Golden San Andreas Care Center

Inspectors wroteBased on interviews and record reviews, the facility failed to develop person-centered interventions for a fall care plan for one of three sampled residents (Resident 1), when Resident 1 had a witnessed fall from her wheelchair on 9/7/25, struck her head, and the facility revised the care plan to only include alert charting for 72 hours (a documentation process used to track changes in a resident's health) without including an intervention which would address Resident 1's specific fall risk of pitching forward from the wheelchair prior to Resident 1 sustaining a second fall approximately two hours later on 9/7/25. This deficient practice resulted in Resident 1's care plan not including an individualized intervention to address the resident's specific fall risk and had the potential to result in additional falls.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure timely procurement and administration of physician-ordered medications for one of three sampled residents (Resident 1), when the facility did not timely coordinate with the pharmacy, physician, and hospice (comfort-focused care for a person with a terminal illness) staff after Resident 1's ordered medications were unavailable upon admission. This deficient practice resulted in Resident 1 missing three doses of Seroquel (a medication used for mood or behavior symptoms) and two doses of Sertraline (a medication used for mood symptoms) from 9/4/25 through 9/6/25 and placed the resident at risk for unmanaged mood and behavior symptoms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meal service in a dignified manner for 13 Residents during the lunch in the assisted dining room (for residents who need staff assistance to consume their meals/drinks) on 6/9/26 when 13 Residents were served their meals on a food tray (a flat tray utilized to carry plates/bowls/drinks/utensils to a dining area) while 23 Residents in the independent dining room had their meals without the food tray and and the food were set on the dining table. This deficient practice had the potential to negatively affect the 13 Residents' psychosocial (involving mental, emotional, social, an spiritual aspects of a person's life) well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain kitchen equipment and food-contact surfaces in accordance with professional standards for food safety for 87 residents when:1. Food preparation equipment was not maintained in clean and sanitary conditions in accordance with food safety standards; and,2. The top of the convection oven (a standard oven equipped with a built-in fan and exhaust system) was observed covered with dust and sticky in touch and, the interior surfaces of the convection oven doors were observed to have multiple light brown spots and accumulations of oil/grease residue.3. The top of the dishwasher was observed to be visibly soiled with accumulated debris. These failures had the potential to expose 87 residents to food contamination and foodborne illness (an illness that comes from eating contaminated food. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe infection prevention and control practices for census of 87 when:1. Resident 14, Resident 8 and Resident 65's oxygen tubing was not properly stored when not in use,2. Resident 11's indwelling urinary catheter (also known as foley catheter, a flexible, hollow tube inserted into the bladder to continuously drain urine out of the bladder, through the tubing and into an external collection bag) tubing and catheter bag (collects urine drained from the bladder via a catheter, also known as drainage bag) were touching the floor while wheeling herself in the hallway,3. Shared glucometer (a device that measures blood sugar) were not cleaned and sanitized in-between resident care for Resident 98 and Resident 100,4. Pill cutters in the medication cart contained white and yellow medication residue, and5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent (a process of documenting that a healthcare professional educated a resident about the risks, benefits, and alternatives of a prescribed mental health drug) for psychotropic drug (mind-altering drugs) use followed the facility's policy and resident notification requirements in two (Resident 1 and Resident 3) out of 5 residents reviewed for unnecessary medications. This failed practice may violate residents' rights to be informed of mind-altering medications given to them while in the facility.

Inspectors wroteBased on interview and record review the facility failed to implement non-pharmacological interventions (drug-free approaches and/or resident care interventions without use of drugs that may help with mental health issues) for psychotropic drug use (mind-altering medications) in the plan of care for one out of five residents (Resident 6) reviewed for unnecessary medications. This failed practice may discourage use of drug-free approaches to improve residents' quality of life, reduce distress, and psychotropic medication use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and prevent pressure injury (a localized injury to the skin and/or underlying tissue because of prolonged pressure) for two residents (Resident 25 and Resident 56) who used a low-air loss mattress (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) in a sample of 26 residents, when Resident 25's and Resident 56's LAL was not correctly calibrated according to Resident 25's and Resident 56's current weight. This deficient practice had the potential to place Resident 25 and Resident 56 at increased risk for developing pressure injury and/or skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and hazard free environment for one of twenty-six sampled residents (Resident 19) when Resident 19's cigarettes and lighter were in her possession and not securely stored. This failure had the potential to affect Resident 19's safety, causing a smoking related injury and fire hazard in the facility, and putting the other residents and staff at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe pharmaceutical services with census of 87 residents when:1. Prescription and narcotic medication delivery manifest or receipts from provider pharmacy were not signed by licensed staff for accountability.2. Resident 24 and Resident 4's prescribed medications were not available and not refilled in a timely manner3. Hazardous drugs (medications that may pose health hazard when not handled appropriately) stored in the medication carts were not labeled alerting staff for safe use and handling. These deficient practices had the potential for unsafe medication exposure, medication errors, risk of drug diversion (drug loss) and residents not receiving prescribed medications as a result of unavailability and delay in refill process.

Inspectors wroteBased on interview and record review the facility failed to document and provide clinical justification or expert consultation for switching a blood thinner (rivaroxaban or Xarelto, medication that prevents or slows down the clotting of blood by interfere with the chemical processes that cause blood to clot, helping prevent life-threatening conditions) to an anti-platelet medication (clopidogrel or Plavix, medications that prevent blood cells called platelets from sticking together & primarily used to prevent and treat heart attacks in people with heart disease) for treating recurrent and active blood clot in one out of five residents reviewed for unnecessary drugs (Resident 3). This failure could contribute to ineffective treatment and risk of blood clot formation leading to serious health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were properly labelled and stored in the medication and treatment carts to ensure they remain effective and safe for use with a resident census of 87 when:1. Medication cart in C wing stored an unlabeled insulin glargine pen (Long-acting insulin in pen shape help reduce blood sugar) for Resident 100 which did not have a pharmacy prescription label. The resident's name was handwritten on the product with a permanent marker.2. Medication cart in B wing stored a box of single use eye drops called Dorzolamide-Timolol ophthalmic solution (eye drop used to treat an eye disease called Glaucoma) and was found in the medication cart out of its foil wrap without an opened date marking. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to carry out physician orders on two (Resident 1 and Resident 3) out of five residents reviewed for unnecessary drugs. These failures could have contributed to unsafe care and not following the physician orders for the treatment of medical problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 1 of 26 sampled residents (Resident 17) when Resident 17's Documentation Survey Report (form used by Certified Nurse Assistants (CNA) to document patient care and report observations as a proof that required care was provided) did not reflect activities were provided on daily basis from 5/1/26 through 5/31/26. This failure had the potential to not provide sufficient information that reflected Resident 17's activity participation on a daily basis.

Inspectors wroteBased on interview and record review, the facility failed to report the facilities investigation findings to the appropriate parties for an allegation of abuse for two of four sampled residents (Resident 1 and Resident 2), when the results of the investigation for the alleged allegation of abuse that occurred on 4/1/26 was not reported to the Department. This failure had the potential to compromise the facility's ability to ensure that appropriate corrective action was taken as the result of the investigation and could have compromised Resident 1 and Resident 2's safety.

Inspectors wroteBased on interview and record review, the facility failed to document the administration of controlled drugs (medications that are tightly controlled by the government because they may be abused or cause addiction) for one of five (5) sampled Residents (Resident 5) when, Resident 5's controlled medication count sheet indicated three doses of hydrocodone/APAP (a controlled medication prescribed for pain management) had been signed out (taken out of the medication container) by a licensed nurse but had not been documented as administered to the resident on the medication administration record (MAR). These failures had the potential to cause medication errors and for Resident 5 to be inadvertently overmedicated.

Inspectors wroteBased on interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for two of three sampled residents (Resident 1 and Resident 2) when:1. Resident 1's low pulse rate (PR) readings of 46 on 3/19/25 were not rechecked and not reported to the medical doctor (MD) in a timely manner; and,2. Resident 2's left knee x-ray result was received and not reported to the MD.These failures had the potential for the facility not to recognize Resident 1 and Resident 2's potential change in conditions which could result in delays in their care and physical harm.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical record for one of three sampled residents (Resident 1) when, Resident 1's Activity of Daily Living (ADL - refer to the basic self-care tasks essential for independent living, like bathing, dressing, eating and toileting) charting tasks for July of 2024 had multiple shifts that lacked Certified Nursing Assistant (CNA) entries. This failure had the potential to provide insufficient information regarding the condition, care, and services provided to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure that nursing staff followed established protocols for the initiation and discontinuation of Cardio-Pulmonary Resuscitation (CPR - an emergency lifesaving procedure performed when the heart stops beating) for one out of three sampled residents (Resident 5) when, nursing staff discontinued CPR prior to the arrival of Emergency Medical Services (EMS - a system that provides emergency medical care) and without a physician's order or confirmation of death. This failure resulted in a lack of adherence to professional standards of practice and the facility's policies regarding life-saving interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure that adequate supervision and safety interventions were implemented for one out of three residents (Resident 3) when Resident 2 grabbed Resident 3 ' s right wrist and shirt and attempted to strike her. This incident occurred 3 days after Resident 2 had been involved in a separate incident with another resident (Resident 4). This failure had the potential to negatively affect Resident 3 ' s physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) received care to prevent the development of pressure ulcers/injuries (PU/PI - areas of damaged skin caused by staying in one position for too long, usually over an area on the body where a bone is close to the skin's surface (bony prominence)) when: 1. Resident 1 was at risk for developing pressure ulcers and worsening of a shearing wound (a force that causes the skin and underlying tissues to move in opposite directions, often due to pressure and friction) on the coccyx (tailbone). Resident 1's skin assessments and wound documentation were incomplete, the physician was not notified the wound had worsened, and PU preventative measures were not correctly identified and implemented upon admission; and, 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure 7 of 25 sampled residents (Resident 56, Resident 69, Resident 91, Resident 24, Resident 3, Resident 75, and Resident 82) rights related to treatment choices were known and protected when: 1. Resident 69, Resident 24 and Resident 3's POLST (Physician Orders for Life Sustaining Treatment: care directives during life threatening situations), did not have documented evidence that an Advance Directive (legal documentation consistent with a person's medical preference when they were no longer able to make decisions for themselves) was requested/discussed with Resident 69, Resident 24 and Resident 3; 2. Resident 56's and Resident 91's code status order (to provide or not provide life saving measures in the event of an emergency) in the electronic medical record (EMR) did not match the code status listed on the POLST; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement care plans (a list of resident specific problems, goals, and interventions) for 3 of 25 sampled residents (Resident 8, Resident 18, Resident 91) when: 1. Resident 8 and Resident 18, who were roommates, were on Enhanced Barrier Precautions (EBP - use of gown and gloves to prevent the spread of Multi-Drug Resistant Organisms (MDRO's illnesses/infections resistant to some antibiotics) but did not have a care plan for MDRO's developed and implemented; and, 2. Resident 91's care plan for Do Not Resuscitate (DNR - allow natural death to occur) was not implemented (Refer F684). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food from the kitchen was prepared and served to meet the needs of 3 out of 13 Residents (Resident 8, Resident 42, and Resident 54) on a fortified (added calories) diet, and 1 of 1 Residents (Resident 65) on a finger food diet, for the lunch meal on 2/5/25, when: 1. Resident 8, Resident 42, and Resident 54, who were on an ordered fortified diet did not receive the added food items to increase calories; and, 2. Resident 65 did not receive his/her ordered diet of finger foods. These failures had the potential to result in residents not receiving adequate nutrients, which could lead to unplanned weight loss, vitamin imbalances, and further compromise their medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 89 residents who received facility prepared meals when: 1. The stove, oven, convection oven (ovens that have a fan to circulate heat and bake more evenly), back splash, and sides of oven contained grease, buildup of food particles, and white, black, brown colored encrusted grimy areas; and, 2. Sliced yellow cheese was removed from its original package and was stored in the refrigerator without being labeled; Food stored in the refrigerator was available for use beyond the use by date (UBD). 3. The kitchen was found with following unsanitary conditions: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain its infection prevention and control program, for a census of 89 residents, when: 1. Physical therapy assistant (PTA) 1 was not wearing an N95 respirator (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) in a COVID 19 positive resident room; 2. Certified nurse assistant (CNA) 5 was not wearing a gown when transferring a resident on enhanced barrier precautions (EBP a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs microorganisms that are resistant to multiple classes of antibiotics and antifungals)), from her wheelchair to her bed; 3. Two residents (Resident 8 and Resident 18), who were roommates with MDROs, were not placed on EBP; and, 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of 3 of 25 sampled residents (Resident 16, Resident 58, and Resident 83) when: 1. Resident 16's call light was not within reach; 2. Residents 58's call light was attached to the bottom of the bed rail not within reach; and, 3. Resident 83's call light was on a chair not within reach. These failures placed Resident 16, Resident 58, and Resident 83 at risk of falls and unmet needs due to the inability to request assistance from staff.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three residents (Resident 91) sampled for a closed record review, received care in accordance with Resident 91's Physician Orders for Life-Sustaining Treatment (POLST; a medical document that outlines a resident's treatment preferences for when they are seriously ill or dying ) when, Resident 91's POLST indicated Do Not Resuscitate (DNR; a medical order that instructs healthcare providers not to perform CPR (cardiopulmonary resuscitation; an emergency lifesaving procedure performed when the heart stops beating) and the facility provided CPR to Resident 91 on [DATE]. This failure resulted in Resident 91 receiving CPR against Resident 91's wishes to be DNR, with the potential to cause trauma and psychosocial harm to Resident 91 and Resident 91's family.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper hydration (process of providing fluid to the body) for 1 of 25 sampled residents (Resident 16) per facility policy and Resident 16's care plan when Resident 16's water was out of reach. This failure resulted in Resident 16 having dry, cracked lips and had the potential to have complications associated with fluid imbalance (when the body loses or gains too much water/fluids).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for 2 of 19 residents when: 1. Oxygen therapy was provided without a physician order for Resident 192 and an oxygen in use sign was not posted outside of Resident 192's room; and, 2. An oxygen in use sign was not posted outside of the room for Resident 296. These failures had the potential to result in negative impacts on the residents' health and safety including risks for ineffective oxygen therapy, and respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 25 sampled residents (Resident 3) was provided pain management that met professional standards of practice when Resident 3's Lidocaine patch (used to relieve nerve pain) was signed off by licensed nurse (LN) 9 as if it had been applied as ordered by the physician but was not placed until three hours later. This failure resulted in Resident 3's pain being unrelieved, negatively impacting Resident 3's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 25 sampled residents' (Resident 3 and Resident 24) medications were administered as prescribed when: 1. Resident 3's PRN (as needed) pain medication, acetaminophen, was left at the bedside; and, 2. Resident 24's medication Sucralfate (used to prevent stomach ulcers) was not administered before meals as prescribed. These failures resulted in Resident 3's pain going unrelieved, the potential for Resident 3 to accumulate the medication, or for another resident to take the medication, and for Resident 24 to experience abdominal discomfort, negatively impacting Resident 3's and Resident 24's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a closed garbage dumpster bin. This failure had the potential to lead to insect and rodent (mice and rats) infestation for the 89 residents who lived at the facility.

Inspectors wroteBased on interview, and record review, the facility failed to maintain complete and accurate medical records for 2 of 25 sampled residents (Resident 43 and Resident 77) when: 1. Protected Health Information (PHI - any information that can be used to identify a person and is related to their health including any information about a person's physical or mental health, treatment, and payment for healthcare) of another person was found in Resident 43's medical record; and, 2. The facility failed to ensure psychotropic medication (type of drug that affects behavior, mood, thoughts, or perception) informed consent documents included the frequency, dose, and duration for Resident 77. These failures resulted in an inaccurate account of information in Resident 43 and Resident 77's medical records.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 25 sampled residents (Resident 75) was offered the Pneumococcal booster Vaccine (vaccine to prevent pneumonia) even though Resident 75 was eligible to receive the vaccine. This failure resulted in Resident 75 being at higher risk for contracting pneumonia from not receiving the pneumococcal vaccine when eligible.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain kitchen equipment for 89 residents who received food from the kitchen when the steamer (small appliance that cooks food using steam) was leaking water onto the ground. This failure had the potential to injure staff due to a wet floor and compromise food safety for the 89 residents receiving food from the kitchen.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) remained free of accidents and hazards when Certified Nursing Assistant (CNA) 1 gave Resident 1 a vape pen (also known as using an electronic cigarette - the act of inhaling an aerosol from a battery-powered device) that contained tetrahydrocannabinol (THC - the mind-altering compound of marijuana - a federally illegal drug that can cause increased heart rate and blood pressure, and confusion). This failure could have resulted in Resident 1 having an adverse reaction to the drug such as lung injury, confusion, and/or injury from the vape pen which could have been being laced with an unknown drug.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) received adequate supervision and that care plan (an individualized set of goals and interventions specific to the Resident 1 ' s needs) interventions were implemented to prevent an injury when, Resident 1 ' s care plan interventions of a fall mat (a soft pad at the side of the bed to soften a fall) and two person staff assist with activities of daily living (ADL ' s; a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility) were not implemented and Resident 1 fell from the bed on 9/24/24. This failure led to Resident 1 sustaining multiple skin tears, pain, a broken clavicle (also called collarbone; [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the rights of Resident 3 to be free from physical abuse, when on [DATE] unsupervised Resident 2 with history of inappropriate behavior and aggression grabbed Resident 3 by the neck. This deficient practice resulted in Resident 3 sustained skin marks to the neck and voicing safety concerns, distress of being chocked by the beast (Resident 2), and having a hurt reputation.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards were met when Licensed Nurse (LN2) left refused medications scheduled for the morning administration at Resident 4 ' s bedside, marked them as administered and took medications back during the evening shift, crushed them and mixed them with food and attempted to administer the medications to the Resident 4. These failures resulted in Resident 4 ' s distrust of staff, refusing care and food, and stating that staff are trying to poison her. These failures also had the potential for unattended medications to be taken by other residents which could result in bodily harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free of accident hazards for one of two sampled residents (Resident 1) with falls when, Resident 1 was left alone in the wheelchair in her room while staff attempted to locate the footrests for the wheelchair and Resident 1 sustained a fall from the wheelchair during that time on the morning of 2/15/24. These deficient practices resulted in Resident 1 sustaining an avoidable fall [NAME] resulted in a scalp laceration (cut on the head).

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of care were met for Resident 1, when neurological checks (neuro checks, assessment of nerve and motor responses to determine if the nervous system is impaired) and 72-hour alert charting (documentation of assessments and observations) were not completed after Resident 1 sustained a fall in the facility. These failures increased the risk of unrecognized injuries for Resident 1, and could result in a delay in treatment for an injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall prevention measures were implemented according to the plan of care for Resident 1, when Resident 1 ' s anti-slip pad was not on her wheelchair and her fall risk bracelet was not in place. These failures had the potential for Resident 1 to sustain further falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to protect the right of Resident 45, 1 of 25 female residents in the facility with a diagnosis of dementia (impaired ability to remember or make decisions) to be free from sexual abuse, when interactions of a sexual nature occurred between a male resident (Resident 36) who had a history of known sexual behaviors directed towards females in the facility, and Resident 45; and the facility lacked a process to evaluate the capacity for residents in the facility to consent to sexual activity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that two of twenty-one sampled residents (Resident 64 and Resident 49) functional abilities did not diminish when: 1. Resident 64 had a decline in her ability to feed herself and services were not provided to determine the cause and/or maintain her abilities. 2. Resident 49 was not provided Restorative Nursing Assistant (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services per her care plan interventions. These failures resulted in Resident 64's decline in range of motion (ROM, the full movement potential of a joint) to her right arm, left arm and hand, increased pain, and a loss of the ability to feed herself; [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not implement its abuse program for 1 of 21 sampled residents (Resident 45) when Resident 45 was involved in sexual interactions with another resident (Resident 36) who had a history of sexually inappropriate behavior with staff and residents, and the facility did not report the incidents as possible sexual abuse. This failure resulted in three instances of possible sexual abuse on 12/15/23; 12/17/23; and 12/23/23 not being reported; and resulted in the State Agency being unaware of potential danger to Resident 45.

Inspectors wroteBased on observation, interview, and record review, the facility did not implement its abuse program for 1 of 21 sampled residents (Resident 45) when Resident 45 was subjected to sexual interactions with another resident (Resident 36) who had a history of sexually inappropriate behavior with staff and residents, and the facility did not investigate the incidents. This failure resulted in three instances of sexual interaction on 12/15/23; 12/17/23; and 12/23/23, not being investigated, and had the potential for further incidents to occur.

Inspectors wroteBased on interview and record review the facility failed to consistently complete Interdisciplinary Team (IDT, care team consisting of different disciplines who assess and coordinate care) care plan conferences (a meeting which provides opportunities for the resident's and/or their representative, and each discipline to revise the residents care plans) for 5 of 21 sampled residents (Resident 54, Resident 2, Resident 18, Resident 45, and Resident 30). These failures had the potential for unmet care needs for Resident 54, Resident 2, Resident 18, Resident 45, and Resident 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of quality were met when: 1. One of five sampled residents' (Resident 15) medical record was marked with schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) as a diagnosis for use of risperidone (antipsychotic drug class, a mind-altering medication used to treat mental disease) with no prior history of such a diagnosis; 2. The facility did not ensure an accurate psychiatric (mental health) diagnosis was documented in the medical record for one resident (Resident 30) based on the standards of practice; and, 3. The facility did not ensure 1 of 3 sampled residents (Resident 49) with a Foley catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) had an appropriate diagnosis for Foley catheter use. [...]

Inspectors wroteBased on interview and record review the facility failed to provide adequate and sufficient nursing staff to ensure the Restorative Nursing Aide program (RNA, nursing aide who helps residents to maintain their function and joint mobility) services were available for the 19 residents on the RNA schedule for the month of January. This failure had the potential to decrease the residents' range of motion and mobility, which could adversely affect their overall function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure narcotic medication patches were disposed of and accounted for appropriately, non-narcotic medications were disposed of properly, and medications were administered in a timely manner when: 1. Licensed nurses were not aware of where to dispose of narcotic medication patches (Fentanyl patch-a very strong narcotic which is absorbed through the skin) and did not co-sign the disposal of narcotic medication patches; 2. The facility did not ensure non-narcotic medications were disposed of appropriately; and, 3. Medications were not administered in a timely manner for 1 sampled resident (Resident 30), and 9 unsampled residents (Resident 22, Resident 3, Resident 41, Resident 60, Resident 12, Resident 56, Resident 4, Resident 31, and Resident 11). These failures had the potential for: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication rate of less than 5 % when 5 of 33 opportunities resulted in an error rate of 15.15 % as follows: 1. A medication was not administered in a timely manner for 1 of 21 sampled residents (Resident 30); 2. Medications for administration were crushed for one unsampled resident (Resident 12), who did not have an order to crush her medications. This failure had the potential to negatively impact the therapeutic benefits of the medications prescribed to residents receiving medications in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled and stored appropriately when: 1. The facility did not ensure consistent temperature monitoring in the Central Supply room where over the counter (OTC) medications were stored; 2. The facility did not ensure two of five medication carts were locked when left unattended; and, 3. The facility did not ensure a bottle of turberculin solution (a medication used to test for a severe lung disease called tuberculosis) was labeled with the use-by date after opening. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food production when: 1. Multiple food items were found not labeled with a use by date in the refrigerator, freezer, and the dry storage area (foods that do not require to be kept cold), and were available for resident consumption; 2. Expired (outdated) food products were not removed from the kitchen, and were available for resident consumption; 3. Kitchen appliances were dirty with grease and food particles; 4. Kitchen drawers containing clean utensils had dirt and debris; 5. Kitchen staff were not wearing a hairnet properly while handling food; and, 6. Plastic cups were stacked wet. These failures had the potential to expose 73 residents who received meals from kitchen to food borne illnesses (illnesses caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the failed to maintain and implement its infection protection and control program when: 1a. Resident 50 was not placed on contact precautions (residents with known or suspected infections that could be spread by contact. Health care personnel must wear a gown and gloves for all interactions that involve contact with the patient and the patient environment) for MRSA (methicillin resistant staphylococcus aureus - a multi-drug resistant organism also called an MDRO); 1b. Resident 6 was not placed on airborne (for residents with known or suspected to be infected with microorganisms transmitted by airborne droplet germs) and droplet (used to prevent the spread of pathogens that are passed through respiratory secretions and do not survive for long in transit) precautions for shingles and COVID-19; 1c. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure 2 of 21 sampled residents (Resident 6 and Resident 67) needs were accommodated when their call lights were not in reach. These failures had the potential risk of falls and unmet care needs for Resident 6 and Resident 67.

Inspectors wroteBased on interview and record review the facility failed to report a change of condition (COC, a change in the residents normal physical, mental, or behavioral state) to the responsible party (RP) and the physician for 1 of 21 sampled residents (Resident 54) when Resident 54 had a weight loss of 17.6 pounds (Lbs) in 3 weeks and his responsible party and physician were not informed of the change. This failure had the potential for a delay in interventions and care for Resident 54 and resulted in the RP not being able to participate in and make decisions about Resident 54's plan of care.

Inspectors wroteBased on interview and record review the facility failed to provide one of three sampled Residents (Resident 273) a Notice of Medicare Non-Coverage (NOMNC, a form that contains information regarding the end date of Medicare covered services and how to initiate an appeal). This failure had the potential for Resident 273 to be uninformed of her specific rights and protections related to financial liability for potential incurred medical expenses as well as the right to appeal the discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 273) discharge information was documented in the medical record when Resident 273 was discharged home and the facility did not document the date or time of her discharge, where she discharged to, how she was transported, a summary of her stay, or the disposition (a detailed list) of her personal effects and her medications. This failure had the potential risk of Resident 273 receiving inadequate care or services after discharge.

Inspectors wroteBased on interview and record review, the facility failed to issue a transfer/discharge notice for one of three closed record review sampled residents (Resident 72), when Resident 72 was transferred from the facility to the hospital on [DATE] and the facility did not provide a transfer/discharge notice to Resident 72's Responsible Party (RP) and the State Long-Term Care Ombudsman (an advocate for residents in long term care facilities). This failure resulted in the State Long-Term Care Ombudsman being unaware of Resident 72's transfer and removed the opportunity for Resident 72's RP and/or the State Long-Term Care Ombudsman to advocate on their behalf.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR- a federal requirement to screen all potential nursing home residents for mental illness and intellectual disability, to help ensure that individuals are not inappropriately placed in a nursing home, and to ensure they receive any specialized services that are required) provided accurate information for 3 of 21 sampled residents, (Resident 14, Resident 15, and Resident 23) when Resident 14 and Resident 15's PASARR screenings did not include diagnoses of schizophrenia (a mental disorder that affects a person's ability to think, feel and behave clearly) and Resident 23's PASARR did not reflect diagnoses of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and anxiety disorder These failures [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement a person-centered care plan for 3 of 21 sampled residents (Resident 10, Resident 44, and Resident 49) when: 1. Resident 10's fall risk care plan intervention of a fall mat at bedside (a specially designed floor mat that is placed on the floor near the bed to protect the elderly from serious physical injury resulting from a fall) was not implemented; and 2. Resident 44 did not have a care plan developed for his fluid restriction (physician ordered limited amount of fluid per day) ; and 3. Resident 49 did not have a care plan developed for the use of a foley catheter (flexible tube that empties urine from the bladder into a collection bag). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure neurological checks (neuro checks, assessing mental status, pupil response, strength, and sensation) were completed for one of three sampled residents (Resident 30) who had a fall with injury when Resident 30 had a fall with a head laceration. This failure had the potential to result in unrecognized head trauma negatively impacting Resident 30's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were in place for the prevention of pressure ulcers (PU, areas of damaged skin typically caused by staying in one position for too long) for two of twenty-one sampled residents (Resident 18 and Resident 49) when: 1. Resident 18 was at risk for developing pressure ulcers and her care plan interventions were inadequate to prevent skin breakdown from occurring; and, 2. Resident 49 was at risk for a worsening pressure ulcer and her care plan interventions were inadequate to prevent further skin damage, and did not address Resident 49's refusal to reposition. These failures put Resident 18 and Resident 49 at potential risk of increased pain, infection, and muscle or bone loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent falls and accidents for 1 of 21 sampled residents (Resident 45) when: 1. Resident 45's bed was not in a low position and Resident 45's call light was not within reach; 2. Resident 45's wheelchair (W/C) seatbelt with an alarm was not secure; and the alarm was not on when Resident 45 was in her W/C; and, 3. Staff were not knowledgeable in how to check the [Brand Name] signaling bracelet (device which alarms if the wearer leaves the building without staff knowledge) for functioning. These failures had the potential to result in Resident 45 sustaining injuries from falls, being unable to call for help, staff being unaware of Resident 45 getting out of her WC, and for Resident 45 to leave the facility without staff knowledge.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for 2 of 16 residents (Resident 5 and Resident 15) receiving oxygen therapy when: 1. Resident 15's physician order did not indicate parameters for increasing or decreasing her oxygen flow rate; and, 2. Resident 5 and Resident 15's oxygen concentrator (machine used to deliver oxygen to a person) filters contained dust and debris.

Inspectors wroteBased on interview and record review the facility failed to complete annual performance evaluations for 2 of 3 sampled nursing assistants when Certified Nurse Assistant (CNA) 3 and CNA 4 did not have annual performance evaluations completed every 12 months. This failure had the potential for resident needs to go unmet by CNA's whose competence had not been determined through annual performance evaluations.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of ten residents (Resident 30) on anti-psychotic medication had an appropriate diagnosis obtained by a comprehensive assessment for anti-psychotic drug use; and that a gradual dose reduction (GDR) was completed. This failure resulted in Resident 30 receiving an anti-psychotic medication without an appropriate diagnosis and potentially resulted in Resident 30 receiving the medication unnecessarily, placing Resident 30 at risk for adverse effects from the use of an anti-psychotic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the correct portion size for one of five residents (Resident 12) during dinner tray line on 1/23/24, when Resident 12's preference was a small portion size and [NAME] (CK)1 did not follow Resident 12's preference. This failure had the potential to negatively impact Resident 12's health and well-being.

Inspectors wroteBased on interview and record review, the facilty failed to implement an antibiotic stewardship program and monitor antibiotic use when 1 of 21 sampled residents (Resident 14) received an antibiotic without an ending date. This failure could contribute to antibiotic resistance for Resident 14. A review of Resident 14's admission Record indicated Resident 14 was admitted to the facility with diagnoses which included diabetes (problems with blood sugar) and adult failure to thrive (when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received vaccine education and residents were offered the Pneumococcal (vaccine to prevent pneumonia) vaccine when: 1. The facility did not have documented evidence of educating one of five sampled residents (Resident 26) on the influenza and Pneumococcal vaccines received; and, 2. The facility did not offer the Pneumococcal vaccine to two of five sampled residents (Resident 30 and Resident 48) when they were eligible to receive the vaccine. These failures resulted in Resident 26 not receiving information on the risk and benefits of the vaccines administered and Resident 30 and 48 being at higher risk for pneumonia from not receiving the pneumococcal vaccine when eligible.

Inspectors wroteBased on interview and record review the facility failed to ensure one of five sampled residents (resident 30) received education regarding the COVID-19 vaccine when Resident 30's clinical record did not contain documented evidence that Resident 30 was educated regarding the risk and benefits of the COVID-19 vaccine. This failure had the potential to result in Resident 30 being unaware of the risks and benefits to receiving the vaccination and being unable to make an educated decision on whether to receive the vaccine.

Inspectors wroteBased on observation and interview the facility failed to ensure equipment utilized by residents received preventative maintenance when 2 of 13 facility owned oxygen concentrators (machine used to deliver oxygen to a person) annual preventative maintenance (PM) checks were not performed, and the concentrators were in use by Resident 5 and Resident 15. This failure had the potential to affect the health and well being of Resident 5 and Resident 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment free of accidents and hazards when: 1 of 16 residents at risk for falls did not have all the required fall prevention interventions in place (Resident 2) This failure had the potential to contribute to an injury related to a fall or elopement while residing at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure quality care was provided to one of three sampled residents (Resident 2) when: 1. Staff were notified on [DATE] that Resident 2 had signs and symptoms of a urinary tract infection (UTI, a common infection which happens when bacteria, often from the skin or rectum, enter the urinary system) by Resident 2's family member but assessment and monitoring of Resident 2's condition was not done; and, 2. Resident 2 had a lung infection which began on [DATE]. Resident 2's physician examined her on [DATE] and did not document an assessment of Resident 2's lung infection was done; and, 3. [...]

Inspectors wroteBased on interview and record review the facility failed to evaluate resident specific risk factors and changes in health conditions that caused the development of pressure ulcers (an injury that breaks down the skin and underlying tissue caused by being in one position for too long) for two of three residents (Resident 1 and Resident 2) when: 1. Resident 1's person centered risk factors to prevent and treat pressure ulcers were not documented on a risk for skin breakdown care plan, risk factor interventions were not implemented to prevent/heal pressure ulcers, and Resident 1's nursing assessment was not completed on 8/3/23 upon the discovery of a stage three pressure ulcer (affecting the deepest layer of your skin) to Resident 1's ischial tuberosity (also known as the sitting bone, as this is where the weight of the body is held when seated); and, 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement person centered care planned interventions including the use of a seat belt alarm and sensory blanket to prevent accidents for one of three sampled residents (Resident 1). These failures potentially resulted in Resident 1 having three falls including one that required transfer to an acute care hospital for staples (used to close deep cuts in the skin) to her head.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently implement care planned interventions including the use of a wheelchair seatbelt alarm and a sensory lap blanket (a blanket that can have weight, and sensory items to touch) to prevent falls and injury for one of three sampled residents (Resident 1). These failures potentially allowed for Resident 1 to have three falls including one that required transfer to an acute care hospital for staples (used to close deep cuts in the skin) to her head.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed at a high risk for falls due to a history of falls, received adequate supervision and assistance to prevent a further fall and a left thigh bone fracture. This failure resulted in Resident 1 to experience pain related to the fall and having a surgical procedure to fix the bone fracture which led to decreased level of functioning.

Inspectors wroteBased on interviews and record reviews the facility failed to provide two of two sampled residents (Resident 1 and 2) with quality care in accordance with professional standards when: 1. Staff did not monitor Resident 1's ostomy (An ostomy is a medical device that provides a means for the collection of waste from the body) output. 2. Staff did not monitor Resident 1's clinical laboratory values (blood tests) while on intravenous fluids (liquids given to replace water, sugar and salt given through the vein.) 3. Staff did not perform dressing changes per policy on Resident 1 and Resident 2's Peripherally Inserted Central Catheters (PICC, a long thin tube which is inserted in the vein in the arm then passes through the larger veins and ends near the heart). 4. [...]