Greenfield Care Center of Fairfield

Inspectors wroteBased on interview, and record review, the facility did not adhere to the resident's rights when they failed to follow their own theft and loss policy and procedures for one out of 17 sampled residents (Resident 27), when Resident 27's cell phone was lost and was not followed up and resolved timely. This failure resulted in Resident 27 experiencing emotional distress and not being able to use her personal property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the accepted professional principles and current standard of practice for a census of 51 when:1. Multiple DuoNeb (a combination medication containing albuterol sulfate and ipratropium bromide used to treat tightening of the muscles lining the airways) vials (small container) were found stored out of its foil package;2. A total of five loose pills were found in medication cart D wing; and,3. Two expired bottles of Vitamin B12 were found stored in the medication room. These failures had the potential for diversion of the loose medications, and for residents to receive medication that was expired or with unsafe or reduced potency.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Supervisor (DS) met the required job qualifications of Dietary Supervisor per facility policy and procedures. This failure had the potential for unsafe food handling, and food borne illness in a highly susceptible population of 51 residents. During an interview on 3/9/26, at 9:45 a.m., with the DS, the DS confirmed she had been employed at the facility for one year in the position of Dietary Supervisor. DS stated she did not have a Certified Dietary Manager certification, nor was she currently enrolled in a Dietary Manager training program. The DS further stated she was responsible for all the training, hiring, and scheduling of dietary staff and ordered the food and kitchen supplies. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 51 when:1. Facility did not have an enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use) signage for Resident 1 and Resident 8 who were both on EBP;2. Residents' non-pharmaceutical (not medicinal drug related) personal belongings were found stored in one out of two sampled medication carts with pharmaceutical products; and,3. Kitchen staff was observed not wearing facial hair restraints as required. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive person-centered care plan for one out of 17 sampled residents (Resident 3) when Resident 3's care plan interventions for recording and monitoring fluid intake and output were not implemented. This failure had the potential to result in Resident 3 not attaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and proper delivery of respiratory care consistent with the facility's policy and procedures (P&P) for one out of 17 sampled residents (Resident 27) when Resident 27's physician's order for oxygen therapy was not followed. This failure had the potential to result in Resident 27's oxygen needs to be not met and for Resident 27 to not achieve her highest practicable well-being.

Inspectors wroteBased on interview, and record review the facility failed to ensure safe and effective pharmaceutical services for a census of 51 residents when Resident 36's controlled drug (drug with potential for abuse) uses and removal signed out from the Controlled Drug Record (CDR- a paper log of controlled drug removal for administration to resident) were not documented in the Medication Administration Record (MAR-a legal document that list administered drugs). This failed practice may contribute to a possible medication administration error for Resident 36, unsafe controlled medication handling, and risk of controlled drug diversion (unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of nine sampled residents for medication administration (Resident 60) was free from significant medication error when Resident 60 did not receive prescribed insulin (medication used to manage blood sugar level) in accordance with the physician's order. This failure has the potential to result in Resident 60 experiencing hypoglycemia (too low blood sugar level) and other unnecessary insulin side effects which could negatively affect Resident 60's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food in accordance with the physician's prescribed diet for one out of 17 sampled residents (Resident 55) when Resident 55 who was on Renal diet (a diet aimed at keep levels of fluids, electrolytes, and minerals balanced in the body in individuals with kidney disease) received a salt packet during the 3/9/26 lunch meal. This failure had the potential to negatively affect Resident 55's medical condition and for Resident 55 to not achieve his highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to adequately assess and initiate timely emergency response for one of three sampled residents (Resident 1) when Licensed Nurse (LN) 3 did not call 911 after Resident 1 had a very low oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) than normal and showed signs of distress and altered level of consciousness. This failure had the potential to delay the initiation of treatment for Resident 1, which could potentially led to respiratory arrest.

Inspectors wroteBased on interview, and record review the facility failed to ensure safe and effective pharmaceutical services for a census of 55 residents when Resident 41 and Resident 47's controlled drug (drug with potential for abuse) uses and removal signed out from the Controlled Drug Record (CDR- a paper log of controlled drug removal for administration to resident) were not documented in their Medication Administration Record (MAR-a legal document that list administered drugs). This failed practice may contribute to unsafe controlled medication handling and/or risk of controlled drug diversion (unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication administration practices were followed when the facility's medication error rate was more than 5% (percentage- number or ratio that expressed as a fraction of 100) for a resident census of 55. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 36 opportunities which resulted in a facility wide medication error rate of 8.33% in one out of 9 residents (Resident 32) observed for medication administration. These failures had the potential for unsafe and ineffective medication use for Resident 32 and had the potential to negatively affect the residents' medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmaceutical products were properly handled and stored in accordance with the facility's policies and procedures (P&P), and accepted professional principles for a census of 55 when:1. Multiple expired wound dressings (a material applied to a wound to protect it, promote healing, and prevent infection) were stored in the treatment cart;2. An expired medicated shampoo prescribed for a resident was stored in the treatment cart; and,3. An out of the package syringe needle (injection needle) was found in the treatment cart. These failures had the potential for residents to receive pharmaceutical products that were expired or with unsafe or reduced potency, and risk for residents and/or staff injury and/or infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to enrich the caloric content of meals for five of seven residents (Resident 3, Resident 4, Resident10, Resident 37 and Resident 42) with fortified (increased calorie and/or protein content) dietary orders when the cook omitted the scoop of melted butter intended for fortification. This failure had the potential to put these residents at risk for poor nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, serve food in accordance with professional standards for food service safety when:1. Four steamtable pans were found wet, stacked in the ready to use shelves. 2. One cook failed to follow food safety/sanitation procedures while preparing cooked ready to eat foods.3. One diet aide was observed putting a clean and sanitized dish rack on the kitchen floor. These failures had the potential to lead to food borne illness for the 51 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 55 when:1. A shared manual blood pressure machine (a device which measures blood pressure), a shared stethoscope (a device used to listen to the body's internal sounds), and a shared pulse oximeter (a medical device that measures the pulse rate and oxygen level in the blood) was not sanitized properly in between use of residents.2. One facility staff did not remove or properly cover a bracelet under personal protective equipment (PPE) while performing wound care for Resident 25.3. Enhanced Barrier Precaution (EBP, an infection control intervention that utilizes the use of gowns and gloves during direct care activities to reduce transmission of multi-drug-resistant organisms) guidelines were not followed for Res 5 and Res 53. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide appropriate treatment and services to maintain or improve mobility, and prevent decline in range of motion (ROM) for two out of 19 sampled residents (Resident 30 and Resident 23) when:1. Resident 30's restorative nursing program (RNA program- interventions that actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning) frequency was not followed; and,2. An RNA program referral from Physical Therapy (PT) was not implemented for Resident 23. This failure had the potential for Resident 30 and Resident 23 to experience a decline in range of motion and/or function and not achieve their highest practicable physical wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of 19 sampled residents (Resident 2) was provided with appropriate care and services with enteral feeding (also referred to as tube feeding/ feeding tube- the delivery of food and nutrients through a feeding tube directly into the stomach or part of the intestines) when Resident 2's gastrostomy tube (G-tube- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) was not flushed with water before medication administration and enteral feeding. This failure had the potential for Resident 2 to experience complications of the G-tube such as clogging and for the resident not to attain his highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 19 sampled residents (Resident 8) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 8's pain medication order was not consistently followed. This failure had the potential for Resident 8 to develop medication dependence (the inability of the individual to function normally in the absence of the drug), experience unrelieved pain, and not attain her highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to resident's food preferences as listed on their meal ticket for three of 14 sampled residents, Resident 32, Resident 4, and Resident 42 when:1. Resident 32 was served pot roast, but her meal ticket indicated that she disliked meat; and 2. Resident 4 was served brussels sprouts that was on her list of food dislikes.3. Resident 42 was given polenta (side dish made from cornmeal) with a documented corn allergy. These deficient practices had the potential for Resident 32, Resident 4, and Resident 42 to refuse to eat, potentially leading to weight loss, worsened medical conditions like slow wound healing, and a weakened immune system and for Resident 42 to have an allergic reaction.

Inspectors wroteBased on interview and record review, the facility failed to permit one of three sampled residents (Resident 1) to return to facility after the facility sent the resident to emergency room (ER). This failure resulted in denial of Resident 1's rights to return to the facility, which resulted in the resident's continuation of unnecessary hospital stay while waiting for placement.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision, accurate assessment, and interventions for one of 3 sampled residents (Resident 1) to prevent the resident leaving the facility, when Resident 1 left the facility without staff's knowledge (eloped), crossed a busy street, and was found wandering on the parking lot of another facility. This failure resulted in exposing Resident 1 to health hazards and fatal accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four out of 31 sampled residents (Resident 265, 264, 160, and 266) were free from significant medication errors when Resident 265, 264, 160, and 266 did not receive prescribed pain medications in accordance with the physician's order. These failures resulted in Resident 265, 264, 160, and 266 experiencing unnecessary pain and emotional distress which had negatively affected the residents' level of comfort, activity and sleep.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for two of 31 sampled residents (Resident 16 and Resident 266) when: 1. Resident 16's call light system was not appropriate; and, 2. Resident 266's call light system was broken, and she was provided with a nonfunctional alternative. This failure placed Resident 16 and Resident 266's safety at risk and had the potential for the residents' needs to be not met.

Inspectors wrote6. A review of Resident 48's admission record indicated admission to the facility on [DATE] with a diagnosis of Cyst of Pancreas (a fluid filled sac forming on the pancreas-a large organ producing hormones and enzymes that help with digestion)) and aftercare for G-Tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). A review of Resident 48's MDS dated [DATE], indicated a BIMS score of 11, which indicated moderate cognition (relating to processes of thinking and reasoning impairment. A review of Resident 48's Order Summary Report, dated 3/10/25, indicated the following physician orders: Enteral Feeding (nutritional liquid formula): Bolus (administered at one time) feeding, [Brand Name nutritional formula] 480 ml (milliliters, a unit of volume) via G Tube every 6 hours. Enteral Feeding: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure garbage was in a closed dumpster for a census of 60 residents when a dumpster was observed overflowing, and the lid was unable to be closed. This failure had the potential to attract insects and pests that could affect the health and safety of a highly vulnerable population of 60 residents, and could lead to the spread of infection among staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident privacy and confidentiality when meal tray tickets were thrown into the trash for a census of 54 out of 60 residents who ate facility prepared meals. This failure had the potential for 54 residents' personal and protected health information to be exposed and unprotected from unintended access.

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of 31 sampled residents (Resident 264 and Resident 265) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 264 and Resident 265's pain medication order was not followed. These deficient practices negatively affected the residents' physical comfort and psychosocial well-being as evidenced by unnecessary pain and emotional distress which caused sleeplessness and resulted in unmanageable pain levels.

Inspectors wrote1h. During a review of Resident 28's Progress Note dated 1/31/25 at 3:35 p.m. indicated she was admitted to the facility on [DATE] around 12:30 p.m. During a review of Resident 28's Order Summary Report for January 2025 contained a physician's order dated 1/31/25 for Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated (to treat difficulty breathing and reduce swelling in the airways) one puff inhale two times a day. Review of Resident 28's January 2025 MAR indicated the Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated was to be given twice a day at 9 a.m. and 5 p.m. The MAR indicated on 1/31/25 at 5 p.m. the Licensed Nurse (LN) documented 5 in the initial box. Under the section Chart Codes on the MAR indicated 5=Hold/See Nurse Notes. Review of a Progress Note (Type: eMAR Medication Administration Note) dated 1/31/25 at 6:26 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe medication administration practices when the facility's medication error rate was less than 5% for a facility census of 60. The facility had a total of 3 errors out of 30 opportunities, which resulted in a facility wide medication error rate of 10%. These failures had the potential to negatively affect the health of Resident 48 and Resident 16.

Inspectors wroteBased on observation, interview and record review, the facility failed to safely store medications when, unused medications from a discharged resident (Resident 41) were stored in the bottom drawer of the Medication Cart C (Med Cart C) and an expired narcotic for Resident 15 found in the bottom drawer of Med Cart C. These failures had the potential to contribute to unsafe medication use and storage, and potential for diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure a full-time Dietary Manager / Supervisor position was filled, when a kitchen staff member, lacking the training and qualifications for the Dietary Manager / Supervisor role, was placed in the position to cover for the Dietary Manager during a leave over the past 4 months. This failure had the potential for providing inadequate nutritional needs for a census of 60 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and store food in a sanitary manner for 54 residents who received food from the kitchen out of a census of 60 residents when: 1. Sanitizing solution was found to be under the minimum effective concentration, 2. Dietary Aide 1 (DA 1) did not cover his facial hair/beard while working in the kitchen, 3. Foods found in containers that were not sealed or closed tightly, 4. Foods found without labels indicating their use by date (expiration date), 5. Expired food found in food storage area, 6. Dishware found in ready to use areas in unsanitary condition. These failures had the potential to result in foodborne illness for all facility residents receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 60 when: 1. Facility staff did not wear required personal protection equipment (PPE) while providing wound care to Resident 13 who was on enhanced barrier precautions (EBP-also known as enhanced standard precautions, infection control intervention designed to reduce transmission of multidrug-resistant organisms that employes targeted gown and glove use); 2. A caregiver did not wear required PPE while providing care for Resident 17, who was on EBP; 3. Facility staff did not wear required PPE while providing direct care for Resident 53, who was on EBP; 4. Facility staff did not perform hand hygiene prior to and after medication administration; and, 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that Effective Communications in-services were done as a mandatory training for direct care staff for a census of 60. This failure had the potential to result in staff with poor communication skills and may negatively affect the residents' quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that in-direct staff members (staff that do not provide direct resident care) were educated on the rights of the residents and the responsibilities of a facility to properly care for its residents, for a census of 60. This had the potential for residents to not recieve care according to their rights.

Inspectors wroteBased on interview and record review, the facility failed to conduct mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI (Quality Assurance and Performance Improvement a systematic and interdisciplinary approach to maintaining and improving safety and quality in nursing homes while involving residents and families in practical problem solving) ) for a census of 60. This deficient practice had the potential to result in poor communication among staff, lack of awareness of facility updates, lack of collaborative work, and compromised resident care.

Inspectors wroteBased on interview and record review, the facility failed to conduct staff training on behavioral health for a census of 60. This had the potential for staff to not have the knowledge to care for residents with behavioral health issues and needs.

Inspectors wroteBased on interview and record review, the facility failed to maintain dignity and respect for three out of 60 sampled residents (Resident 160, Resident 45, Resident 6) when: 1. Certified Nurse's Assistant 2 (CNA 2) made demeaning and rude comments to Resident 160 for using the commode rather than the restroom. This resulted in Resident 160 to feel humiliated and embarrassed. 2a. Certified Nurse 6 (CNA 6) was standing over Resident 45 while assisting him with his meal; and 2b. CNA 3 was standing over Resident 6 while assisting him with his meal. These failures caused embarrassment and had the potential to minimized the residents' feelings of self-worth.

Inspectors wrote2. A review of Resident 48's admission Record, indicated, Resident 48 was admitted to the facility on [DATE] with diagnosis that included Hemiplegia (paralysis on one side of the body), Epilepsy (brain disorder characterized by recurring seizures) and Dysphagia (difficulty swallowing). During an interview with a family member (FM) of Resident 48 on 3/10/25 at 12:30 p.m., the FM stated, Resident 48's right upper arm and right lower leg are contracted and he's unable to move them. The FM was frustrated with the staff when she visited Resident 48 and found his call light on his right side of the bed. The FM further stated, Resident 48 should always have the call light within his reach, on his left side, so he can call for help anytime. [...]

Inspectors wroteBased on interview, the facility failed to ensure there was a written transfer agreement with a local General Acute Care Hospital (GACH) when the facility failed to provide a copy of a current transfer agreement upon request. This failure could potentially place residents at risk for inadequate continuity of care and treatment.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to practice appropriate infection prevention and control measures for one out of six sampled residents (Resident 1), when his Foley catheter (FC- a hollow tube inserted into the bladder to drain or collect urine) drainage bag was left on the floor. This failure had the potential to cause Resident 1 to experience a urinary tract infection (UTI- an infection in the bladder/urinary tract).

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure two out of six sampled residents (Resident 1 and Resident 2) had their call light (a device used to communicate with staff when assistance is needed) within reach. This failure could impair the residents ' ability to call for assistance when needed, potentially leading to safety concerns and delays in getting necessary care.

Inspectors wroteBased on interview and record review, the facility failed to ensure four out of four sampled residents received care which met professional standards when: 1. One Resident (Resident 1) suffered a 22 day delay in treatment of urinary tract infection and 2. three residents (Residents 3, 5 and 7) did not receive medications per order which had the potential to result in a stroke, high blood pressure, and for one resident (Resident 7) who suffered breathing problems and requested to be transferred to a facility for a higher level of care through emergency transport.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents and or their Responsible Parties (RP, an individual who is designated by the resident to help with placement or take on some responsibility for the resident's well-being) were aware of any Change of Condition (COC, significant alteration in a person's health or functional status that will not usually resolve itself without further intervention) or medication order changes, for two out of two sampled residents (Residents 2 and 3), when: 1. Resident 2 ' s RP was not notified of the change of his skin status. 2. Resident 3 was not aware he would need to continue his intravenous (IV, administered into a vein) antibiotic (ABX, drug used to treat infections-growth of germs in the body) therapy. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to: 1. Ensure Licensed Nurse (LN A) was following the Physician ' s Order for one out of two sampled residents (Resident 1), when LN A injected the long-acting insulin (injectable medication used to control blood sugar for people with Diabetes Mellitus -- DM,high blood glucose group of diseases that result in too much sugar in the blood) on Resident 1 ' s right lower abdomen at 11:18 a.m. instead of 9 a.m., per physician ' s order. 2. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure proper infection protocol was provided for one out of two sampled residents (Resident 1), when licensed nurse (LN) A reused an alcohol wipe (a sterile wipe saturated with a high concentration of alcohol used to clean the skin and prevent infection) to wipe Resident 1 ' s abdomen after insulin (injectable medication used to control blood sugar for people with Diabetes Mellitus -- DM, high blood glucose group of diseases that result in too much sugar in the blood) administration. This failure put Resident 1 at risk for risk for infection by introducing germs and bacteria into broken skin.

Inspectors wroteBased on interview and record review, the facility failed to ensure all facility staff received training in CPR (Cardiopulmonary Resuscitation, an emergency life-saving procedure performed when the heart stops beating) for healthcare providers, when four Certified Nursing Assistants (CNAs) did not have CPR certifications and did not know the facility's policy and procedure (P&P) for CPR. This failure reduced the facility's potential to provide life-saving procedures to residents during a medical emergency such as a resident having a heart attack or breathing failure.

Inspectors wroteBased on interview and record review the facility failed to ensure services met professional standards for one resident (Resident 10) of eight sampled residents when: 1. Licensed Staff B (LS B) administered Tacrolimus (a medication used in the prevention and treatment of organ transplant rejection) 0.5 milligram (mg) (medication to prevent the activity of the immune system) without a prescriber's order. 2. Tacrolimus 4.5 mg dose was changed by LS B without discussion with transplant coordinator (health professional who manages the organ transplant care); and, 3. Resident 10's weekly Tacrolimus lab was not done and carried out per prescriber's order. This failure decreased the facility's potential to administer medications safely to residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent accidents for one of 4 sampled residents (Resident 1) when a non-skid mesh, an intervention used to minimize risks of sliding from the wheelchair cushion and falling was not consistently implemented. This failure had the risk potential to increase falls and injuries for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four residents (Resident 2) was free from abuse when facility staff witnessed Resident 1 punch Resident 2 in the face, resulting in Resident 2 sustaining a swollen upper lip, scratches on his right forearm and scratches on his left-hand middle finger. This failure resulted in Resident 2 not being free from abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan with interventions to support one of three residents (Resident 1) with pneumonia (an infection of the lungs that causes shortness of breath and respiratory distress) after Resident 1 had a change in condition indicating the onset of pneumonia. This failure placed Resident 1 at risk of respiratory discomfort and exacerbation of pneumonia.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to accurately assess, monitor, and provide wound care treatment to prevent development of facility acquired pressure ulcer (PU, a damage to an area of the skin caused by constant pressure on the area for a long time) and to prevent the worsening of an existing pressure ulcer for three of 23 sampled residents (Resident 21, Resident 33, and Resident 122), when: 1. a. The facility did not monitor Resident 21's right heel when he was wearing a Pressure Relief Ankle Foot Orthosis (PRAFO, an orthosis with an aluminum heel connecting bar that helps to hold the ankle in a neutral (90 degree) position. b. The facility was not able to provide documentation Resident 21 was being turned from side-to-side at least every two hours, per facility policy and per care plan (CP, a road map for the care of a patient). c. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement an effective fall management program for three out of 23 sampled residents(Residents 38, 13 and Resident 26) with Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), when: A. 1. The facility did not follow its fall care plan (CP, a form where you can summarize a person's health conditions, specific care needs, and current treatment) when Resident 38 was not observed frequently and was not placed in a supervised area when out of bed such as when she was ambulating. 2. The facility did not address the causal factors such as poor balance, poor/comprehension leading to Resident 38's fall incident in developing and implementing relevant, consistent, and individualized interventions to prevent future fall incidents. 3. [...]

Inspectors wroteBased on interviews and records review, the facility failed to assess, monitor and provide necessary care and services, in accordance with professional standards of practice, for two of 23 sampled residents (Resident 21 and Resident 61), when: 1. Resident 21, who was at high risk for wounds due to Diabetes Mellitus (disease that result in too much sugar in the blood), developed a facility-acquired deep tissue injury (DTI - purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) on his right heel on 12/20/23, and developed an open wound on his right lateral lower leg on 12/24/23, from the facility's use of a PRAFO boot (Pressure Relief Ankle Foot Orthosis - a device worn on the calf and foot, designed to, float the heel and hold the ankle in a neutral, 90 degree, position). [...]

Inspectors wroteBased on observation and interview, the facility failed to: 1) employ staff who treat the residents (Resident 12, 31 and 18) with respect and dignity; and, 2) the facility did not follow its policy with regards to the laundry services, resulting in one of one sampled Residents (Resident 7) refusing to wear anything other than a patient gown (a type of gown usually worn in hospitals which does not close in the back, it only has ties to attempt to close the back part). This left Resident 7 not trusting the laundry services to return her personal clothes and left her not feeling like an individual.

Inspectors wroteBased on observations, interviews and records review, the facility failed to meet professional nursing standards for 5 of 23 sampled residents (Resident 35, 33, 21, 12 and Resident 47), when: 1. Resident 35 and Resident 33, who had pressure ulcers (also known as bedsore - damage to an area of the skin caused by constant pressure on the area for a long time) were provided with Low Air Low (LAL) Mattress (mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown); however, the air mattress was not inflated according to the resident's weight, and the facility staff did not follow its policy and procedure for, Pressure-Reducing Mattresses, Pressure Relieving Mattresses and Support Surfaces. [...]

Inspectors wroteBased on observation, interviews and records review, the facility failed to ensure showers for one of 23 sampled residents (Resident 21) were given during his scheduled shower days. This failure to maintain Resident 21's personal grooming and hygiene needs had the potential to raise the risk of unidentified skin issues, bacterial and fungal infections.

Inspectors wroteBased on observations, interviews and records review, the facility failed to provide activities to meet the needs and preferences for four of 23 sampled residents (Residents 12, 21, 33, and 40). This failure resulted in Resident 12 feeling lonely, isolated, and depressed. Residents not receiving activities, according to their preference and needs, could potentially impact their physical, mental, and psychosocial well-being.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure it was adequately staffed for Certified Nursing Assistants (CNAs), for 20 out of 30 days, and two out of 21 days for Licensed Nurses, for the month of 1/2024, which resulted in complaints of the facility being inadequately staffed. This could put residents' safety at risk, falls, accidents, late provision of care or care not being rendered at all. During an interview on 1/30/24 at 10:42 a.m., Resident 2 stated staff did not pay attention to residents and that was why, people here fall all the time. He stated, Do you see anyone supervising me or other patients? Resident 2 stated he felt the facility was inadequately staffed, the staff were lazy and did not want to do the work. During an interview on 2/23/24 at 1:31 p.m., Licensed Staff F stated the facility was short staffed but was better compared to before. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide one sampled lunch test tray which had the appropriate temperature for the vegetables and meat, and the vegetables were not palatable. These failures had the potential to increase weight loss and one out of two sampled residents (Resident 7) frustrated that the hot food was served cold.

Inspectors wroteBased on observation, interview and document review, the facility failed to label items in the freezer with their contents or delivery date and failed to discard expired fresh fruit. These failures had the potential of serving residents food not fit for consumption and enabling residents to become sick by ingesting expired food. The Dietary Supervisor indicated the cause of the colder temperature might be due to the plate being cold and not having resided in a hot plate warmer prior to being served. The meat (meatloaf) entrée was tested in the whole form and in the pureed form and both were found to be bland and not palatable. The spinach was watery in texture and not having any taste, also considered not palatable.

Inspectors wroteBased on interview and record review, the facility's Quality Assurance and Performance Improvement Committee (QAPI, a data driven and proactive approach to quality improvement; process used to ensure services are meeting quality standards and assuring care reaches a certain level) failed to identify quality deficiencies and subsequently investigate and act upon the deficiencies, once identified, as evidenced by: 1. Facility leadership failed to identify nursing staff were not providing services, per facility policy and professional standards, regarding bowel care management and RNA (Restorative Nurse Assistants; staff with special knowledge, skills, and techniques in therapeutic rehabilitation; work alongside rehabilitation staff caring for patients with limited mobility and capacity for self care) services (Cross reference F658); 2. [...]

Inspectors wroteBased upon observation, interview and record review, the facility failed to have a plate warmer in the kitchen in fully operational condition. Failure to have a functional plate warmer resulted in residents not having hot food for their meals, potentially causing weight loss due to lack of palatability.

Inspectors wroteBased on interviews and record reviews, the facility failed to: 1. Report the verbal altercation between Residents 30 and 49 to the California Department of Health (CDPH, the State department responsible for public health in California) timely. 2. Ensure staff were aware of the correct reporting time fame for reporting abuse allegations to the CDPH, the Ombudsman (an official who investigates complaints, usually lodged by private citizens against businesses, public entities, or officials) and the local Police Department (PD). 3. Include in the Abuse Prohibition policy the correct time frame on when to report abuse allegations to the CDPH, the Ombudsman, and the local (PD). These failures led to the late reporting of abuse allegations to the CDPH, the Ombudsman and the local PD. These failures could also lead to ongoing abuse and residents feeling anxious and depressed.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure injuries of unknown source (the source of injury was not observed by any person or the source of injury could not be explained by the resident and the injury is suspicious because the extent of the injury or the location of the injury is located in an area not generally vulnerable to trauma) was thoroughly investigated and reported to the appropriate agency, for one out of one resident (Resident 38). This failure could lead to not knowing the extent of injury, worsening of an injury or the incident to recur.

Inspectors wroteBased on observation, interview and record, the facility failed to provide one of one sampled resident (Resident 12) follow-up psychiatric services to correspond with anti-depression medications. This failure resulted in Resident 12's depression to increase and failure to participate in therapy services, which now had encouraged Resident 12 to remain bed-bound and subjecting Resident to 12 to contractures and pressure sore development.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the baseboards in residents' rooms were well maintained, were properly sealed and attached firmly to the wall. This failure could result in safety issues, cross-contamination, and pest infestation.

Inspectors wroteBased on interview and record review, the facility failed to prevent an avoidable physical altercation between two residents, Resident 3 & Resident 4 who were left alone, unsupervised in the Activity Room on 11/18/22. This failure resulted in a bloody nose injury to Resident 4, which required transfer to Emergency Department by ambulance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe environment for residents who frequently used the Activity Room, Dining Room, Lobby, Hallway, and a resident ' s room, when: 1) Residents 1 & 2 had a verbal altercation in the hallway. 2) Residents 3 & 4 had a physical altercation in the Dining/Activity Room on 11/18/22. 3) Residents 5 & 6 had verbal altercation while in the bathroom. 4) Residents 7 & 1 had a loud verbal altercation in front of other residents during an activity in progress in the Activity Room on 8/1/23. Resident 7 had multiple verbal altercations while raising his arms and was very angry at the staff while in his room & hallways on 8/10/22. These failures had the potential to result in fear of getting physically hurt, feeling anxious and frequent exposures to a noisy and hostile environment by residents, staff, and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its Policy & Procedures titled, Unusual occurrences, when it did not report multiple altercations for 5 out of 5 sampled residents (Residents 1, 2, 5, 6 & 7) to the State Agency (SA), to the Local Police Department (LPD) and to the State Ombudsman. These failures had the potential to results in physical harm due to frequent and multiple altercations, that may possibly lead to more serious physical injury and possible death.

Inspectors wroteBased on interview and record review, the facility failed to inform the Responsible Party (RP=Responsible Party is the person who has a level of control over, or entitlement to, the funds or assets in the entity that, as a practical matter, enables the individual, directly or indirectly, to control, manage or direct the entity and the disposition of its funds and assets) of one of three sampled residents, Resident 7, before sending Resident 7 for a procedure (CT scan of the neck -- A computerized tomography (CT) scan combines a series of X-ray images). This failure had the potential to result in a feeling of uncertainty and unawareness by the Responsible Party when Resident 7 had a change of condition requiring a CT scan, leading to dissatisfaction of services provided.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that three (3) out of five (5) Licensed Nurses (LN), LN I, LN N, LN T (Charge nurses) implemented the Competency training (Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) to keep residents safe when: 1) There was no Staff Supervision while Residents 3 & 4 were alone in the dining/activity room. Residents 3 & 4 had a physical altercation in 11/18/22. There were no witnesses to confirm the event. 2) There were no documentation's by Licensed Nurses (LN) and IDT (Intradepartmental Team) in Resident 7 ' s medical records when Resident 7 had verbal altercation; [...]

Inspectors wroteBased on interviews and records review, the facility failed to assess and monitor for signs of constipation (a condition of the bowels in which the feces [stool - waste matter discharged from the bowels after food has been digested] are dry and hardened and evacuation is difficult and infrequent) and did not administer medication to relieve constipation according to the doctor ' s order for one of three sampled residents (Resident 1). This failure resulted in Resident 1 ' s emergent transfer to the hospital due to large bowel (large intestine - the place where feces are formed) obstruction (a blockage that keeps gas or stool from passing through the body).

Inspectors wroteBased on interviews and records review, the facility failed to ensure transfer notice was provided for one of two sampled residents (Resident 1), when Resident 1 was transferred to the hospital without notifying the Long-term Care Ombudsman Program. This failure did not ensure the Ombudsman was duly notified, to advocate for Resident 1's best interest during transfer from the facility.

Inspectors wroteBased on interviews and records review, the facility failed to ensure notice of the bed hold policy was provided to one of two hospitalized residents (Resident 1). This failure could have resulted in Resident 1 ' s being unaware she could return to the facility after hospitalization, and whether she needed to submit payment to reserve a bed.