment for Resident 1. 2. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure inventory of all clothing, valuables were documented, signed and dated in the Inventory Form for one of four sampled residents (Resident 1). This deficient practice had the potential to cause misappropriation of property related to the lack of safekeeping of the residents' personal belongings.

Inspectors wroteBased on interview and record review, the facility failed to administer Vimpat ([Lacosamide] an antiepileptic [anti-seizure] medication) 100 milligrams (mg - a unit of measure of mass) from 9/10/23 and 11/16/23 as ordered for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at increased risk for uncontrolled seizure activity, hospitalization, and decline in the resident's health.

Inspectors wroteBased on interview, and record review, the licensed nursing staff failed to ensure one of two sampled residents (Resident 1), who has a diagnosis of neuromuscular dysfunction of the bladder unspecified (when a resident lacks bladder control due to brain, spinal cord, or nerve problems) and/or responsible party (RP) were informed of the resident ' s treatment plan regarding the discontinuance of the use of foley catheter (a thin flexible tube to drain urine from the bladder) without foreknowledge of Residents 1 ' s physician, as indicated on the facility policy. This deficient practice violated the residents' right and/or RP to make an informed decision regarding change in resident ' s plan of care with the use of a foley catheter.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of Resident 1's change of condition when resident's foley catheter (a thin flexible tube to drain urine from the bladder) was removed on unknown date for one of four sampled residents (Resident 1), as indicated on the facility policy. This deficient practice had the potential to not provide the necessary urinary care and services needed by Resident 1, which can affect resident's overall wellbeing.

Inspectors wroteBased on interview and record review the facility failed to provide pharmacy services for one of two sampled residents (Resident 1) by: 1. Failed to ensure accurate Controlled Drug Record (documentation of the controlled medication [CM- medications which have a potential for abuse and may also lead to experiencing unpleasant physical symptoms when one stops the medication or get emotionally and mentally addicted]) for Resident 1's oxycodone (a CM used to treat pain) 10 milligram (mg, unit of measurement) in one of four inspected medication carts (Medication Cart [NAME] Station). 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure and maintain: 1) Accurate Controlled Drug Record (documentation of the controlled medication [CM- medications which have a potential for abuse and may also lead to experiencing unpleasant physical symptoms when one stops the medication or get emotionally and mentally addicted]) for Resident 1's oxycodone (a CM used to treat pain) 10 milligrams ([mg]- a unit of measure of mass) was signed twice by Licensed Vocational Nurse (LVN) 1 on 7 different dates and time in one of four inspected medication carts (Medication Cart [NAME] Station). 2) Controlled Drug Record for oxycodone 5 mg dated from 8/16/23 to 8/31/23 were retained in the facility for Resident 1 in one of four inspected medication carts (Medication Cart [NAME] Station). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide qualified personnel to assist seven of thirteen sampled residents (Resident 1, 2, 3, 4, 5, 6, and 7) on mechanical ventilation (MV, a form of life support that helps you breathe [ventilate] when you cannot breathe on your own) on 10/14/2023 for the night shift (10 PM to 10/15/2023 at 6 AM). This deficient practice resulted to Resident 1 not attended by a qualified personal to assist with the resident ' s MV when the resident experienced breathing above the MV with rapid respirations and extensive use of accessory muscle (muscles of the shoulder girdle and chest wall) which resulted to transfer to general acute care hospital (GACH) on 10/15/2023 at 1:44 AM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive resident-centered care plan (a written plan that focuses on the choices of the resident and outlines how the nursing home staff will help the resident) to monitor one of two sampled residents (Resident 1) for 72 hours after Resident 2 hit Resident 1 in the left leg with Resident 2's wheelchair leg rest on 9/14/23. This failure resulted in Resident 1 not receiving 72-hour nurse monitoring after a resident-to-resident altercation, which had the potential to cause a delay or lack of necessary care for Resident 1 following a resident-to-resident altercation.

Inspectors wroteBased on interview, and record review the facility failed to ensure all controlled medications (CM, medications which have a potential for abuse and may also lead to physical or psychological dependence) for three (3) of 3 medication carts (Medication Cart Subacute 1, East, and West) were properly accounted for as indicated on the facility policy and procedure when: 1. 117 Licensed Nurse signatures were missing on the Narcotic Count Sheets (NCS, document where two licensed nurses sign at each shift change verifying the CM inventory) from July 2023 to September 2023. 2. 14 doses of CM administrations documented on the Controlled Drug Record (CDR, inventory and accountability record for CM for each resident) were not reflected on the Medication Administration Record (MAR) for Resident 1. [...]