Grace Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for an average daily occupancy of 60 residents according to the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing. This failure had the potential to impact the quality of care and outcomes of residents who require advanced care activities such as assessments, developing and evaluating care plans, consulting with physicians, and administering intravenous fluids or medications. During a concurrent interview and record review on 7/24/26 at 12:58 p.m. with the Director of Nursing (DON), the Staffing Schedule (SS) dated 7/2026 was reviewed. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate an individual as the Infection Preventionist (IP) who is responsible for the facility's Infection Prevention Control Program (IPCP - a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment) for 62 residents and staff when the IP resigned in 6/2026. This failure had the potential for the development and transmission of communicable diseases and infections resulting in an unsafe, unsanitary, and uncomfortable environment for residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice according to the facility's policies and procedures (P&P) titled, Enteral Nutrition, Administering Medications, and Nutrition (Impaired)/Unplanned Weight Clinical Protocol, for two of three sampled residents (Resident 1 and Resident 2) when the facility failed to ensure tube feedings and water flushes were administered as ordered by the physician and Registered Dietitian (RD). Nursing staff did not administer Resident 1's tube feeding and free water flushes according to physician orders. Nursing staff did not administer Resident 2's tube feeding as ordered on 7/10/26 at 2:43 a.m. The tube feeding was not infused as prescribed and nursing staff were unable to demonstrate the ordered volume was delivered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one of three sampled residents (Resident 1) when Resident 1 required enteral feeding (EF- a method of supplying nutrition directly into the stomach or intestines through a flexible tube) diet and the facility failed to administer physician-ordered enteral nutrition (often called tube feeding essential liquid nutrition) and free water flushes (a specific volume of water administered to a person receiving tube feeding (enteral nutrition) through( gastrostomy tube) G-tube) in accordance with physician orders, facility policies and procedures, and professional standards of practice. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection prevention and control practices for two of three sampled residents (Resident 1 and Resident 2) requiring Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of infection). Nursing staff failed to utilize required personal protective equipment (PPE) while providing feeding tube care and skin assessment, in accordance with the facility EBPs policy. The facility's failure to implement proper infection prevention and control practices created a potential risk for the spread of infectious germs and bacteria. Consequently, the residents were exposed to an increased likelihood of the spread of harmful infections, which could be transferred from one resident's environment to another. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice according to the facility's policies and procedures (P&P) titled, Weight Assessment and Intervention, Nutrition (Impaired)/Unplanned Weight - Clinical Protocol, Change in a Resident's Condition or Status, Care Planning - Interdisciplinary Team, Administering Medication, and Enteral Nutrition, for four of eight sampled residents (Resident 1, 6, 7, and 8) when Resident 1, 6, 7, and 8 had unplanned weight loss from 4/20/26 to 5/25/26 and:The facility did not accurately obtain the weights of Resident 1, 6, 7 and 8 from 4/20/26 to 5/25/26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status for four of eight sampled residents (Resident 1, 6, 7 and 8) when Resident 1, 6, and 7 required enteral feeding (a method of supplying nutrition directly into the stomach or intestines through a flexible tube) and Resident 8 required regular, mechanical soft texture (a texture-modified eating plan for individuals with difficulty chewing or swallowing), regular consistency (thin liquids such as water) diet and staff did not administer nutrition in accordance with policies and procedures and professional standards of practice. [...]

Inspectors wroteBased on observation, interviews and review of facility documents, the facility failed to ensure:1. The Certified Dietary Manager (CDM) met state requirements, California Code of Regulations (CCR), Health and Safety Code 1265.4 when the CDM did not complete the six hours of in-service training on the CCR, Dietetic Services Requirements of Title 22 and;2. The CDM received frequently scheduled consultation from the Registered Dietitian (RD). [...]

Inspectors wroteBased on interviews and observations during the survey period from 3/17/26 through 3/20/26, the facility failed to ensure eight of eight sampled bedrooms, accommodated no more than four residents each. This failure had the potential for residents to not have reasonable privacy or adequate space. Throughout the survey period from 3/17/2026 through 3/20/2026, eight rooms in Building Two had more than four residents in each bedroom. The variations were in accordance to residents particular care needs and comfort. Wheelchairs and toilet facilities were accessible to residents. A reasonable amount of privacy was provided and adequate closet and storage space were available. There was sufficient space for residents to ambulate and staff to provide care to residents. Nursing care of the residents was not impacted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for four of eight sampled residents (Resident 5, Resident 6, Resident 11 and Resident 40) when:1. The facility did not follow their Policy and Procedure (P&P) for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities) by placing EBP signage inside the room on the wall and EBP containers were below the EBP signage inside the room.2. Personal Protective Equipment (PPE) was not worn during care for Resident 11, Resident 40 and Resident 5. 3. [...]

Inspectors wroteThe facility failed to follow its own policy and procedure to complete quarterly smoking assessments when three out of four sampled residents (Residents' 41, 52 and 54) quarterly assessments were not completed on time. These failures had the potential for Residents' 41, 52 and 54 to experience accident related to smoking like burn.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff provided care in a manner that maintained resident dignity during mealtime assistance for one of four sampled residents (Resident 1)This failure to ensure staff assisted residents at eye level, rather than standing over residents during feeding, had the potential to cause Resident 1 to feel intimidated, uncomfortable and experience a loss of dignity during care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician (MD) notification of elevated blood glucose (the amount of sugar in the blood that the body used for energy) levels per facility procedure for one of four sampled residents (Resident 33). When Resident 33 had seven blood glucose readings from 3/1/26 through 3/18/26 that were greater than 350 milligrams per deciliter (mg/dL a unit of measurement. Blood glucose normal range is 80 to 130 before meals). This failure resulted in Resident 33's blood glucose levels to go unmonitored and delayed adjustment of the treatment regimen and had the potential to result in adverse outcomes including significantly elevated blood sugars, dehydration (when the body did not have enough water to stay healthy and work the way it should), infection and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS- MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for two of four sampled residents (Residents' 9 and 52) when:1. Resident 9's surgery was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 9's surgical care needs to not be treated properly. 2. Resident 52's dental health was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 52's dental health problems to go untreated due to inaccurate assessments of missing and broken natural teeth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a level 1 Preadmission Screening and Resident Review (PASARR-federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in a nursing home) level 1 screening notifying the state mental health authority or state intellectual disability authority promptly after a significant change for one of three sampled residents (Resident 36). This failure had the potential for Resident 36 not to receive the appropriate services related to her diagnoses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for two of four sampled residents (Resident 9 and Resident 36) when Resident 9 and Resident 36 did not have care plans for the use of antibiotics (medication used to treat infections caused by bacteria). These failures placed Resident 9 and Resident 36 at a potential risks for harm by not identifying and monitoring for side effects of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plans (CP) were reviewed and revised for two of eight sampled residents (Resident 6 and Resident 11) when:1. Resident 6 had yankAuer suction catheter (YSC-a rigid, oral suction instrument used to clear blood, saliva, and secretions from a patient's mouth and throat, primarily to prevent aspiration) that he uses for his mouth and nose, and the CP was indicated for oral (relating to the mouth) suctioning use only.2. Resident 11's CP did have interventions reflective of their physician order dated 1/21/26. These failures had the potential for Resident 6 and Resident 11's needs to not be met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure1. Two of four Registered Nurses (RN 2 and RN 4) were competent in the enteral feeding (tube feeding- is a method of delivering liquid nutrients directly into the stomach or small intestine via a tube) process when providing care to Resident 40 during enteral feeding.2. The Licensed Nurse (LN)s Competency/ Skills checklist (CSC) (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) was performed upon hire for one of six staff members (RN 4). These failures had the potential for the facility to not be able to assess the skills necessary to provide nursing services such as enteral feeding and thus placed the Resident 40 at riskFindings:1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure completion of a performance review/evaluation of nurse's aides were competed at least every 12 months for two of three Certified Nurse Assistant (CNA 8 and CNA 9) when the CNAs personnel files review did not have annual performance evaluations since their Date of Hire (DOH). This failure had the potential to negatively affect the competency of the CNAs and the quality of care provided to the facility residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure appropriate monitoring and follow-up for a resident receiving valproic acid for one of four sampled residents (Resident 1) when Resident 1 had an active order for valproic acid (medication used to help control seizures and stabilize mood by affecting how the brain worked) since 12/4/26 for mood stabilization related to bipolar disorder (a condition that caused a person to have extreme mood changes, including very high moods and very low moods), and no valproic acid level had been obtained since initiation per facility procedure and and there was no documentation the physician (MD) or Responsible Party (RP) were notified. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals (a class of drugs that are produced using a live system, such as a microorganism, plant cell, or animal cell) were locked and labeled in accordance with current accepted professional standards of practice and facility procedures for two of thirteen sampled residents (Resident 42 and Resident 36) when:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety when:1. One of two Dietary Aids (DA 1) working in the kitchen did not have a hair net on.2. One wet quarter pan was stacked on top of another quarter pan.3. Ground beef was thawing in the refrigerator with no pull/thaw date on it (the date marked on a food item when it is removed from the freezer to thaw), and no use by date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records which were complete and accurately documented in accordance with accepted professional standards and practices for one of four sampled residents (Resident 9) when Resident 9's weekly wound assessment and change of condition were not completed. These failures resulted in inaccurate medical records being kept for Resident 9 and had the potential to not meet and provided treatment needed which could have resulted to serious health problems.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the environment was free of accident hazards and residents received adequate supervision to prevent accidents for one of five residents (Resident 1) when, nursing staff were aware of Resident 1's behavior to self-propel in a wheelchair equipped with foot pedals and did not adequately supervise Resident 1 while propelling in a wheelchair. Staff did not assess the safety of the wheelchair for Resident 1's physical size and abilities. Resident 1 was not assessed and fitted for a wheelchair for personal use and instead Resident 1 used wheelchairs available for general use in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a full time (working more than 40 hours per week) Registered Nurse as the Director of Nursing (DON) for 58 of 58 residents when the current DON license expired on [DATE]. This failure had the potential to result in a lack of oversight and guidance for the provision of care, which could result in decreased resident safety, optimal well-being, and quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the right to be free from misappropriation of resident property for eight of eleven residents (Resident 55, 57, 59, 67, 69, 71, 73, 75) when: 1. For Resident 67, a licensed nurse removed 41 alprazolam (a highly addictive medication used for generalized anxiety disorders, panic disorders and insomnia [inability to sleep]) tablets from the medication cart and did not administer the medication to the Resident or waste (discard) the medication in accordance with facility policy and procedure and nursing standards of practice for medication administration. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. An adequate system for maintaining controlled drugs (substances that have an accepted medical use and have a potential for abuse and may also lead to physical or psychological dependence) records when facility was unable to provide record account for Resident 63's hydrocodone/acetaminophen (pain medication) 5-325 mg (milligram- unit of measurement), maintenance of records for stored controlled drugs awaiting destruction, maintenance of records for controlled drugs used from the facility's e-kit (emergency kit containing medications for facility use when patient specific medication not available from 7/2024 to 10/2024, and used e-kit was not replenished in accordance with facility policy and procedure. 2. Destruction of controlled drugs not accordance with facility policy and procedure. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of seven sampled residents (Residents 55, 57, 59) were administered medications appropriately when: 1. Resident 55's oxycodone (controlled pain medication that has a potential for abuse and may also lead to physical or psychological dependence) order was changed from as needed (given to resident only if needed on scheduled time) to routine (given to resident around continuously on scheduled time) without clinical justification, with no side effect monitoring. 2. [...]

Inspectors wroteBased on interview and record review, the facility administration failed to ensure one of one sampled employee, Licensed Vocational Nurse (LVN) 1, did not work in the facility while he was suspended from employment and under investigation for drug diversion (theft of resident medications), when he returned to work in the facility with approximately 30 residents during one 12-hour shift. This failure had the potential for further drug diversion, evidence tampering, falsification of records, or other investigation interference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two Licensed Nurses (Registered Nurse, or RN 3, and Licensed Nurse, or LN, 22) properly disinfected a glucometer (a handheld device used to measure how much sugar is in a drop of blood) after obtaining a blood sample from residents. This failure had the potential to spread bloodborne diseases via the glucometer to as many as nine other residents also receiving these blood tests.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three nursing staff (Licensed Vocational Nurse 1, Licensed Nurse 22, and Registered Nurse 3) received essential competencies were conducted on new staff hired by the facility. This failure had the potential for incompetent or untrained nursing staff to deliver care to residents.

Inspectors wroteBased on interview and observation, the facility failed to have an effective QAPI (Quality Assurance and Performance Improvement) program when four of four sampled staff (Licensed Nurse 22, Certified Nursing Assistant 1 and 2, and Registered Nurse Supervisor) were not aware of the facility's QAPI plan, and failed to have a tool for measuring Performance Improvement. This failure led to nursing staff being unable to verbalize an understanding of the facility's active performance improvement goals aimed at successfully implementing a program to improve resident safety.

Inspectors wroteBased on interview and record review, the facility failed to check the references for two of five sampled employees (Licensed Vocational Nurse 1 and Licensed Nurse 22) prior to being employed at the facility. This failure had the potential for the facility to employ unqualified and/or abusive staff to provide direct care to residents.

Inspectors wroteBased on interview, and record review, the facility failed to implement an effective training program for infection control and prevention for two of three Licensed Nurses (Licensed Vocational Nurse 22, and Registered Nurse, or RN 3), when LN 22 and RN 3 did not have documented training on hand hygiene and personal protective equipment (PPE, items such as gloves, gowns, and masks). This failure placed residents at a risk for potential spread of infection from the Licensed Nurses' lack of training on infection control.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure dietary cook (DC) 1 was competent to carry out the functions of food and nutrition services safely and effectively when: 1. DC 1 served to much food for a large portion size diet for Residents' 15, 48 and 50. 2. DC 1 did not fortify food for the fortified diets for Residents' 15, 18 and 50. 3. DC 1 did not follow pureed food recipe for Residents' 11, 18, 44, 53 and 214. 4. DC 1 did not checked the temperature for pureed foods prior to serving. 5. Kitchen did not have enough chile relleno casserole to serve to Residents' 17, 22 and 31. These failures resulted in Residents' 15, 18, 50, 11, 44, 53, 214, 17, 22 and 31's diet orders and the facility menu to not be followed.

Inspectors wroteFACILITY Based on observation, interview and record review, the facility failed to ensure food served met the daily nutritional needs for seven of 54 sampled residents (Residents' 15, 48, 50, 18, 17, 22, 31) when: 1. Residents on large portion diets (Residents 15, 48 and 50) were served more than the required portion size of the chile relleno casserole based on the facility's menu. This failure had the potential to result in Residents 15, 48 and 50 to receive more than the recommended daily caloric intake based on the Medical Doctor's order and Registered Dietitian's (RD) assessment of residents' nutritional dietary needs and the potential for unintended weight gain. 2. Residents' 15, 18 and 50 did not received fortified (foods with nutrients added to help boost nutritional value and benefit health) diet as ordered by physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an effective infection control and prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable (contagious) diseases and infections for 62 of 62 residents when: 1. Resident 4's wheelchair was found to have brown dried matter on the seat and staff did not clean and maintain the wheelchair in accordance with facility policies and procedures. 2. Resident 33's two used urinal bottles (a container used to collect urine) were found on top of his nightstand. Staff did not follow established facility policies for the discarding of urine and the cleaning of urinal bottles. 3. Dirty water was found pooled in the laundry room where clothing and linens were being washed for the entire facility of 62 residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, and comfortable environment for residents, staff and the public when: 1. Eight of eight resident rooms were observed with non functioning privacy curtains. These failures had the potential of violating residents rights to their privacy. 2. Water leaked from one of three washing machines amd water pooled underneath and around the floor where the machines were located. This failure had the potential to place residents and staff in an unsafe and unsanitary environment which had the potential to lead to electrocutions, slips, and other avoidable accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for two of 10 sampled residents (Residents' 53 and 51) when: 1. Resident 53 did not have a care plan for apixaban (anticoagulant - prevent blood clots from forming). This failure put Resident 53 at risk for harm by not identifying and monitoring for harmful side effects. 2. Resident 51 did not have a care plan for Enhanced Barrier Precaution (EBP-set of infection control practices that uses gowns and gloves during high contact care of residents in nursing homes) status. This failure placed Resident 51 at a potential risk for her needs to go unmet while under enhanced barrier precaution.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice for two of 11 sampled residents (Resident 27 and Resident 44) when 1. A medicine cup with seven tablets was left on top of Resident 27's breakfast tray. This failure had the potential for Resident 27 to not received the prescribed medications and for other residents to have access to the medications which could lead to serious health condition. 2. Resident 44 physicians order for padded siderails were not followed. This failure had the potential to cause injury to Resident 44 if he hit the side rails.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored safely when: one of two medication carts were properly stored when : 1. medication were not labeled in accordance with accepted professional principles for 11 out of 11 residents (Resident 2, Resident 6, Resident 14, Resident 31, Resident 32, Resident 36, Resident 44, Resident 51, Resident 54, Resident 56, Resident 57 ) when medications that are administered via an inhaler (a medical device used for delivering medicines into the lungs through the work of a person's breathing ) to treat difficulty breathing were not labeled with use by dates or the medication expiration dates. This failure had the potential for residents to being given expired medications which could lead to difficulty breathing due to reduced efficacy of the medications. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in for 54 out of 62 resident when the two-compartment prep sink in the kitchen did not have an air gap. This failure had the potential to cause food-borne illness (illnes caused by consuming contaminated foods or beverages) to the facility's fragile residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for one of four sampled residents (Resident 15) when Certified Nurse Assistant (CNA) 9 did not provide privacy while providing personal hygiene care to Resident 15. This failure resulted in Resident 15 not being provided with respect and dignity while receiving care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven residents (Resident 19) was free from abuse and neglect when Resident 19 did not receive the supplies he requested to conduct suprapubic catheter (a hollow flexible tube surgically inserted below the belly button used to drain urine from the bladder) care. This failure resulted in Resident 19 soiling himself with urine.

Inspectors wroteBased on interview and record review, the facility failed to notify the Long Term Care Ombudsman office (LTC-Ombudsman, a resident advocacy agency) of transfer to the hospital for one of four sampled residents (Resident 26) when the facility failed to send a copy of Resident 26's transfer notification to the local LTC-Ombudsman office. This failure resulted in the LTC-Ombudsman not aware of Resident 26's emergency transfer to an acute care facility for treatment on 5/24/24.

Inspectors wroteBased on interview and record review, the facility failed to meet the required timelines for encoding, completion and transmission of Minimum Data Set assessments (MDS-evaluation of cognition, care needs and functional abilities) for one of four sampled residents (Resident 58) when Minimum Data Set Nurse (MDSN) did not complete or transmit discharge MDS assessment for Resident 58. This deficient practice resulted in the potential harm of Resident 58's needs upon discharge going unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to re-evaluate and document current condition for Level I Preadmission screening and Resident Review (PASARR-a federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) for one of four sampled residents (Resident 15). This failure had the potential for Resident 15 to not receive the appropriate services related to his mental disorder, intellectual disabilities or other related cognitive impairment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess one of seven residents (Resident 59) for risk of entrapment (caught, trapped, or entangled in the space in or about the bed and side rail) from bed rails (adjustable metal or rigid plastic bars that attach to the bed), obtain informed consent (form signed by resident or family explaining the risks of side rail use), obtain physician order with indication for use, and create care plans prior to the use of bed rails when Resident 59 had his right bed rail raised up. These failures had the potential to place Resident 59 at risk for decreased freedom of movement, entrapment and/or injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide acetylsalicylic acid 325 mg (ASA-a medication that reduces pain, fever, inflammation, and blood clots [mg-milligrams a unit of measurement]) for one of one sampled resident (Resident 1) who has an order for acetylsalicylic acid 325 mg when the facility ran out of the medication. This failure cause Resident 1 to miss a scheduled dose of medication ordered to prevent blood clots (gel like clump of blood that can form inside the veins and restrict blood flow) .

Inspectors wroteBased on interview, and record review, the facility failed to maintain a low air loss mattress (LAL- a special mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) cover sheet in intact for one of three sampled residents (Resident 39) when the LAL mattress cover was torn where Resident 39 rested his head. This failure had the potential to cause the LAL mattress to not function properly and lead the resident to develop skin breakdown.

Inspectors wroteBased on interviews and observations during the survey period from 9/9/24 through 9/13/24, the facility failed to ensure eight of eight sampled bedrooms, accommodated no more than four residents each. This failure had the potential for residents to not have reasonable privacy or adequate space.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report physical abuse in accordance with the facility's policy and procedure titled Abuse Prevention Program, for one of four sampled residents (Resident 1), when a Licensed Vocational Nurse (LVN) 1 reported a physical abuse allegation to the Administrator (ADM) on 5/14/24, and the facility did not notify the appropriate agencies of Resident 1 ' s allegations of abuse within the required timeframe. This failure resulted in a delay of reporting Resident 1 ' s allegation of physical abuse investigation and had the potential to place Resident 1 and other resident ' s health and safety at risk of harm or injury.

Inspectors wroteBased on interview and record review, the facility failed to release medical records requested in writing by on behalf of Resident 1 within the required 48 hours advance notice indicated in facility ' s policy and procedure (P&P) titled, Release of Information dated November 2009. This failure resulted in Resident 1's family, denial of timely documents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) assessment accurately reflected resident's current status for six of six sampled residents (Resident 9, 10, 23, 37, 46 and 47) when MDS assessments failed to accurately code restraints according to the Resident Assessment Instrument (RAI- guidelines on gathering definitive information on a resident's strengths and needs) guidelines. These failures had the potential for Residents 9, 10, 23, 37, 46 and 47 not being provided with the necessary care and services to meet their healthcare needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in the kitchen when: 1. The ice machine was dirty. 2. The two compartment prep sink did not have an air gap. 3. The dish wash machine had higher parts per million (ppm - a unit of measurement) concentration of chlorine than required by manufacturer guidelines. 4. The sprinkler pipes and hood filter above the stove were covered with grease and dust. 5. Torn gasket found on refrigerator number (#) 1's door. 6. Broken tiles found under dish wash machine and around the ice machine air gap. 7. The wooden shelves used to store clean serving plates was rough and had peeling and chipped paint. 8. Dust found on the following areas: a. Ceiling fan, b. Insect light, c. Ceiling above exit door of the kitchen , d. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program when the Infection Preventionist (IP) was assigned the Director of Staff Development (DSD-creates and implements employee training programs, orient new hires, supervise certified nursing assistant staff and serve with the interdisciplinary team) duties which prevented the IP from implementing and maintaining a system to prevent, identify, investigate, and control infections consistent with national standards and the facility's policy and procedures. These failures placed 62 of 62 residents at risk for the transmission of communicable diseases (illnesses that spread from one person to another) and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Comprehensive Minimum Data Set (MDS-an evaluation of care needs, memory and physical functions) were completed and submitted within the required 14 day time frame for four of 14 sampled residents (Resident 3, 15, 21 and 36). This deficient practice had the potential to negatively affect the delivery of care and services needed by the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Quarterly Minimum Data Set (MDS) assessment (an evaluation of care needs, memory and physical functions) were completed and submitted within the 14 days required from the start date of the assessment for nine of 14 sampled residents (Resident 2, 7, 20, 22, 31, 34, 35, 49 and 50). This failure had the potential to delay updating care plans related to providing residents with the appropriate care and services needed.

Inspectors wroteBased on interview and record review, the facility failed to meet the required timelines for encoding (input of information for data transfer), completion, and transmission of Minimum Data Set (MDS) assessments (evaluation of cognition, care needs and functional abilities) for 14 of 14 sampled residents (Resident 2, 3, 7,15, 20, 21, 22, 25, 31, 34, 35, 36,49 and 50). This failure resulted in not using the most up to date MDS assessment information in the residents' clinical record and not communicating to CMS the required quality data.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for five of six sampled residents (Residents 9, 23, 24, 25 and 42) when: 1. The nurses did not monitor and assess Residents 24, 25 and 42 for adverse reactions after receiving COVID-19 (infectious disease caused by the SARS-CoV-2 virus) vaccinations (creates immunity from a disease) on 4/28/23. This failure placed Residents 24, 25 and 42's health and safety at risk for delayed recognition of adverse reactions to the vaccine. 2. Nursing staff did not ensure Resident 9's physician order to check phenytonin (medication used to decrease seizure activity) level quarterly was completed and the last phenytoin level was completed on 1/23/23. This failure placed Resident 9's health and safety at risk for serious medical condition. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 30) received treatment and care in accordance with professional standards of practice when Resident 30's nephrostomy (surgical opening between kidney and the skin with a tube inserted for urine drainage) and suprapubic catheter (placement of a drainage tube between the urinary bladder and skin just above the pelvis) site treatments were not performed according to the physician orders. This failure placed Resident 30 at risk for urinary tract infection (UTI- infection in any part of the urinary system-kidneys, ureters or bladder), sepsis (the body's life-threatening response to an infection), and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess six of 17 sampled residents (Residents 9, 10, 23, 37, 46, 47) for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars that attach to the bed), prior to installation. The facility failed to ensure safety for Resident 37 when staff did not obtain an informed consent (form signed by resident or family explaining the risks) and physician orders prior to use. These failures had the potential to place Residents' 9, 10, 23, 37, 46, and 47 at risk for decreased freedom of movement, entrapment and/or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when: 1. Licensed Vocational Nurse (LVN) 4 administered Resident 1 [brand name] insulin (medication used to treat diabetes mellitus) after its expiration date. This failure had the potential for Resident 1 to not received the full therapeutic effect of the medication which could lead to elevated or low blood sugar and serious medical condition. 2. LVN 1 administered phenytoin (medication used to treat seizure) suspension to Resident 9 and did not used the recommended tool to measure accurate dose. This failure had the potential for Resident 9 to not received the therapeutic effect of the medication which could lead to more seizure activities and serious medical condition. 3. [...]

Inspectors wroteBased on observation, interview and record review, the faciltiy failed to ensure three of 10 sampled residents (Residents 1, 9 and 44) were free from significant medication errors when: 1. Licensed Vocational Nurse (LVN) 4, administered expired [brand name] insulin (medication used to treat diabetes mellitus) to Resident 1. This failure had the potential for Resident 1 to not receive the full therapeutic effect of the medication which could lead to lower or higher blood sugar results which could lead to more serious medical complications. 2. LVN 1 administered phenytoin (medication used to treat seizure) suspension to Resident 9 and did not use the recommended tool to measure the accurate dose. This failure had the potential for Resident 9 to not receive the full therapeutic effect of the medication which could lead to seizure activity and more serious medical complications. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles when: 1. Two tuberculin (combination of proteins that are used in the diagnosis of tuberculosis [potentially serious infectious bacterial disease that mainly affects the lungs]) vials (small container for liquids) were opened with no indication of used-by date or open date. This failure had the potential to produce inaccurate purified protein derivatives (PPD) test (skin test is a test that determines if you have tuberculosis) results and or cause harm to vulnerable population if administered beyond the manufacturer's used by date. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that staff safely and effectively carried out the functions of food and nutrition services when: 1. Maintenance Director did not follow manufacturer guideline to clean the ice machine. (Cross reference 812) 2. Two Dietary Aides (DA 1 and DA 2) and Dietary Manager (DSS) were unable to accurately test the concentration of chorine as per manufacturer guideline in the dish wash machine. (Cross reference 812) 3. One Dietary Aide (DA 3) and one evening (PM) [NAME] were unable to accurately test the sanitizing solution used to sanitize food preparation surfaces in the kitchen. 4. DSS did not follow physician order for honey thick beverages for two residents (Resident 2 and 205) during lunch on 6/13/23. (Cross reference 805) 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate food textures was provided when two of two residents (Residents 2 and 205) did not receive honey thickened liquids as ordered on 6/12/23 and 6/13/23. These failures had the potential to place the residents at risk of aspiration (when food is breathed into the lungs) and choking. (Cross reference 802)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's beverage preference was honored for one of 57 sampled residents (Resident 2) when apple juice was placed on Resident 2's lunch tray on 6/13/23. This failure had the potential to result in decreased liquid intake, and could result in unplanned dehydration, further compromising Resident 2's nutritional and medical status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive and effective systematic approach was implemented to monitor and maintain optimal nutritional status for one of two sampled residents (Resident 17) when: 1. The facility failed to ensure the weight goal range for Resident 17 was established with the involvement of the resident's legal representative (RP). 2. The facility failed to follow standards of practice for Resident 17 and find a substitution or alternate nutritional intervention for [brand name] (a frozen dessert used for adding calories and protein) which the facility no longer provided. These failures had the potential for Resident 17 to experience continued weight loss.

Inspectors wroteBased on interview and record review, the facility failed to meet the minimum requirement of a registered nurse (RN) on duty when an RN was not scheduled for eight consecutive hours per day, seven days a week for 17 (3/4/23, 3/5/23, 3/9/23, 3/11/23, 3/12/23, 3/18/23, 3/19/23, 3/21/23, 3/22/23, 3/25/23, 3/26/23, 4/4/23, 4/6/23, 5/7/23, 5/16/23, 5/23/23 and 5/30/23) of 103 days sampled. This failure had the potential to result in residents not receiving appropriate services with RN oversight.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when two of the three dumpsters did not have the lids of the dumpsters closed properly. This failure had the potential to attract pests and rodents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure an effective pest control program was in place for the kitchen when house flies were observed flying and landing in the facility. This failure had the potential to lead to food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites or toxins) in the facility residents who eat food prepared in the kitchen.

Inspectors wroteBased on interviews and observations during the survey period from 6/12/2023 through 6/16/2023, the facility failed to ensure eight of eight sampled bedrooms, in building two, accommodated no more than four residents each. This failure had the potential for residents to not have reasonable privacy or adequate space.