Gordon Lane Care Center

Inspectors wroteBased on interview, medical record review, facility document, and facility P&P review, the facility failed to protect the resident's rights to be free from physical abuse by another resident for one of 10 sampled residents (Resident 1). * The facility failed to ensure Resident 1 was free from abuse when the CNA heard yelling and slapping noise and observed Resident 2 pushed Resident 1 on the shoulder out the door. This failure posed a risk for the resident to sustain an injury and experience negative psychosocial outcome.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one of 10 sampled residents (Resident 4) investigated for abuse. * The facility failed to report Resident 4's allegation of feeling her rights were disregarded and when Resident 5 was being rude to her. This failure posed a risk for the abuse allegation to go unreported and uninvestigated, and put the residents at risk for further abuse.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to show documented evidence one of one final sampled resident (Resident 2) reviewed for personal property was provided with an explanation of his rights regarding personal property. * The facility failed to show documentation Resident 2 was provided with an explanation to address the risks of having a razor and a blade at the bedside, and his right to access the razors he bought online. These failures resulted in Resident 2 feeling upset and frustrated about the facility controlling the use of his razors.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs of one nonsampled resident of 96 facility census (Resident 105). * The facility failed to ensure Resident 105's call light button was within the resident's reach. This failure posed the risk of delay in providing care to Resident 105, and the potential to negatively impact the resident's psychosocial well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain a copy of the advance directive in the medical record readily accessible to the facility staff for one of six final sampled residents (Resident 1) reviewed for advance directives. This failure had the potential for Resident 1's decision regarding his healthcare and treatment options to not be honored.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 17 and 68) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure Resident 17 was monitored for the specific behavior related to the use of the Seroquel ( antipsychotic medication) medication. In addition, the facility failed to ensure Resident 17's orthostatic blood pressure (measure the blood pressure while laying down and sitting) was monitored for the use of the Seroquel medication. Furthermore, the facility failed to ensure the non-pharmacological interventions were identified and implemented for the psychosis behavior exhibited by Resident 17 related to the use of the Seroquel medication. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the notice of discharge and notify the Ombudsman for two of three sampled residents (Residents 9 and 99) reviewed for the closed records. * The facility failed to provide the notice of discharge and notify the Ombudsman when Resident 9 was discharged from the facility AMA (against medical advice). * The facility failed to notify the Ombudsman of the resident's discharge from the facility when Resident 99 passed away. These failures had the potential for the residents and/or representatives and Ombudsman to not know the specific details/reason/basis of the residents' discharge from the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the PASRR screening for one of two final sampled residents (Resident 5) was accurately completed as per the facility's P&P. * The facility failed to accurately complete the PASRR screening to reflect Resident 5 was on a psychotropic medication and had history of developmental delay. This failure had the potential for the resident to not be screened for mental illness, intellectual disabilities or related conditions, and received any additional resources if needed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop and implement a comprehensive person-centered care plan for two of 21 final sampled residents (Residents 2 and 63). * For Resident 2, there was no care plan developed for the resident's surgical wound. * For Resident 63, there was no care plan developed and implemented for the scabies and contact isolation. These failures had the potential of not providing the residents with person-centered plans of care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure three of 21 final sampled residents (Residents 2, 4, and 63) attained and maintained their highest practicable well-being. * The facility failed to ensure Resident 2 was monitored post removal of staples from a wound on the resident's left foot. Additionally, there was no care plan developed to address the removal of the staples. * The facility failed to monitor Resident 4's vital signs every shift as per plan of care when the resident had a change in condition for weight gain of 3 (three) pounds related to edema (swelling that occurs when fluid builds up in the body's tissues). * The facility failed to ensure Resident 63's primary physician was notified of the Wound Physician's recommendation. [...]

Inspectors wroteBased on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure two final sampled residents (Residents 4 and 7) were provided with the necessary care and services when: * The facility failed to monitor Resident 4 when the resident developed a MASD (moisture-associated skin damage caused by prolonged or repeated exposure to moisture) in the sacral area, per the facility's Change of Condition protocols. The facility failed to provide documented evidence Resident 4 was monitored every shift for 72 after the identification of a MASD in the sacral area. In addition, the facility failed to initiate a care plan for Resident 4's non-compliance with the interventions to address the sacral wound. The MASD was classified as an unstageable pressure injury eight days later. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for the use of the GT for two of three final sampled residents (Residents 1 and 8) reviewed for the GT feeding. * The facility failed to ensure the HOB was elevated at a minimum 30-degree angle when the enteral feeding was infusing via GT, to reduce the risk of aspiration (entry of food, liquid or foreign material into the airway) for Residents 1 and 8. This failure posed the risk for complications related to use of GT for Residents 1 and 8.

Inspectors wroteBased on observation, interviews, medical record reviews, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for four final sampled residents (Residents 4, 7, 68, and 102) reviewed for the IV care. * The facility failed to ensure Resident 2's peripheral IV was inserted with an ultrasound by an outside vascular access provider as per the physician's order. * For Resident 4, the facility failed to ensure the midline catheter dressing change, external catheter and arm circumference measurement, the injection cap of the midline lumen and securement device were change upon admission and as per the physician's order. * The facility failed to monitor Resident 68's Port-A-Cath site for the signs and symptoms of infection and bleeding every shift as per the physician's order. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for suctioning for two of two final sampled residents (Residents 1 and 7) reviewed for respiratory care. * The facility failed to ensure the Yankauer suction tip was stored in a bag when not in use, and the suction canister and tubing were dated and changed weekly for Resident 1, per the facility's P&P. * The facility failed to ensure a physician's order was obtained prior to suctioning Resident 7. In addition, the facility failed to ensure the Yankauer suction tip was stored in a bag when not in use, and the suction canister and tubing were dated and changed weekly for Resident 7, per the facility's P&P. These failures posed the risk for complications related to suctioning and affect the residents' wellbeing.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided to four of four final sampled residents (Residents 2, 11, 40, and 96) reviewed for pain management. * The facility failed to ensure Resident 2 was administered the oxycodone (controlled pain medication) medication according to the physician's orders. * The facility failed to ensure Resident 11 was administered with the hydrocodone-acetaminophen (a controlled pain medication) medication according to the physician's order . * The facility failed to ensure Resident 40 was administered with the tramadol (a controlled pain medication) and acetaminophen (a pain medication) medication according to the physician's order. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the dialysis communication forms were completed for one of two sampled residents (Resident 5) reviewed for hemodialysis. * The facility failed to ensure the necessary information in Resident 5's dialysis communication forms between the facility and dialysis center were completed. This failure had the potential for not identifying the changes in resident condition and/or complications prior to, during, and after the hemodialysis.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of the medications as evidenced by: * The facility failed to ensure Resident 102's vancomycin medication was administered timely. This failure had the potential to negatively impact the resident's health outcomes. * The facility failed to ensure the Controlled Substance Shift Count Log (a form where the nurses sign when the controlled medications were reconciled before and after each shift) for Medication Carts A and B were signed by the incoming and/or outgoing nurses. This failure posed the risk for loss or diversion of the controlled medication in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 21 final sampled residents (Residents 4 and 40) was free from the unnecessary medications. * The facility failed to monitor Resident 4 for the signs and symptoms of bleeding related to the use of Eliquis medication (an anticoagulant used to prevent blood clots). * The facility failed to assess, monitor, and provide the insulin medication to Resident 40 as per the physician's order. These failures had the potential for the residents to receive unnecessary medications and develop significant adverse effects.

Inspectors wroteBased on observation, interview, and facility P&P review, facility failed to provide the necessary pharmacy services to ensure proper storage, labeling and disposal of the medications. * The facility failed to ensure the open vial of a PPD test (Purified Protein Derivative, test to diagnose tuberculosis infection) and Humulin N (insulin medication used to lower down blood sugar level) had a written date on when it was opened. This failure has the potential for the medication to lose its stability and effectiveness when the medication was administered beyond the required time. * The facility failed to ensure the expired medication was removed from the medication cart. This failure had the potential for the expired medication to be accidentally administered to the residents.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food brought in from the outside was safely stored for one final sample resident (Resident 96). * The facility failed to safely store the food brought in from the outside for Resident 96. Additionally, the facility failed to ensure Resident 96 was educated on the safe food handling guidelines. These failures had the potential to expose the residents who received food brought in by the family/visitors to food borne illnesses.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; and2. A plan to maximize recruitment and retention of direct care staff. These failures had the potential to not meet the residents' care needs if the assessed population needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was complete and accurate for one final sampled resident (Resident 102), one nonsampled resident (Resident 18) and one closed record sampled resident (Resident 99) when: * The facility failed to ensure Resident 18's blood pressure measurement site was accurately documented in the resident's medical record. * The facility failed to ensure Resident 102's H&P was accurately documented. * The facility failed to ensure the facility staff were not documenting in a deceased resident's medical record (Resident 99). These failures had the potential for the residents' care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of one final sampled resident (Resident 7) reviewed on hospice services attained and maintained their highest practicable well-being. * The facility failed to ensure the hospice physician's orders for the frequencies of the visits of the hospice staff were transcribed in Resident 7's electronic health record. In addition, the facility failed to ensure the CHHA and LVN visited Resident 7 per the hospice physician's orders. This had the potential for a delay in providing hospice care and services to Resident 7.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain proper infection control practices. * The facility failed to ensure one laundry rolling rack with clean residents' clothing was appropriately covered when it was transported through the hallways and was left unattended. * The facility failed to ensure the local public health department was informed of Resident 63's unresolved scabies. Additionally, the facility failed to place Resident 63 on proper contact isolation for the unresolved scabies. * The facility failed to ensure CNA 7 did not use the same pair of gloves and gown when providing care to Resident 48 on EBP and then to Resident 105 who was not on EBP. This posed the risk of cross-contamination and spread of infection. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to monitor and address the use of the antibiotics when the resident's condition did not meet McGeer's criteria for two of five residents (Residents 4 and 53) reviewed for antibiotic stewardship. This failure had the potential for the antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the resident's zone entrapment assessment was completed and the measurements were recorded upon installation during the admission when identifying areas of possible entrapment with the use of side rails for one of two final sampled residents (Resident 4) reviewed for the use of the side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the care was provided in a manner which promoted the resident's dignity and respect for one of four final sampled residents (Resident 36) reviewed for the use of the indwelling urinary catheter. * The facility failed to ensure Resident 36's indwelling urinary catheter drainage bag was fully covered. This failure has the potential to negatively affect the residents' feeling of self-worthy and dignity.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection prevention and control practices to help prevent the transmission of communicable diseases and infections for one of three sampled residents (Resident 1) placed on contact precautions. * The facility failed to ensure the staff donned an isolation gown before contacting with Resident 1 and/or his environment. Additionally, the staff did not properly discard the isolation gown after wearing it in Resident 1's room. * The facility failed to handle the clean linens so as to prevent the spread of infection. These failures posed the risk for transmission of infection and the development of disease-causing microorganisms.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the allegation of abuse was reported within the required time frame, the resident's responsible party was notified of the allegation, the investigation was initiated after the abuse allegation was identified, and the staff were provided an in-service regarding the code of conduct and sexual abuse prevention for one of five sampled residents (Resident 4). * CNA 11 witnessed CNA 10 in Resident 4's room. CNA 10's top scrub was lifted in front of Resident 4. This failure posed the risk for Resident 4 to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the medications were administered as ordered for one of five sampled residents (Resident 2). * Resident 2 did not receive the prescribed medications upon admission as ordered by the physician. This failure had the potential to negatively impact Resident 2's medical condition.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored in a safe and secure manner as evidence by: * Resident 7 had a bottle of One a Day Multivitamin/Multimineral (supplement) on the top of the bedside table. * A Hibiclens (antiseptic skin cleanser) was observed on top of the grab bars unattended inside Shower room [ROOM NUMBER]. These failuresposed the risk for non-licensed staff and visitors to have access to the medications.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current wound care treatment and interventions as ordered for one of three sampled residents (Resident 2). * Resident 2's care plan was not revised to address the use of wound vac for the pressure ulcer of the sacrococcyx area. This failure posed the risk of not providing the resident with individualized and person-centered care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment to prevent the transmission of diseases and infections in the facility. * The facility failed to ensure the staff practiced the EBP during the high contact-care for one of three sampled residents (Resident 3). This failure posed the risk for the transmission of diseases and infections.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report in a timely manner an allegation of staff-to-resident abuse to the CDPH, L&C Program for one of two sampled residents (Resident 1). This failure had the potential for the abuse allegation going unreported and uninvestigated.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their abuse P&P related to the investigation of the physical abuse for one of two sampled residents (Resident 1). * The facility failed to remove the alleged employee from resident care areas while the facility was investigating the abuse allegation. * The facility failed to send the result of the abuse investigation to the CDPH L&C Program. These failures posed the risk of Residents 1 to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from the unnecessary psychotropic medications (any drug that affects brain activity). * The facility failed to obtain the informed consent from Resident 1 or surrogate for the use of Seroquel (brand name for quetiapine fumarate, a drug to treat bipolar disorder) * The facility failed to ensure Resident 1's behavior was monitored for the use of citalopram (to treat depression), quetiapine fumarate, divalproex sodium (to treat the manic phase of bipolar disorder) and lorazepam (to treat anxiety disorder) medications. * The facility failed to ensure Resident 1 was monitored for side effects and/or adverse effects related to the use of citalopram, quetiapine fumarate, divalproex sodium and lorazepam medications. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to protect the resident's rights to be free from the verbal abuse by a staff for one of 10 sampled residents (Resident 1). * Resident 1 was asking for help and CNA 3 answered Resident 1 in a foul language in Spanish. This failure had the potential to negatively impact Resident 1's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections. * Resident 8 who was positive for COVID-19 and required isolation precautions, was cohorted with Resident 9 who was negative for COVID-19. This failure posed the risk of infection and transmission of COVID-19 and other disease-causing microorganisms.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the resident personal belongings were properly recorded for two of 10 sampled residents (Residents 2 and 6). This failure had the potential for the residents' personal belongings being lost or stolen.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of seven sampled residents (Resident 1) attended the scheduled neurology consultation appointment for * Resident 1 had a telemedicine neurology consultation for dementia. Resident 1's appointment was scheduled to take place at the facility utilizing Resident 1's telephone. However, at the time of Resident 1's appointment, no staff were present to assist Resident 1 with her appointment via telephone. As a result, Resident 1 did not attend her scheduled neurology appointment. This failure had the potential to delay Resident 1's plan of care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the plan of care to reflect the individual care needs for one of seven final sampled residents (Resident 1). * The facility failed to develop a care plan to address Resident 1's risk for impaired cognition. This failure posed the risk for not providing appropriate and individualized care to the resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain an accurate medical record for one of seven sampled residents (Resident 1). * The facility failed to ensure the licensed nurse documented her initials on Resident 1's TAR (indicating the treatment was provided) as per the facility's P&P. This failure had the potential for the resident's needs not being met as the medical information was incomplete.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly and failed to ensure the drugs and biologicals were stored in a safe manner when: * One of two medication rooms (Medication Room A) had one opened, unsealed package of IV Statlock PICC Plus (a device to secure an IV catheter from kinking which could lead to blockage of fluids going through the vein). * The facility's Central Supply Room was observed to contain artificial tears, earwax softener drops, dry eye relief, muscle rub cream, and enema bottles stored on the same shelf next to the oral medications such as calcium, omeprazole, sodium chloride, and fish oil. * The facility's treatment cart was observed to contain the expired dressings, topical creams with labels not readable; [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food preparation, storage, and sanitary requirements were met in the kitchen. * The facility failed to ensure the proper disposal, labeling and dating of foods in the kitchen. * The facility failed to ensure the cutting board was in sanitary condition. * The facility failed to ensure the countertop can opener was free from brownish, whitish, and grayish discoloration. * The facility failed to ensure the stainless mixing bowls, knives, and water pitchers were rinsed prior to use. * The facility failed to ensure one knife and blender were air dried prior to use. * The facility failed to ensure a clean spatula was placed on top of an unsanitized preparation area. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment were followed. * LVN 1 used Sanicloth disinfectant wipes with an unreadable expiration date. * LVN 1 placed the spoons directly on the bedside table and used the spoons to stir the medications prior to administering medications. * LVN 1 placed the piston syringe and plunger used for G-tube medication administration directly on the bedside table surface without a barrier. * LVN 4 failed to follow the Enhanced Barrier Precautions when she did not wear a gown during medication administration via G-tube for Resident 72. * LVN 4 did not perform hand hygiene and did not change gloves prior to administering oral, enteral, and subcutaneous medications. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the residents' call light system was fully functional as evidenced by: * The call light system for two of two nursing stations were not audible. * Resident 67's call light was not answered promptly. These failures posed the risk of staff not responding promptly to residents in need of immediate assistance.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 26) reviewed for psychotropic use was informed of the use of the psychotropic medication (medication affecting brain activities associated with mental processes and behavior). * The facility failed to ensure the informed consent was obtained prior to administering the Seroquel (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia) and paroxetine (a medication used to treat depression) for Resident 26. This failure had the potential for Resident 26 to not be informed of the medication and potential effects of Seroquel and paroxetine.

Inspectors wroteBased on observation, interview, and P&P review, the facility failed to ensure the accomodations of needs were met for one of 19 final sampled resident (Resident 67) and two of nonsampled residents (Residents 83 and 84). * The call lights were not within reach for Residents 83 and 84. * The call light was not answered promptly for Resident 67. These failures had the potential for the residents not getting their needs met timely.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement the comprehensive care plan to address the individual care needs for one of one sampled resident (Resident 7) reviewed for IV antibiotic use. * The facility failed to develop a plan of care addressing Resident 7's Vancomycin (antibiotic used to treat and prevent various bacterial infections) treatment given intravenously (giving medicines through a needle or tube inserted into a vein). This failure had the potential for not providing appropriate, consistent, and individualized care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's care needs for one of 19 final sampled residents (Resident 84). * The facility failed to ensure Resident 84's care plan was revised to reflect the treatment for both lower extremities for maintenance of skin integrity from the cellulitis related to venous insufficiency (a condition in which the veins fail to return blood efficiently to the heart). This failure placed Resident 84 at risk for the specific care needs not being addressed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of a wound for one of three sampled residents observed for wound care (Resident 74). * The facility failed to provide skin treatment to Resident 74's right lower leg swelling as ordered by the physician. This failure had the potential for Resident 74 to develop or worsening of skin breakdown.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the worsening of a pressure ulcer for one of the three sampled residents observed wound care (Resident 26). * The facility failed to provide wound treatment to Resident 26's right hip and right lateral malleolus pressure injuries as ordered by the physician. This failure had the potential for Resident 26's worsening of existing pressure ulcer.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary GT care and services for one of two sampled residents reviewed for GT care. * The facility failed to ensure Resident 53 was positioned safely at 30 to 45 degrees during the enteral feeding via GT. This failure posed the risk for developing complications related to GT.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of one sampled resident (Resident 74) reviewed for the use of BiPAP (Bilevel positive airway pressure, a form of noninvasive ventilation that providers use to help with breathing) was provided with the appropriate respiratory care. * The facility failed to ensure the BiPAP mask was cleaned according to the facility's P&P. This failure had the potential to negatively impact Resident 74's medical condition.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pain management was provided to two of two sampled residents (Residents 7 and 23). * The facility failed to notify the physician of Resident 7's pain to obtain a pain medication to manage the resident's pain. * The facility failed to ensure Resident 23 was administed the pain medications as ordered. These failure had the potentitial for not providing the necessary care and services and effectively managing the residents' pain.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure two of two sampled residents (Residents 59 and 61) reviewed for dialysis services were monitored for fluid restriction as ordered. This failure posed the risk of the residents' not receiving appropriate care.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the nursing services were provided by the appropriate staff (four of four CNAs) as evidenced by: * Two CNAs (CNAs 9 and 10) applied the oxygen tubing and set the residents' oxygen rate. * The facility failed to ensure CNAs 1 and 2 were provided training on the implementation of the enhanced barrier precautions. CNAs 1 and 2 were observed not wearing a gown while transferring Resident 35 on enhanced barrier precautions. These failures posed the risk of the residents not receiving appropriate care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of the residents when: * The facility failed to ensure all controlled medications were accurately documented for one of 19 final sampled residents (Resident 61) and one nonsampled resident (Resident 46). * The facility failed to ensure the oral and IV E-Kit(s) for Nursing Station A were refilled/replaced by pharmacy within 72 hours of opening the E-Kit(s). These failures posed the risk for diversion of the controlled medications and medication administration errors; and timely replacement of medication for emergency use.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for one of five unnecessary medication sampled residents (Resident 23). * The facility failed to follow-up on the Pharmacy Consultant recommendation to monitor for CNS (central nervous system) and respiratory depression for Resident 23 who was taking routine gabapentin (nerve pain medication), methadone (opioid narcotic analgesic), and Dilaudid (opioid narcotic analgesic) medications. In addition, the facility failed to follow-up on the Pharmacy Consultant recommendation to place hold parameters for gabapentin medication for Resident 23. These failures had the potential to put the resident at risk for adverse consequences related to the medications.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 24%. Two licensed nurses (LVNs 1 and 4) who were observed during the medication administration were found to have made errors. * LVN 1 failed to check Resident 53's heart rate prior to administering metoprolol (blood pressure medication) per the physician's orders. In addition, Resident 53 received partial dose for one medicaiton when residual of the medication was left in the medication cup. * Resident 72 received partial doses for three medications when residual of the medications were left in the medication cups. These failures had the potential to negatively impact the residents' health status and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of two LVNs observed for medication administration administered the medications without significant medication errors. * LVN 1 failed to check Resident 53's heart rate prior to administering metoprolol per the physician's orders. This failure placed Resident 53 at risk for medical complications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed as evidenced by: * The facility failed to ensure the spreadsheet was followed for the liberal house renal diet and renal diet. The facility failed to provide 10 pieces of cheese ravioli for Residents 13 and 34 as per the menu. *The facility failed to ensure the menu for the pureed breadstick and butter was followed when the wrong scoop size was used to serve the pureed bread for Residents 16 and 78. * The facility failed to provide butter or margarine, and milk to Resident 78 as per the menu. In addition, the facility failed to provide coffee to Resident 78 as per the resident's lunch tray ticket. * The facility failed to provide the appropriate dessert portion to one nonsampled resident (Resident 4). [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food served was palatable. * The facility failed to ensure the roast beef served to Residents 78, 27, and 392 was not tough and not hard to cut or chew. This failure had the potential for the residents to not eat the food served and could affect their nutritional status.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P, the facility failed to ensure the residents on pureed diet were provided with food prepared in a form to meet the residents' individual needs. This failure risk posed the risk for residents on pureed diet to develop complications like aspiration (accidental breathing in food or fluid into the lungs) and choking.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure the food preferences was honored for one nonsampled resident (Resident 543). * Resident 543's tray card showed puree regular with dislikes all dairy products; however, he was served pureed breadstick and butter with milk. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain the complete and accurate medical records for two of 19 final sampled residents (Residents 23 and 31). * The facility failed to ensure the complete documentation for Resident 31's ADL- Bed Mobility Intervention/Task. * The facility failed to ensure the informed consents obtained from Resident 23 were signed by the physician. These failures had the potential for the resident care needs not being met as the medical information was incomplete and inaccurate.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure one glucometer (Glucometer C) from one of five medication carts (Medication Cart C) was maintained in safe operating condition. This failure had the potential for residents requiring glucose checks to have inaccurate readings.

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to promote the dignity and respect for one nonsampled resident (Resident 65). * CNA 7 was observed standing over Resident 65 while assisting and feeding the resident with lunch. This failure posed the risk of not treating the resident with dignity and respect.

Inspectors wroteBased on interview and medical record review, the facility failed to thoroughly investigate a grievance for one of 19 sampled residents (Resident 87). This failure posed the risk of not taking all appropriate corrective action.

Inspectors wroteBased on interview, medical record review, document review, and facility P&P review, the facility failed to provide the written information regarding the rights to accept or refuse medical or surgical treatments and formulate the advance directives for two of the fivesampled resident (Residents 2 and 3). This failure had the potential for the residents ' decision regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to assess one of the five sampled residents (Resident 4) for their risk for falls. This failure had the potential for the resident not receiving appropriate interventionsbased on the resident ' s fall risk assessment.

Inspectors wroteBased on interview and medical record review, the facility failed to notify the resident and their representative of the transfer/discharge and reasons for the transfer in writing for one of six sampled residents (Resident 1). This failure had the potential for the resident and their representative not knowing about the appeal process should the resident and their representative believe the transfer or discharge was inappropriate or involuntary.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 1) and/or their representative were provided with the written information regarding the facility's bed-hold policy when the resident was transferredto the acute care hospital. This failure had the potential for Resident 1 or their representative to be unaware of their rights to request a bed hold and return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services for one of six sampled residents (Resident 5) to ensure the resident maintained their highest physical well-being. * The facility did not notify the primary physician when Resident 5 refused her meals (breakfast and lunch) and was given sixunits of insulin as per the sliding scale as ordered by the physician. This failure had the potential for not providing necessary care and services to Resident 5.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the controlled medications signed out of the controlled drug records were administered and documented on the MAR for four of six sampled residents (Residents 1, 2, 3, and 4). In addition, Resident 2's pain medication was signed out on the controlled drug record two hours apart on 9/12/23 at 1400 and 1600 hours, instead of every four hours as ordered by the physician. These failures had the potential to result in controlled medications abuse or diversion and poor health outcomes to the residents.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to follow the menu for 13 of 13 residents (Residents 8, 11, 16, 27, 28, 38, 41, 49, 50, 70, 86, 535, and 536) who were on the pureed textured diets. This failure posed the risk of the residents' nutritional needs not being met and/or residents' food preferences not being honored.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to follow proper sanitation and food storage practices. * There were multiple expired food items in the kitchen. * The facility failed to ensure the low-temp dishwasher was checked for chlorine concentration properly and the chlorine test paper was not expired. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, fundamental nursing skills review, and facility P&P review, the facility failed to meet the professional standards of care for one of the 20 final sampled residents (Resident 71). * LVN 5 failed to follow the standard nursing procedures for the administration of eye drops to Resident 71. This failure posed the risk for developing complications related to inappropriate technique in eye medication administration.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 75) was provided restorative nursing care as ordered by the physician. * Resident 75 had a physician's order to provide a rolled washcloth for the right hand contracture. The facility failed to ensure a rolled washcloth was applied to Resident 75's right hand to prevent further decline in the contracture. This failure had the potential to decrease Resident 75's optimal physical functioning.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to address the nutritional needs for one of 20 final sampled residents (Resident 76). * The facility failed to ensure Resident 76's weight was monitored as ordered by the physician. Resident 76 was experiencing weight loss and had a physician's order to be weighed every 48 hours for 10 days. This failure had the potential to contribute to Resident 76's unmonitored weight loss and delayed intervention.

Inspectors wroteBased on observation, interview, medical record review, and manufacturer's instructions, the facility failed to provide safe respiratory care for one of 20 final sampled residents (Residents 48). * The facility failed to ensure Resident 48's nebulizer mask kit was stored in accordance with the manufacturer's instructions. This had the potential for increased risks of infection.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for two of 20 final sampled residents (Residents 71 and 72) and one nonsampled resident (Resident 4). * The number of tablets for Resident 4's tramadol documented in the Controlled Medication Count Sheet did not match the number of tablets remaining in the medication bubble pack. * Resident 72's Controlled Medication Count Sheet for buprenorphine (narcotic medication) did not match the entry in the MAR. * Resident 72's buprenorphine was not administered as ordered by the physician. Resident 72's buprenorphine was not available. * The facility failed to ensure Resident 71's Trajenta (medication for blood glucose control) was administered as ordered by the physician. Resident 71's Trajenta was not available. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of five unnecessary medication sampled residents (Residents 12) was free from unnecessary drugs. * The facility failed to ensure Resident 12's midodrine hydrochloride (medication used to treat low blood pressure) was administered based on the physician's ordered parameter. This failure had the potential for Resident 12 to receive unnecessary medication and develop significant side effects arising from errors in administration.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure two of 20 final sampled residents (Residents 41 and 58) were free from unnecessary psychotropic medications. * The facility failed to ensure to monitor for a specific behavior manifestation related to Resident 41's use of mirtazapine (anti-depression medication). This had the potential for inaccurate behavior monitoring and Resident 41's physician not having the necessary information to determine the effectiveness of the medication. * The facility failed to monitor the side effects and behavior manifestation for Resident 58's use of Zoloft (anti-depression medication). [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner for three of the 20 sampled residents (Residents 23, 53, and 57). * Topical, suppository, liquid and tablet forms of medications were observed to be stored together in a drawer in Medication Cart 3. The failure post the risk for contamination of medications. * Multiple expired medications and insulin pen with no open date were observed in Medication Cart 3. This failure had the potential for the administration of expired or deteriorated medications or biologicals. *A bottle nasal spray was observed on top of Resident 57's bedside table. This failure had the potential for residents, staff and visitors to have access to the medication. [...]

Inspectors wroteBased on the observation, interview, and medical record review, the facility failed to provide one of the 20 final sampled residents (Resident 58) the appropriate diet to meet individual needs. * The facility failed to ensure Resident 58 was provided the appropriate meal substitute. Resident 58 had a physician's order of puree diet and was provided a whole uncut cheese quesadilla at lunch. This failure posed the risk for the resident to develop complications like aspiration and choking.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain the effective infection control practices. * LVNs 3 and 4 failed to perform hand hygiene before donning and after doffing gloves during resident care. * LVN 5 failed to perform hand hygiene when she administered the eye drops medication to Resident 71 These failures placed the residents and the staff at increased risk for infections.

Inspectors wroteBased on interview and facility document review, the facility failed to establish the infection control program designed to provide a safe and sanitary environment. * The facility failed to ensure Resident 29 was accurately assessed for the presence of sings and symptoms of infection based other Mc Geer's criteria. Resident 29 who present with manifestations of a wound infection was erroneously classified as not a true infection even if the Mc Geer's criteria was met. This failure posed the risk for the development of complications when the resident's infection was not properly addressed and the documentation of inaccurate data within the antibiotic surveillance program.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain a safe and homelike environment. * Rooms A, B, C, and D were observed with torn floor mats at the resident's bedside. This lack of maintenance placed the living conditions of residents in an unkempt environment.