Golden Sonora Care Center

Inspectors wroteBased on interview and record review the facility failed to ensure professional standards of care were met for one of three sampled residents (Resident 1), when the licensed staff did not obtain a physician's order for care and monitoring or develop a specific care plan related to when Resident 1 sustained an abrasion (wound) to his right thigh during a witnessed fall on 4/8/26. These failures placed Resident 1 at risk of infection and unidentified wound deterioration.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received the appropriate care and services for bladder incontinence (involuntary leakage of urine) when the facility staff did not perform incontinence care during mealtimes. This failure had the potential for Resident 1 to experience skin breakdown (sores) and/or infection.

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 four sampled residents (Resident 1 and Resident 2) when: 1. Resident 1's ammonia levels test results (blood test that measures waste buildup caused by liver or kidney failure) on 3/23/26, 3/26/26 and 3/29/26 were not reported to the MD (medical doctor), and; 2. Resident 2's basic metabolic panel (BMP - laboratory test to check on fluid balance, kidney function and blood sugar levels) laboratory results on 3/23/26 and 3/30/26 were not reported to the MD. These failures had the potential for the facility to not recognize Resident 1 and Resident 2's potential change in conditions which could have resulted in delays in their care and worsening conditions.

Inspectors wroteBased on interview, and record review, the facility failed to obtain laboratory testing for one of four sampled residents (Resident 1) when Resident 1's order for daily ammonia level tests (blood test that measures waste buildup caused by liver or kidney failure) was not completed on 3/25/26, 3/28/26 and 3/31/26. This failure had the potential for Resident 1's ammonia levels to further increase which could potentially lead to confusion, extreme fatigue and severe health issues affecting his brain function.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident rights were maintained when five of five sampled residents' (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) mobility assist rails (supportive devices installed on the side of a bed to assist individuals with limited mobility in sitting up, shifting positions, or entering and exiting the bed safety) were removed against Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5's wishes. This failure resulted in decreased independence, decreased mobility, feelings of humiliation, frustration and fear in Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5, negatively impacting their physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications with physician-ordered parameters were safely administered for one of three sampled residents (Resident 1) when metoprolol (a medication used to control blood pressure) was given to Resident 1 on 11/16/25 and 11/29/25 despite her vital signs (VS-includes heart rate (pulse) and blood pressure) being outside the physician's parameters and not documented on her medication administration record. These failures potentially contributed to Resident 1 experiencing hypotension, requiring emergency evaluation on 11/18/25, and increasing the risk of further health complications.

Inspectors wroteBased on interview, and record review, the facility failed to immediately notify the responsible party or family member about a resident's death for 1 of 1 resident (Resident 1). This deficient practice violated Resident 1's responsible party (RP), the right to be informed of the resident's change in condition or death. A review of Resident 1's admission RECORD, indicated Resident 1's contact list had 7 different contact persons and Family Member (FM) 1 was the responsible party (RP) for Resident 1. During an interview on [DATE], at 12:53 PM, with Family Member (FM) 1, FM 1 stated she was at the facility the night before and when she came back the next morning, she found Resident 1's room empty and was told that Resident 1 passed away. FM 1 stated that she reviewed Resident 1's medical records, which indicated that the reporting party was notified. [...]

Inspectors wroteBased on observation, interview, and record review, the facility compromised the personal privacy and confidentiality of a census of 173 residents when meal tray tickets (a crucial document that ensures each resident receives the correct and personalized meal based on their individual needs and preferences) were thrown into the trash. This failure had the potential to expose personal and medical health information to non-facility staff. During the initial kitchen tour on 8/4/25, at 10:12 a.m., meal tickets with resident names were observed in the garbage can in the dishwashing area. During the initial kitchen tour on 8/4/25 at 10:22 a.m., the path taken of kitchen trash to the outside dumpsters in the parking lot was observed. The parking lot was not gated or secured from the public. During a review of tray tickets for lunch on 8/5/25, the meal tickets included the following information: [...]

Inspectors wroteBased on interview and record review, the facility failed to verify that the Preadmission Screening and Resident Review (PASRR - a federally required screening process designed to ensure that individuals with serious mental illness [SMI], intellectual disability [ID], or related conditions are not inappropriately placed in nursing facilities) was accurate for four out of 38 sampled residents (Resident 11, Resident 81, Resident 131 and Resident 47), when: Resident 81's SMI was not indicated on the PASRR; and,Resident 11's PASRR Level I Screening indicated the need for a Level II Screening, but none was found in the medical record; and,Resident 131 had a positive Level I PASRR screening and the required level II PASRR (Mental Health Evaluation) screening was not completed due to facility not being available on repeated attempts for contact in June of 2025; [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure safe pharmaceutical services with resident census of 172 when:1. Non-controlled prescription medications (drugs that can only be prescribed by a doctor for a specific resident) were not disposed and documented to reflect safe and accountable drug disposition.2. Emergency Kits (or Ekit, box of medications for emergency use) for IV (Intravenous- Into the Vein) and oral medications were not replaced in a timely manner, narcotic (opioid) medication removal documented without provider pharmacy approval code and opened Ekit medications were co-mingled unsafely at the East and North station medication rooms.3. Controlled medications (narcotic opioid- drugs of abuse) use and pain level were not accurately documented in Medication Administration Record (or MAR) for Resident 122 and Resident 160. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices in two out of four medication rooms (a locked room used to store medications and supplies) and three out of 7 medication carts (a mobile cart stored medication and supplies for immediate use) with census of 172 when:The medication room in East station stored expired (the date after which the drug should not be used), undated and unlabeled medications and the sink was kept in an unclean condition. The medication room in the North station stored expired blood tube supplies (a test tube is a cylindrical, transparent container used to store and transport samples of blood for testing) and opened an undated over-the counter medication bottle. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food served was prepared by methods that conserve nutritive value, flavor and appearance for 172 of 172 residents that consumed facility prepared meals. These failures had the potential for decreased meal intake which could result in weight loss, malnutrition, and negatively impact the residents' quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide alternate food choices with similar nutritive value to the main meal for 172 residents who received food from the kitchen. These failures had the potential of not meeting estimated nutrient needs and potential weight loss. During an initial kitchen tour on 8/4/25 at 8:11 a.m., the alternate menu was reviewed. The alternate menu included chef's salad, grilled cheese sandwich, cottage cheese and fruit, and hamburgers. During a subsequent interview on 8/4/25 at 8:15 a.m. with the Certified Dietary Manager (CDM), the CDM confirmed that the alternate meal choices were chef's salad, grilled cheese sandwich, cottage cheese and fruit, and hamburgers. During an interview on 8/4/25 at 2:54 p.m. Resident 84 stated that they used to get alternatives like sandwiches but all they get now are snack type items. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food per safety standards when:Cool down log was not followed consistently. Sugar and flour were stored in the same container. Bowls and pans were found stored wetSmall wares (pans, bowls, cutting board, can opener) were not replaced when worn. Shelves were found discolored and worn (under microwave and grill). Fans were found with black residue (dust) Forks stored in a manner causing fingers to touch the eating surface. Resident refrigerator logs were not acted upon when out of range, and had foods improperly labeled and not discarded per policy. These failures had the potential to lead to cross contamination and food borne illness for the 172 residents eating facility prepared meals. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate antibiotic monitoring documentation and failed to implement all core elements of the Antibiotic Stewardship Program (ASP, antibiotic use protocols and a system to monitor antibiotic use) for a census of 173 residents when the facility did not have:1. A current infection Surveillance Plan (a written guide that explains how to watch for and track infections), 2. Complete antibiotic tracking data (the information collected by the facility regarding how antibiotics are used and how effective they are against bacteria),3. Documented evidence of antibiotic time-outs (a planned pause usually 48-72 hours after starting antibiotics, to ensure the medication is still appropriate). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program when multiple flies were seen in the food preparation area. This failure had the potential of contamination of food and food poisoning for the 172 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy and dignity were maintained for one of 38 sampled residents (Resident 127) when Resident 127's urinary catheter bag (catheter bag - a bag that collects urine draining from the bladder) did not have a privacy cover (a cover designed to discreetly conceal the visible urine in a urinary catheter bag, improving resident dignity, comfort, and self-worth in public or social settings) over it. This failure had the potential to negatively impact Resident 127s feelings of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage of bedside self-administered medication was reviewed and approved by a doctor and the care team for one resident (Resident 1) out of 12 sampled residents observed for medication administration when Resident 1's albuterol inhaler (a medication used to treat shortness of breath) was found on her bedside table. This failure had potential to contribute to unsafe and unsecure medication use by Resident 1 and other residents including Resident 1's roommates. During a medication administration observation with Licensed Nurse (LN) 10, at the facility's [NAME] Station hallway, on 8/4/25, at 8:37 a.m., LN 10 was observed giving six medications to Resident 1, which included TRELEGY Ellipta (inhalation drug to treat chronic breathing disease) as a scheduled drug to treat a breathing condition. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the Responsible Party (RP - an individual chosen by a resident or appointed by a judge to make personal and/or financial decisions for an adult who cannot care for or make decisions for themselves) for one out of thirty-eight sampled residents (Resident 153), when Resident 153 had a change in condition (any change in a resident's physical, mental, or emotional state from their normal baseline, possibly indicating a new illness or injury or worsening of a condition, recognized and treated to prevent serious complications, and to maintain resident health and safety), was sent to the emergency room (ER), and an RP was not notified in a timely manner. This failure resulted in miscommunication between the facility, the RP, and the ER when medical decisions were made for Resident 153 without input from the RP.

Inspectors wroteBased on interview and record review, the facility failed to immediately resolve a grievance and did not respond in writing within five business days to one out of 38 sampled residents (Resident 81), in accordance with facility policy when Resident 81 submitted a grievance form in June 2025, but the facility did not provide a resolution or follow-up until August 2025. This delay in addressing the grievance negatively impacted the psychosocial wellbeing of Resident 81.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of seven sampled residents (Resident 3) who received hospice care services (a specialized care that provides physical comfort and emotional, social and spiritual support for people nearing the end of life), when a hospice care plan was not developed for Resident 3. This failure had the potential to have a negative impact on Resident 3's quality of life, as well as the quality of care and services received.

Inspectors wroteBased on interview and record review, the facility failed to update and revise the comprehensive care plan for one of three sampled residents (Resident 19) who had a pressure ulcer (a skin and tissue injury caused by prolonged pressure, typically on bony areas of the body), when Resident 19's pressure ulcer care plan was not updated to reflect his current treatment plan and pressure ulcer stage (pressure ulcers are categorized into stages based on their severity, ranging from early warning signs to deep tissue damage) after a change on 6/26/25. This failure placed Resident 19 at risk of not receiving adequate wound care, delayed wound healing, potential wound complications, and worsen wound condition.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the safe storage and handling of hazardous medications (HD - medications that pose potential risks to healthcare workers, patients, or the environment during handling, preparation, administration, or disposal). Additionally, continuous glucose monitoring (CGM) was not used safely according to standards of practice and manufacturer specifications with a census of 172, when:1. Hazardous drugs were stored in active storage areas without warning labels in the facility's medication cart at North-B station, and Finasteride (HD), a drug that blocks hormone production, was administered to one resident (Resident 169) out of 12 residents observed for medication administration without gloves on at South station.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate interventions for one of thirty-eight sampled residents (Resident 14), when Resident 14's hand splint (a device designed to protect and support painful, swollen or weak joints and their surrounding structure) used to address Resident 14's hand contractures (a permanent shortening of muscle, tendon, or scar tissue producing deformity or distortion) were not followed up by Occupational Therapy or facility staff. This deficient practice placed Resident 14 at risk for further decline related to her hand contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's environment remained free of accident hazards for a census of 173 when:1. oxygen signage was not posted outside the door of Resident 36 who was receiving oxygen; and,2. Resident 119, diagnosed with dementia (a decline in mental ability severe enough to interfere with daily life) and a history of exit-seeking behavior, eloped (leaving a healthcare facility or care setting without authorization or discharge, often due to confusion, disorientation, or a lack of safety awareness, putting them at risk of injury or even death) from the facility unsupervised, and was missing for an unknown period of time before being found down the street by family. This failure placed residents at risk of injury due to fire hazards and placed Resident 119 at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate health treatment and services to meet the urological (the branch of medicine focused on the urinary tract/system) health needs for two of 38 sampled residents (Resident 70 and Resident 12) when: 1. There was no record of indwelling catheter (urinary catheter, a tube which is inserted into the bladder and left in place to drain urine) care being provided to Resident 70's urinary catheter every shift each day per physician order, and Resident 70's urine output was not documented every shift each day per physician order. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with resident census of 172. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 57 opportunities which resulted in a facility wide medication error rate of 5.26% in 3 out of 14 residents (Resident 30, Resident 45, and Resident 169) observed for medication administration. The medication errors were as follows: 1. Resident 30 received the wrong formulation of aspirin (medication used to help prevent stroke or heart attack); 2. Resident 45 received the wrong formulation of aspirin; and, 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the garbage storage area when 2 out of 6 dumpsters were observed overflowing the sides of the dumpster and the lids could not close. This had the potential of attracting pest potentially leading to food contamination for the 172 residents' eating facility prepared meals. During the initial kitchen tour on 8/4/25 at 10:12 a.m., the dumpster area was observed. Two of the six dumpsters were noted to have garbage exceeding the side walls of the dumpsters, interfering with the closure of the lids. One lid was noted to rest approximately 6 inches above the bin, supported by bags of garbage. The second lid had been left open. The dumpsters were housed in an area approximately 15 to 20 feet from the door to the hallway of the kitchen. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one out of thirty-eight sampled residents (Resident 153), when the facility did not update Resident 153's admission Record (a comprehensive collection of documents and information gathered at the time a resident is admitted or readmitted to a facility) with afterhours and weekend phone numbers for notification to the Responsible Party (RP - an individual chosen by a resident or appointed by a judge to make personal, medical, and/or financial decisions for an adult who cannot care for or make decisions for themselves) when status changes and health updates occurred. This failure resulted in Resident 153's RP 3 and RP 4 not receiving notification when Resident 153 had a change in condition that occurred after regular business hours or on weekends.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection prevention practices (a set of measures taken to stop the spread of germs and infections) were implemented and followed for a census of 172 when there were two unlabeled urinals (portable, bottle-shaped containers designed for male patients to urinate into when they cannot reach a toilet) on the nightstand next to Resident 133's bed. This failure had the potential to place residents at risk for developing an infection and the potential to result in transmission of infection in the facility. During an observation on 8/4/25 at 11:40 AM, in Resident 133's room, there were two urinals on the nightstand next to Resident 133's bed and they were not labeled with a name, initials or other identifying information indicating to whom they belonged. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to prevent a fall for 1 of 5 sampled residents (Resident 1) when, Resident 1 was left unattended in the bathroom. This failure caused Resident 1 to sustain a fall which resulted in a scalp laceration (cut to the head).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide podiatry services (service provided by a podiatrist; a health professional trained to diagnose and treat diseases and other disorders of the feet) for one of three sampled residents (Resident 1) as ordered by the physician. This deficient practice had the potential to affect Resident 1 ' s foot health with a possibility to contribute to pain and podiatric complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure all necessary baseline care plans were created within forty-eight hours of admission for 1 of 3 sampled residents (Resident 1) when, Resident 1 ' s conditions and risks identified upon admission were not created and implemented as part of Resident 1 ' s baseline care plans. This failure resulted in Resident 1's care plan for communication, dehydration, skin, and incontinence not being created and initiated during any part of Resident 1's stay at the facility as they were not initiated until after Resident 1 was discharged from the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care in accordance with professional standards of practice when: 1. Resident 1's blood pressure (BP - the measurement of the pressure in your arteries when your heart contracts and pumps blood out) medication amlodipine was administered without consistent monitoring of Resident 1's BP prior to administration of the medication and there were no parameters listed on the order to indicate when to hold the medication; and, 2. Resident 1's BPs were not taken regularly during his stay at the facility and a BP of 272/114 was not acted upon (normal blood pressure is less than 120/80). These failures resulted in Resident 1's BP becoming increasingly elevated with inconsistent BP monitoring once Resident 1 started receiving the BP medication amlodipine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of four sampled residents' (Resident 1) property from loss. This failure resulted in Resident 1 having lost property and had the potential to cause Resident 1 emotional distress.

Inspectors wroteBased on interview, and record review, the facility failed to ensure professional standards of care were met for one out of three sampled residents (Resident 1) when Resident 1's post incident documentation (documentation of assessments and observations after an incident occurs) was incomplete. This failure had the potential for Resident 1 to have unassessed injuries and/or illnesses and unmet psychosocial needs.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the right to return to the facility was protected for one of one sampled resident (Resident 1), when: 1. Resident 1 was sent to the hospital and was not allowed to return to the facility on 6/7/24, 2. A facility physician did not document a basis for Resident 1's discharge; and, 3. The facility failed to provide a written Notice of Transfer or Discharge to Resident 1, Resident 1's representative (RP), and the Long-Term Care (LTC) Ombudsman (a patient rights advocate). These failures placed Resident 1 at risk for emotional distress, removed the opportunity for the State LTC Ombudsman to advocate on Resident 1's behalf, and deprived Resident 1 or his RP of information regarding rights to appeal the transfer/discharge.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan to address resident-specific care needs for one of three sampled residents (Resident 3) when, there was no care plan with interventions developed to address Resident 3's dysphagia (difficulty swallowing foods or liquids). This failure had the potential to result in staff being unaware of Resident 3's aspiration [accidentally inhaling your food or liquid through your vocal cords into your airway, which increases your risk of developing pneumonia (infection in the lungs)] risk and not knowing interventions to reduce possible physical harm and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) received care in accordance with professional standards when, speech therapy placed a sign above Resident 3's bed which indicated no straws and Resident 3 had a straw in her milk for the lunch meal on 7/18/24. This failure had the potential to result in Resident 3 aspirating (aspirate; accidentally inhaling your food or liquid through your vocal cords into your airway, which increases your risk of developing pneumonia (infection in the lungs)) on liquids, which could result in physical harm and/or death.

Inspectors wroteBased on interview and record review the facility failed to ensure a process was in place for 42 residents, who had funds in the facility trust account (a legal arrangement through which funds are held by a third party), to request and receive personal funds on the weekends or after hours. This failure had the potential to result in residents not having access to their personal funds for dining, shopping, or other resident centered activities after business hours and on the weekend which could adversely affect their psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food being served for the lunch meal on 6/19/24 was accurate for 10 residents when 10 residents with an order for Double Protein instead received double of each food item for a census of 171. This failure had the potential for all 10 residents' nutritional needs not to be met and could lead to nutritional related health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices for 171 residents who received food from the kitchen when: 1. Multiple food items were found not labeled with a use by date (the last date recommended for the use of the product while at peak quality) in the refrigerator, freezer, and the dry storage area (foods that do not require to be kept cold), and were available for resident consumption (to eat/drink); 2. Expired (outdated) food products were not removed from the kitchen, and were available for resident consumption; 3. A fan above the double coffee maker in the kitchen had dust and lint; 4. Plastic cups in the kitchen were stacked wet after washing; 5. Three opened boxes of plastic silverware were opened and uncovered in the dry storage area; 6. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain its infection control program when: 1a. The facility did not ensure enhanced barrier precautions (targeted gown and glove use during high contact care activities for those with indwelling devices and/or certain infections) were observed when completing a dressing change for Resident 126; 1b. The facility did not ensure the dressing changes were dated, timed, and initialed for Resident 126; 2. A clean linen cart, containing clean linen items, was transported with the cover flap open; and, 3. Hand hygiene was not performed during wound care for Resident 2. These failures had the potential to spread infections to residents residing in the facility, negatively impacting their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy and dignity were maintained for one of seven resident's (Resident 2) with a urine collection bag (urinary catheter-a tube that is inserted into the bladder and drains into a collection bag) in a census of 170, when Resident 2's urine collection bag did not have a privacy cover over it. This failure had the potential to negatively impact Resident 2's feelings of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 2 of 39 sampled residents (Resident 103 and 169) when: 1. Resident 103's call light (a device used to call for assistance) was not within reach; and, 2. Resident 169's call light was not within reach. This failure had the potential to result in Resident 103 and 169 being unable to ask for needed assistance.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 39 sampled residents (Resident 150) right to self-determination was respected when Resident 1 requested to get a shower instead of a bed bath and staff did not honor his wishes. This failure had the potential to negatively impact Resident 150's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR, 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) program for 1 of 39 sampled residents (Resident 26) when Resident 26's PASRR level I screening assessment did not include her mental illness diagnosis of schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves). These failures had the potential for Resident 26 to not receive the necessary services to meet her mental and psychosocial (link between social factors and individual thought and behavior) needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accidents or hazards for one resident (Resident 80) in a census of 170 with access to smoking paraphernalia when Resident 80 went to the sidewalk in front of the facility to smoke unsupervised. This failure had the potential to place Resident 80 at risk for accidental burns and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of thirty nine sampled residents (Resident 189) was provided services consistent with professional standards of practice when Resident 189's Peripherally Inserted Central Catheter (PICC line; a thin, soft long tube that is inserted into a vein in the arm with the tip of the catheter positioned in a large vein that carries blood to the heart in order to provide medications) dressing was not changed per physician orders. This failure had the potential to result in a PICC line malfunction and/or infection for Resident 189.

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 one of 39 sampled residents (Resident 52) when Resident 52's oxygen tubing was not changed per physician order. This failure had the potential to result in a negative impact on the Resident 52s' health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of thirty nine sampled residents (Resident 71) received services consistent with professional standards of practice when Resident 71's pre and post dialysis (treatment of kidney failure that rids the blood of unwanted toxins, waste products, and excess fluids by filtering the blood) documentation (documentation that communicates the residents weight, blood pressure, temperature and heart rate,vital signs), dialysis catheter site (flexible tube placed in the blood vessel inserted in the chest consisting of two tubes one to take blood to the dialysis machine and one to return blood to the body) assessment, medication changes, changes in condition, and other pertinent clinical information, between the facility and dialysis center) was incomplete for 5 out of 6 days of treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate dispensing and administering of narcotic drugs (regulated and highly addictive pain medication) for one of 39 sampled residents (Resident 545). This failure resulted in Resident 545 not being administered pain medication for the management of pancreatic (pancreas, an organ in the body that makes juices that help break down food into substances the body can use) cancer and lung cancer.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper use of psychotropic drugs (affecting brain activity) for 1 of 39 sampled residents (Resident 155) when: The physician did not document a rationale for extending PRN (as needed) medication beyond 14 days for Resident 155. This failure could have resulted in the use of unnecessary medications and placed the residents at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled and stored appropriately when: 1. Medication bottles had spillage on them, and there was a sticky substance on the bottom of the medication storage drawers in the medication carts; and, 2. An insulin pen (a device used to inject insulin, a medication to control blood sugar) for Resident 92, was available for use past its expiration date. These failures had the potential to cause illness in residents receiving medications from bottles of medications with spillage on them and Resident 92 was at risk of receiving insulin that had lost is efficacy (potency).

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS, a resident assessment and screening tool) Assessment was completed on admission, within 21 days of the assessment reference date (ARD) for one of three sampled residents (Resident 3) when Resident 3 was admitted to the facility on [DATE] and the MDS assessment was incomplete on 5/17/24. This failure had the potential to delay the development of individualized care plans based on Resident 3's needs, strengths, and goals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of quality care were met for 5 of 6 sampled residents, (Resident 1, Resident 2, Resident 4, Resident 5, and Resident 6) when their scheduled morning medications were not administered in a timely manner. This failure had the potential to negatively affect the therapeutic benefits of the medications prescribed to Resident 1, Resident 2, Resident 4, Resident 5, and Resident 6.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide an environment free from the risk of infection for a census of 183 residents when, 1. The facility did not provide or ensure working hand sanitizer dispensers throughout the facility when eight of fifteen hand sanitizer dispensers on the South Wing and six of twenty-two hand sanitizer dispensers on the East Wing were found to not be functioning; and 2. Staff did not perform hand hygiene (washing your hands) prior to entering and exiting residents ' room and before and after performing resident care. These failures resulted in a potential for the spread of infection to residents, visitors, and staff of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify one of three sampled residents (Resident 1) responsible party (RP, one person has the authority to make decisions for another person) of the results of a hearing examination performed on 11/7/23, Resident 1's need for hearing aids after the hearing examination, and when hearing aids were recommended and issued to Resident 1. This failure prevented Resident 1's RP from being involved in Resident 1's care and removed the opportunity for the RP to make decisions for Resident 1 regarding a medical examination (hearing test) and a medical device (hearing aids).

Inspectors wroteBased on interview, observation, and record review the facility failed to provide an environment free of hazards to prevent an accident from occurring for two of two sampled residents (Resident 1 and Resident 2) when: 1. The facility did not also remove the brackets that held the footboard in place when the footboard had been removed from Resident 1 ' s bed which resulted in a laceration (a cut) to Resident 1 ' s right lower leg on 2/13/24 and an infection to the laceration on 2/22/24; and 2. The mattress keeper rod to hold Resident 2 ' s mattress in place on the bed frame was not in the correct position. This failure resulted in an extensive injury to Resident 1 ' s leg which required an emergency room intervention of ten staples (metal material used to close a wound to help it heal). Subsequently Resident 1 ' s injury became infected which had the potential for further bodily harm. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their care plan interventions and/or develop care plans for 2 of 4 sampled Residents (Resident 2 and Resident 3) when: 1. Resident 2 and Resident 3 ' s fall risk care plan interventions of call lights in reach were not followed and, 2. Resident 2 did not have care plans developed for the psychotropic medications she received for striking out, yelling, social isolation and attention seeking behaviors. These failures had the potential for Resident 2 and Resident 3 to sustain further falls and Resident 2 ' s behavioral care needs and goals to not be addressed and reassessed.

Inspectors wroteBased on interview and record review the facility failed to ensure that one of four sampled residents (Resident 2) was free from unnecessary psychotropic drugs (drugs that effect brain activities associated with mental processes and behaviors) when Resident 2 was prescribed: 1. Lorazepam (antianxiety medication) as needed (PRN) twice a day for greater than 14 days with inconsistent documentation of behaviors to justify its use, and 2. Sertraline (Antidepressant medication) without an appropriate diagnosis and no documentation to justify its use. These failures placed Resident 2 at risk of unsafe medication use and adverse medication side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of care were met for one out three sampled residents (Resident 3), who had sustained a fall, when post fall alert charting (documentation of assessments and observations) was not completed for Resident 3. This failure had the potential for Resident 3 to have sustained an injury which was not identified, and could result in a delay of treatment.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of care for one of three sampled residents (Resident 1), when Resident 1's laboratory test (a medical procedure performed to detect, diagnose, or monitor disease) result was missing from Resident 1's record, and was not followed up on by the facility. This failure had the potential abnormalities in Resident 1's lab results would be undetected and could result in a delay of treatment for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) received adequate care and treatment, when the facility: 1. Failed to promptly inform Resident 1's physician of her abnormal laboratory test results indicating that the resident had a urinary tract infection (UTI, an infection involving any part of the urinary system, including urethra, bladder, and kidney) start treatment; and, 2. The facility failed to assess Resident 1 and identify the cause of the resident's cognitive decline, lethargy, and decreased food and fluids intake after her delayed treatment for her UTI. These failures resulted in a delay in promptly identifying, assessing, and treating Resident 1's urinary tract infection until 12 days after results were obtained. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure drug record forms were in order and an account of all controlled drugs (drugs whose use and distribution are tightly controlled because of their abuse potential) was maintained and periodically reconciled when 64 tablets of various narcotics (prescribed by doctors to treat persistent or severe pain) were found to be missing out of the emergency drug kit (E-Kit) by the Pharmacy. This failure allowed for possible diversion (the illegal distribution or abuse of prescription drugs) of controlled drugs.

Inspectors wroteased on observation, interview and record review, the facility failed to provide the necessary care and services to ensure that one of 39 sampled residents (Resident 108's) functional abilities did not diminish when Resident 108 had a decline in his ability to transfer and walk, and services were not provided to determine the cause and/or to maintain his abilities. This failure resulted in Resident 108's decline in range of motion, (ROM, the full movement potential of a joint) to his left leg, and a decline in his transfer and ambulation abilities.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to follow proper sanitation and food handling practices for 157 residents, in a census of 158, receiving food from the kitchen when: 1. Storage bins containing clean utensils had dust and debris on the bottom; 2. Food items were available for use past the expiration date; 3. The nourishment refrigerator in the kitchen did not have a June temperature log; 4. Overhead lights above steam table were dusty, cracked, and with debris; 5. Unit nourishment refrigerators contained food items past their expiration date; and, 6. Unit refrigerators contained food debris and stains. These failures had the potential to cause an outbreak of foodborne illnesses (eating or drinking something that is contaminated with germs or chemicals that can make people sick).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person centered care plan for 3 of 39 sampled residents (Resident 19, Resident 109 and Resident 66) when: 1. Range of motion (ROM) care plans were not developed for Resident 19 and Resident 109; and, 2. An anticoagulant (medication to prevent blood clots) care plan was not developed for Resident 66. These failures had the potential to result in adverse effects to the health and well- being of Resident 19, Resident 109 and Resident 66.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 39 sampled residents (Resident 38, Resident 5, and Resident 19) were assisted with nail care as part of their Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when: 1. Resident 38 had long, jagged fingernails with sharp edges, and with blackish substance underneath the fingernails; 2. Resident 5 had fingernails that were long and with blackish substance underneath the fingernails; and, 3. Staff did not trim Resident 19's fingernails. These failures resulted in Resident 38 sustaining scratches on the right forearm, Resident 5 to be at risk for worsening skin condition of lower back and buttocks due to scratching, and had the potential for Resident 19 to sustain injury and/or for the residents to acquire an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment in accordance with professional standards of practice for one of thirty-nine sampled residents (Resident 116) when, Resident 116's wound care dressings were not consistently changed as ordered. This failure had the potential to result in infection and delayed wound healing for Resident 116.

Inspectors wrote2. a. During an observation on 6/19/23, at 8:35 a.m., Resident 104's oxygen flow rate was at 5 liters per minute (LPM). During an interview on 6/19/23, at 8:40 a.m., with LN 7, she stated the oxygen flow rate for Resident 104 should be at 4 LPM. During a review of Resident 104's oxygen order, dated 6/19/23, indicated, Oxygen 2-4 liters per nasal canula. b. During an observation on 6/19/23, at 8:53 a.m., Resident 549's oxygen flow rate was at 5 liters per minute (LPM). During an interview on 6/19/23, at 8:53 a.m., with LN 8, she stated the oxygen flow rate for Resident 549 should be at 4 LPM. During a review of Resident 549's oxygen order, dated 6/19/23, indicated, Oxygen 4 L [liters] nasal canula or mask .Document .liters per minute. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of 39 sampled residents (Resident 53) was free of significant medication errors, when Resident 53 did not receive insulin (medication to regulate blood sugars) as ordered by the physician. This failure had the potential for Resident 53's blood sugars to remain above 200 which could adversely affect her health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food served was palatable and at an appetizing temperature when: 1. 2 of 39 sampled residents' (Resident 110 and Resident 81) meals were delivered late and cold; 2. The facility failed to ensure standardized recipes were followed for puree (smooth texture) food preparation for 1 of 15 residents (Resident 450) who received pureed food; and, 3. The facility failed to provide 1 of 39 sampled residents (Resident 133) with a salt substitute. These failures had the potential for decreased meal intake which could result in weight loss, and decreased nutritive value and negatively impact the residents' quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for two of thirty-nine sampled residents (Resident 108 and Resident 440) when; 1. Resident 440's meal intake documentation was incomplete; and 2. Resident 108's ADL (activities of daily living) documentation was incomplete. This failure had the potential to not provide sufficient information that reflected the condition, care and services provided for Resident 440 and Resident 108. 1. During a concurrent interview and record review on 6/22/23, at 2:50 PM, Resident 440's Task: Amount Eaten, for the month of 6/2023 was reviewed with the Assistant Director of Nursing (ADON). The ADON stated CNA's (certified nurse assistant's) were required to document the meal intake for every meal, three times a day. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices for a census of 158 when; 1. Staff did not wear gown and gloves while providing care for a resident on contact precautions (used to prevent the spread of infectious germs); 2. Two out of two clean linen delivery carts were found with a thick layer of dust on the inside corners; and, 3. Resident 83's indwelling urinary catheter (a tube inserted into the bladder to drain or collect urine) bag was placed on the floor. These failures had the potential to spread germs and cause infection among residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect two out of 39 sampled residents' (Resident 33 and Resident 51) right to be treated with respect and dignity when Resident 33 and Resident 51's meals were not served at the same time with other residents in the east dining room during the 6/20/23 lunch meal. This failure resulted in Resident 33 and Resident 51 experiencing emotional distress and irritation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (device used to communicate a need for assistance) was in reach for 2 of 39 sampled residents (Resident 3 and Resident 87), when Resident 3 and Resident 87's call lights were attached to the bottom of the bed rail out of reach. This failure had the potential for Resident 3 and Resident 87 to suffer adverse consequences and potential harm due to the inability to call for assistance.

Inspectors wroteBased on interview and record review, the facility failed to provide three of three sampled residents (Resident 11, Resident 19, Resident 99), whose funds were managed by the facility, with quarterly financial statements. This failure resulted in Resident 11, Resident 19, Resident 99 lacking information regarding the status of their funds.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, comfortable, homelike environment for 2 of 39 sampled residents (Resident 2 and Resident 66) when: 1. The wall beside Resident 2's bed had deep gouges and peeling paint in an area measuring 20 inches in length by 11 inches in width; and, 2. Resident 66's bedside table had a torn foam border surrounding the table edges with exposed glue. These failures resulted in Resident 2 and Resident 66 not being provided a homelike environment, with the potential to negatively impact their psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop all of the identified components of a baseline care plan within 48 hours of admission, to address resident-specific care needs for one of thirty-nine sampled residents (Resident 444) when, Resident 444's oxygen use care plan was not created upon admission. This failure had the potential to result in unmet oxygen use needs for Resident 444.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of thirty-nine sampled residents' (Resident 451) comprehensive care plan interventions met professional standards of practice when, Resident 451's infection care plan interventions did not include the correct Personal Protective Equipment (PPE; protective clothing, goggles, facemask, or other garments used to prevent the spread of germs) for staff to put on prior to providing care to Resident 451. This failure resulted in insufficient interventions to provide appropriate infection control, with the potential for staff to spread infectious germs to others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of thirty-nine sampled residents (Resident 108) received activities that met their interests and needs, when Resident 108 did not attend group activities and in room activities were offered infrequently. This failure had the potential to adversely affect the psychosocial needs and well-being of Resident 108.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide preventive care and treatment consistent with professional standards of practice for two of 39 sampled residents (Resident 32 and Resident 7) when: 1. Resident 32's pressure injury (PI, injury to skin and underlying tissue resulting from prolonged pressure) treatment order on the left heel was not followed; and, 2. Resident 7's variable pressure pump system overlay pad (a specialized overlay mattress designed to prevent prolonged/constant pressure on any skin area and is used for prevention and treatment of pressure injuries) was found folded/curled on the bottom of the bed and the pad was only reaching up to Resident 7's waist while in use. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of thirty-nine sampled residents (Resident 133) received proper treatment and care to maintain good foot health when, Resident 133 was not referred to podiatry (a branch of medicine devoted to the study, diagnosis, and treatment of disorders of the foot and ankle) services when requested. This failure resulted in Resident 133 attempting to maintain his own footcare and had the potential to result in injury and/or infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accident hazards for one of thirty-nine sampled residents (Resident 444) when, Resident 444's oxygen cylinder (a metal cylinder containing oxygen under pressure) was placed on the floor in Resident 444's room without a cylinder stand. This failure had the potential to cause injury to Resident 444 if the oxygen cylinder fell over.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one resident (Resident 116) who received parenteral fluids (delivery of fluid or medication through a vein) was provided services consistent with professional standards of practices when: 1. Resident 116's PICC (Peripherally Inserted Central Catheter; a thin, soft, long catheter (tube) that is inserted into a vein in the arm with the tip of the catheter positioned in a large vein that carries blood into the heart in order to provide medications) line hubs (the area of the cap where syringes are attached) were not cleaned with alcohol for the appropriate length of time; 2. There were no PICC line dressing change or cap change (removable caps at the end of the PICC line) orders for Resident 116; and, 3. There was no care plan created in relation to Resident 116's PICC line. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided for one of thirty-nine sampled residents (Resident 448) when, Resident 448's lidocaine patch (a medicated patch applied to the skin to relieve minor pain) was not applied and a pain care plan was not created. This failure has the potential to result in poorly controlled pain for Resident 448.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than five percent when two medication errors occurred, out of 31 opportunities, during medication administration for one out of five residents observed (Resident 53). The facility error rate was 6.45 percent. This failure had the potential to negatively impact the health and well-being of Resident 53.

Inspectors wroteBased on interview and record review, the facility failed to store medications in accordance with professional standards for one of four medication rooms when the north station medication room temperatures were not monitored as required. This failure had the potential for medications to lose effectiveness.

Inspectors wroteBased on interview and record review, the facility failed to ensure that food preferences were assessed in a timely manner and honored for one of thirty-nine sampled residents (Resident 440) when: 1. Resident 440's food allergies, intolerances, and preferences were not assessed until 8 days after admission; and, 2. Resident 440 was not provided coffee and was served eggs and milk for breakfast on 6/22/23 which was not in accordance with Resident 440's assessed preferences. These failures had the potential to result in unintended weight loss and other medical complications such as constipation for Resident 440.