Griffith Park Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for one of four sample residents (Resident 1), to ensure resident was monitored for the effectiveness and side effects of Percocet (a strong pain medication combination of Oxycodone [a strong opioid] and Acetaminophen [Tylenol]) 5-325miligrams (mg, unit of weight) that was given as needed for moderate to severe (4-10/10 on the numerical pain scale [a way to rate pain intensity, ranging from 0 - no pain to 10 - worst pain felt]) pain in accordance with the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, This deficient practice placed Resident 1 at risk for ineffective pain management, overdose of medication or delayed identification of preventable side effects of Percocet such as drowsiness, constipation, dizziness, and nausea or vomiting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to receive necessary services with activities of daily living (ADL) for one of four sample residents (Resident 2), a resident with a recent below the knee amputation (BKA, surgical removal of the portion of the leg below the knee), when the staff did not answer his call light (a safety and communication device resident use to signal staff for assistance) when he needed help to transfer in and out of his wheelchair (a chair with wheels used as a mode of transportation) to go to the bathroom for bowel movement in accordance with the facility's policy and procedure titled, Activities of Daily Living, Supporting, This deficient practice resulted in Resident 2 attempting to self-transfer in and out of his wheelchair to use the bathroom without assistance which could result in Resident 2 decline in performing ADLs and [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assist and supervise one of three sampled residents (Resident 2) who was at risk for fall, recent left below the knee amputation (BKA- surgical removal of the limb below the knee) and history of fall in the last three months, in accordance with the facility's policy and procedure titled Safety and Supervision of Residents when the facility staffs did not answer his call lights when the resident needed assistance with transfers from bed to wheelchair to go to the toilet due to having diarrhea. This deficient practice resulted in Resident 2's losing his balance when transferring to and from the wheelchair and had a near fall incident that could result in pain and injuries prolonging resident's hospitalization on 7/22/2026.

Inspectors wroteBased on interview and record review , the facility failed to provide quarterly statements of the residents personal trust fund account ( P&I - money that belongs to the resident but is held, safeguarded, and managed by the facility on the resident's behalf) for 3 of 3 sampled residents ( Resident 2, 3, and 4), in accordance with the facility's Policy and Procedure (P&P) titled, Quarterly Accounting of Resident Funds. This deficient practice had the potential to prevent residents and / or their representatives from monitoring account balances and ensuring proper management of resident personal funds.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services consistent with the resident's condition, physician orders, and professional standards of practice for one of three sampled residents (Resident 1). The facility failed to: 1. Assess known risk factors and develop a care plan associated with Resident 1's use of anticoagulant and antiplatelet medications addressing Resident 1's anticoagulant related bleeding risks (Apixaban and Clopidogrel), despite active orders requiring monitoring for bleeding. 2. Conduct an adequate post fall assessment after Resident 1 slid from the bed and struck his head on [DATE], including failure to assess for possible delayed intracranial bleeding or other complications expected in an anticoagulated resident. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and hazard free environment for one of four sampled residents (Resident 1), who was bedbound and required total care, by failing to identify and address Resident 1's specific risks associated with the use of the Low Air Loss (LAL- an air powered mattress that helps prevent skin breakdown by keeping the skin dry and reducing pressure) Mattress. The facility failed to: 1. Assess and monitor Resident 1's LAL mattress for proper functioning, appropriate settings, and the resident's tolerance to the LAL mattress in accordance with the resident's care plan. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect three of three (Resident 2, 3 and 4) to be free from sexual abuse (non-consensual [without the person's permission] sexual contact of any type with a resident who does not wish to engage in sexual activity or may not have the capacity to consent) when the facility failed to: 1. Monitor Resident 1 for aggressive behaviors and verbal threats as indicated in his care plan created on 4/28/26 after Resident 1 verbally threatened to harm his roommate when Resident 1 was transferred to a new room with Resident 3. 2. Maintain close supervision and vigilance at all possible times for Resident 1, who had a reported history of inappropriate sexual behavior toward females, as indicated in his care plan initiated on 3/28/26. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to report resident-to-resident verbal abuse to the California Department of Public Health (CDPH- the state agency responsible for providing regulatory oversight of healthcare facilities), local police department (PD), and the local ombudsman (omb- an independent, impartial official who investigates and helps resolve complaints or concerns about an organization's services, practices, or compliance) as written in their policy titled, Abuse Investigation and Reporting when Resident 1 made verbal threats to physically beat his roommate on 4/28/26. This deficient practice compromised the protection of residents, denied timely intervention by oversight and law enforcement authorities, and increased the potential for further harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly supervise Resident 1, allowing the resident to enter the rooms of three of three sample residents (Residents 2, 3, and 4) and engage in inappropriate behavior, which occurred as a result of inadequate monitoring by failing to: 1. Monitor Resident 1 for aggressive behaviors and verbal threats as indicated in his care plan created on 4/28/26 after Resident 1 verbally threatened to harm his roommate when Resident 1 was transferred to a new room with Resident 3. 2. Implement a care plan of Resident 1's inappropriate sexual behaviors of touching his genital area in front of Resident 4 as Resident 1 had previously performed prior to his admission to the facility. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive resident specific care plan for one out of five sampled residents (Resident 3) by failing to ensure to implement a care plan for Resident 3, who had a gastrostomy tube (G-tube, a device surgically inserted through the abdominal wall directly into the stomach to provide long-term nutrition, hydration, and medication to individuals unable to eat enough by mouth). These deficient practices had the potential to result in confusion of resident's care and negatively affect the residents psychosocial wellbeing.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper and effective Basic Life Support (BLS-the level of care provided to victims of life-threatening illnesses or injuries until full medical care is available, including recognition of cardiac arrest and activation of the emergency response system), that included cardiopulmonary resuscitation (CPR, an emergency procedure combining chest compressions and rescue breaths to circulate blood and oxygen when the heart stops or breathing ceases). The facility did not perform BLS for one of two sampled residents (Resident 1) identified full code (a resident who wants all possible life-saving measures used if their heart stops or they stop breathing, including CPR. When Resident 1 was found weak, with shallow breathing, no longer talking and became unresponsive and failed to ensure: 1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure three of three licensed nursing staff (LVN 1, LVN 2, RN 1) had the competent skills sets to provide care in accordance with the facility's policy and procedure (P&P) titled Staffing, Sufficient and Competent Nursing) and resident assessment for one of two sampled resident (Resident 1) who was unresponsive with difficulty breathing and required cardiopulmonary resuscitation (CPR - an emergency procedure combining chest compressions and rescue breaths to circulate blood and oxygen when the heart stops or breathing ceases). These deficient practices resulted in delayed provisions of emergency care for Resident 1 and other potential residents with full code status treatment (full support which includes CPR if the patient has no heartbeat and is not breathing) in a life-threatening situation.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a behavioral problem were assessed, monitored, supervised and provided necessary care since admission to the facility on 1/26/2026. This deficient practice resulted in Resident 1 hitting another resident (Resident 2) on 1/29/2026.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive, resident centered care plan was developed for one of three sampled resident (Resident 1), who was legally blind to address and assist specific needs. This deficient practice resulted in Resident 1 not being provided with specific care and services required to maintain her independence.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices in accordance with the facility's Policy and Procedure (P&P) titled Oxygen Administration and Departmental (Respiratory Therapy) for a one of two sampled residents ( Resident 1) by failing to : Ensure Resident 1's oxygen tubing (a flexible plastic tube, often green, that delivers supplemental oxygen from a tank or concentrator to a patient via nasal prongs) was labeled with a date the oxygen tubing was last changed. Ensure Resident 1's breathing nebulizer (a device that converts liquid medication into a fine mist for inhalation) was changed within seven (7) days. The nebulizer was last dated 1/5/2026. Document oxygen set- up, which included the date and time the procedure was performed in Resident 1's medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to three of three (Resident 1, 2 and 3) who needed assistance with ADL (activities of daily living) by not answering the call lights (a button or touch pad device that residents use to communicate assistance from the nursing staff) in a timely manner in accordance with the facility's policy and procedure by failing to assist: 1. Resident 1 and Resident 2 reported it took the facility one (1) to two (2) hours to respond to their call light when their adult briefs needed to be changed. 2. Resident 3 reported he waited about one (1) hour in the bathroom for a nurse to assist in cleaning him after having a messy bowel movement. As a result of this deficient practice, the residents were placed at risk for infection, skin breakdown and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Orajel 2X Toothache & Gum Mouth/Throat Gel 20-0.26% (Orajel cream, topical cream applied to gums to relieve pain and discomfort) as for three days that was ordered by the physician to manage and relieve pain for one of three sample residents (Resident 1) who complained of upper left jaw toothache (pain around the tooth). As a result of this deficient practice Resident 1 reported experiencing consistent pain at 8 of 10 pain on the numerical number scale (a way of rating pain intensity, ranging from 0 - no pain to 10 - worst pain felt) and difficulty eating from 12/27/2025 to 12/29/2025 which could lead to weigh loss and/or prevents the resident to prevent in participation in activities of daily living that affects the quality of life.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide care in a manner that maintained or enhanced residents' dignity and respect in full recognition of their individuality for three (3) of six sampled residents (Residents 32, 69, and 81) by failing to: 1. Ensure Occupational Therapist (OT 1) was seated at eye level while assisting Resident 32 with the use of an adaptive utensil during meals. 2. Ensure Staff were at eye level while assisting with feeding; specifically, certified nurse assistant (CNA) 1 was observed standing over Resident 69 while feeding her. 3. Ensure Staff provided assistance with attention to safety, comfort, and dignity; [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that Resident 34 received appropriate pain management for open wounds on the right and left temporal areas by failing to: 1. Monitor and document Resident 34's pain before, during, and after wound treatments on 5/5/2025, 5/26/2025, 7/24/2025, 8/23/2025, and from 12/1/2025 to 12/13/2025, in accordance with physician orders and the resident's care plan. 2. Reevaluate Resident 34's pain management and notify Physician 1 (Attending Physician) of the resident's refusal of wound care treatments due to pain and sensitivity in the right and left temporal wounds, as required by the facility's policy and procedure (P&P) titled Pain - Clinical Protocol and care plan for refusal of treatments. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure continuous communication and collaboration for Resident 34's overall medical management between Physician 1 (Attending Physician), Physician 2 (Wound Care Specialist, physician who specializes in Wound Care and management), Physician 3 (Dermatologist, physician who specializes in skin care and management), and Physician 4 (Oncologist, physician who specializes in cancer and cancer management). This failure resulted in the breakdown of communication and collaboration between Resident 34's physicians which led to the lack of direction for Resident 34's overall medical care and management.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide sufficient number of staff to provide quality care that meets the individualized needs of the resident population, in accordance with the facility's policy and procedures (P&P) titled Staffing, dated August 2022 and as outlined in its Facility Assessment, revised dated 9/8/2025, by failing to: 1. Provide adequate Certified Nursing Assistants (CNA) coverage for the 7:00 AM-3:00 PM, 3:00 PM-11:00 PM, and 11:00 PM-7:00 AM shifts for multiple days in September and December 2025. 2. Assign a Treatment Nurse (TXN) for two days in September 2025 and two days in October 2025, as required in accordance with the Facility assessment dated [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement the facility's policies and procedures, titled storage of Food and Supplies, Procedures for Refrigerated Storage, professional standards of practice on food storage, food service safety, sanitation and handling practices to prevent the outbreak of foodborne illness (food poisoning) by failing to ensure: 1. Labeled and stored food indicated the use-by-date or expiration date, including: one-gallon bottle of liquid oil, one-gallon of barbecue sauce, four opened cans and a dozen of unopened soup base stock powders, and one bulk container in the dry storage room filled with white powder labeled as Food thickener. 2. Followed appropriate hygiene and sanitary procedures and did not leave ice scooper uncovered to prevent contamination. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Facility Assessment tool, dated 12/10/2025, was updated by failing to indicate the specific staffing needs such as the Certified Nurse Assistants (CNA) and Treatment Nurse (TXN) for each resident unit in the facility and each shift. This deficient practice had the potential for the residents not to receive care and treatment services as needed due to inadequate staffing.

Inspectors wroteBased on interview and record review, the facility failed to provide the pneumococcal vaccine (PCV2) as required and appropriate for three of five residents sampled for immunizations (Resident 68, Resident 42, and Resident 66) when: 1. Resident 68 was not consented for the PCV20 vaccine five days after admission into the facility as per the facility's policy and procedure (P&P). 2. Resident 42 was consented for the PCV20 vaccine but not administered the vaccine within 30 days of admission into the facility as per the facility's P&P. 3. Resident 66 was consented for PCV20 vaccine but was not administered the vaccine within 30 days of admission into the facility as per the facility's P&P. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Provide the COVID -19 vaccine as required and appropriate for one of five residents sampled for immunizations (Resident 66) when Resident 66 consented to receive the COVID-19 vaccine but was not administered the vaccine. 2. Failed to maintain documentation related to staff COVID-19 vaccination status when the newly hired Infection Preventionist (IP) was not endorsed a list of staff members immunized or consented for the COVID-19 vaccine. This deficient practice had the potential to result in the facility's staff and residents contracting, transmitting, and experiencing complications related to COVID-19 such as difficulty breathing, persistent pain or pressure in the chest, or diarrhea.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of three residents (Resident 64) who were sampled for self-administering medications was determined by the facility to safely self-administer medications when Resident 64 was observed in the resident's room with 3 bottles of medications at the bedside table. This failure had the potential to expose Resident 64, who was self-administering medications, to side effects and adverse effects of these medications that could go unmonitored by facility staff.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure completion of the Advance Directive Acknowledgment (ADA- a document where a person confirms they have received information about their right to create an advance directive and understand their options for future medical decisions) and documentation of the resident's exercise of rights regarding advance directives, for 1 of 4 sampled residents reviewed (Resident 77) for Advance Directives. This failure has the potential to result in more than minimal harm because incomplete ADA documentation may prevent staff from being aware of and honoring the resident's treatment preferences in an emergency.

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures titled Abuse Prevention/Prohibition and Abuse Reporting and Investigation for two of two sampled residents (Residents 45 and 46) by failing to protect, prevent, report, and investigate an alleged physical abuse incident that occurred between Residents 45 and 46 on 07/13/2025. Specifically, the facility failed to: 1. Identify the physical altercation between Residents 45 and 46 as a form of abuse, which was reported by Licensed Vocational Nurses (LVNs) 2 and 7 to the Administrator on 07/13/2025, and which resulted in a mark on Resident 45's upper left forehead. 2. Protect Resident 45 and prevent further physical abuse when licensed nurses did not develop a care plan after LVNs 2 and 7 were made aware of the allegation of physical abuse by Resident 46 toward Resident 45. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an alleged resident to resident altercation within 24 hours for two of two sampled residents (Resident 45 and Resident 46) to the California Department of Public Health (CDPH) in accordance with the facility's Policy and Procedure (P&P) titled, Abuse Reporting and Investigation. This deficient practice resulted in the facility underreporting allegations of abuse and Resident 45 sustaining a red mark in between the left frontal and temporal area (upper left portion of the forehead).

Inspectors wroteBased on interviews and record review, the facility failed to complete a Pre-admission Screening and Resident Review Level II (PASRR II)-a follow-up assessment that ensures residents with mental disabilities receive appropriate care-after the initial PASRR Level I assessment was completed for one (1) of three (3) sampled residents (Resident 26), in accordance with the facility's policy and procedure (P&P) titled PASRR Completion Policy. This deficient practice had the potential to put Resident 26 at risk of not receiving appropriate mental health care and placement to appropriate facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the musculoskeletal care plan was updated to reflect the current nursing interventions for one out of five residents (Resident 8) who were sampled for unnecessary medications. This deficient practice had the potential to cause Resident 8 to not receive services and nursing care to address the resident's musculoskeletal issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of five sampled residents for unnecessary medications (Resident 8) had physician orders for PRN (as needed) analgesics (pain reliever) that were clear, specific, and non-conflicting. The physician orders contained overlapping administration parameters, which created a risk for significant medication errors and did not comply with professional standards of quality. This deficient practice placed Resident 8 at risk for potential adverse effects associated with ambiguous pain medication parameters, including inconsistent medication administration, duplicate therapy, or failure to follow physician orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with the resident's care plan and professional standards of practice for one of three residents sampled for quality of care (Resident 54) when: 1. Certified Nursing Assistant (CNA) 4 failed to turn Resident 54, who was bed bound, every two hours or as needed as stated in the resident's care plan. 2. Licensed Nurse (LN) 1 failed to inspect and ensure that Resident 54 had a dressing on her gastric tube (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) site as written in her care plan and ordered by the physician. 3. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that one of three sampled residents (Resident 92), who had an indwelling Foley catheter, and was reviewed for infections, received appropriate monitoring and documentation of intake and output (I&O) and assessment of urine characteristics as required by the physician's order, the resident's care plan, and facility policy. Specifically, staff did not document I&O from 12/1/2025 to 12/12/2025, did not record urine output in the Elimination section, and did not identify or report cloudy urine observed on 12/12/2025. This deficient practice resulted in the potential for undetected urinary tract infection (UTI-an infection in the bladder/urinary tract), catheter obstruction, or urinary retention, which could lead to complications such as sepsis or worsening of the resident's condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one out of one sampled resident (Resident 74) who had food preferences, was prepared a meal that honored the resident's dislikes when Resident 74's meal tray included green vegetables. This deficient practice had the potential to cause Resident 74 to lose his appetite, which could affect the resident's nutritional status.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that are accurately documented for one of six residents sampled for accurate documentation (Resident 54). Specifically, Resident 54's treatment administration record indicated that wound care was provided at a time inconsistent with actual delivery of care. This deficient practice had the potential to compromise continuity of care by inadequately documenting tasks that were or were not completed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inspect and ensure that a dressing was in place on the gastric tube (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) of one of two residents (Resident 54) sampled for g-tube dressings. This failure placed Resident 54 at risk of developing an infection at her g-tube site and had the potential to cause the g-tube to become dislodged, further leading to hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's bedrooms accommodated no more than four residents for five (5) of 36 rooms (Rooms 31, 32, 33, 34, and 35 with six beds in each room) in the facility in accordance with the facility's policies and procedures (P&P) titled Bedrooms, dated May 2017. This deficient practice had the potential to negatively affect the residents' privacy, safety, and quality of care due to inadequate space for quality nursing and emergency care services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's bedrooms measured at least 80 square feet (sq.ft, unit of measure) per resident in five (5) of 36 rooms (Rooms 31, 32, 33, 34, and 35 with six beds in each room) in the facility in accordance with the facility's policies and procedures (P&P) titled Bedrooms, dated May 2017. This deficient practice had the potential to have a negative impact on the care and services of the facility's staff to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a person-centered care plan for one of two sampled residents (Resident 1) with a diagnosis of dysphagia (difficulty swallowing). This deficient practice resulted in the potential for Resident 1 to not receive individualized care and services necessary to address his swallowing difficulties, thereby placing him at risk for adverse outcomes such as aspiration (the inhalation of a foreign substance into the airway), choking, or inadequate nutrition and hydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a person-centered comprehensive care plan to address the resident's medical and physical needs for one of three sampled residents (Resident 2), reviewed for pressure injury and prevention. Resident 2 who was admitted with a Stage 3 pressure injury (an open, full-thickness skin wound that extends into the fatty tissue but not into the muscle, bone, or tendon) on his sacrum (situated just above the buttocks) and a SDTPI (suspected deep tissue pressure injury) to the right and left heel, did not have a weekly treatment documentation from the facility's wound doctor (WMD) nor the treatment nurse (TN) of a risk assessment, that included measurements of each area of the skin breakdown. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together toward the care goals of the resident) failed to evaluate and assess residents mental and physical abilities for one of one sampled resident (Resident 1) to determine whether self-administering medications was clinically appropriate for the resident. Resident 1 was observed with five bottles of supplements at bedside which included vitamin C, calcium, vitamin D3, vitamin E and vitamin B12. This deficient practice had the potential to cause negative side effects to Resident 1's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a complete comprehensive assessment of a resident's needs, strengths, goals, and preferences, using Resident 1's Minimum Data Set (MDS, a resident assessment tool) document, within 14 calendar days after admission, per facility policy. Resident 1 was admitted on [DATE] and the MDS was due to be completed on 8/21/2025 but was completed on 8/25/2025 (four days late). This deficient practice potentially resulted in Resident 1, who had left and right eye blindness category 3 (means severe visual impairment that is worse than legal blindness but can still perceive some light) verbalizing feeling of frustration about her care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), when Resident 1, who was admitted with Moisture-Associated Skin Damage (MASD, skin irritation or breakdown caused by prolonged exposure to wetness from bodily fluids) to the buttocks extending to the groin area, did not have a weekly skin assessment, per facility policy. This deficient practice had the potential to result in worsening the MASD or infection and could negatively affect Resident 1's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures titled Release of Resident's Personal Belongings , to prevent misappropriation (unauthorized or improper use of someone else property) of resident's property and ensure accurate accounting and safe keeping of resident's personal belonging for one of three sampled residents (Resident 1). This deficient practice had resulted in the violation of residents rights for Resident 1 and a potential for other residents in the facility to loose their personal items. CMS 2567 amended [DATE]

Inspectors wroteBased on interview, and record review the facility failed to provide treatment and services to attain the highest practicable mental and psychosocial well- being for Resident 1 who was diagnosed with major depressive disorder, anxiety and schizophrenia (a mental illness that affect how person think, feel, behave, mixed symptoms such as hallucination, delusion, disorganized thinking and who was identified as having behavioral issues and verbalization of wanting to go to the hospital on 6/16/2025 at 8:15 PM to 11 PM, in one of two sampled residents reviewed for behaviors (Resident 1), by failing to: 1. Ensure 1:1 sitter (provide one to one nursing or observation care to an individual patient for a period of time) intervention was put in place for Resident 1 whose behaviors were escalating on 6/16/2025. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident ' s rights to be free from physical and verbal abuse for one of three sampled residents (Resident 2) by failing to protect Resident 2 from Resident 1, after Residents 1 and 2 had a prior physical altercation on 5/29/2025 at around 8 AM and 10 AM. This deficient practice resulted in Resident 2 experiencing physical and verbal abuse from Resideht 1 on 5/29/2025 and had the potential to result to physical injury and/or affect Resident 2 psychosocially.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) and responsible party (RP) was provided written information regarding bed holds (a reservation that allows one to stay in, or return to, a care facility) upon Resident 1 ' s transfer to the General Acute Care Hospital (GACH) in accordance to the facility ' s Policy and Procedure (P&P) for Bed Holds and Returns. This deficient practice had the potential to result in Resident 1 and RP 1 being misinformed or unaware of Resident 1 ' s reservation of a bed and rights to return to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) had a person-centered comprehensive care developed to address Resident 1 ' s behaviors related to bipolar disorder(mood swings that range from the lows of depression to elevated periods of emotional highs) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). This deficient practice had the potential for a delay in care and services specific to Resident 1 ' s needs.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure for abuse prevention and reporting when Resident 1 had a verbal altercation with Licensed Vocational Nurse (LVN) 1. The facility failed to: 1. Investigate the allegation of abuse between LVN 1 and Resident 1 on 2/11/2025. 2. Suspend LVN 1 on 2/11/2025, pending the results of the facility's investigation, as indicated in the facility's policy and procedure (P&P). 3. Prevent further contact between LVN 1 and Resident 1, following the incident of verbal altercation on 2/11/2025. This deficient practice placed Resident 1 and other residents at risk for potential abuse from LVN 1, which could cause physical, mental, and emotional harm.

Inspectors wroteBased on interview and record review, the facility failed to notify the State Srvey Agency (SA) immediately or within two hours of an allegation involving abuse for one of two sampled residents (Resident 1) Resident 1 made an allegation of verbal abuse against Licensed Vocational Nurse (LVN) 1 by calling a Police Officer on 3/11/25 and arrived at the facility at 7:20 PM, as indicated in Registered Nurse (RN) 1's notes. RN 1 and LVN 1 did not notify the facility's Abuse Coordinator and/or the State Survey Agency (SA) within two hours after having knowledge of Resident 1's allegation of verbal abuse against LVN 1 on 3/11/25. This deficient practice had the potential for facility staff to under report all types of abuse allegations and placed Resident 1 at risk for further abuse and caused the facility to fail to address Resident 1's complaints of abuse.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement the facility ' s policy and procedure (P&P) titled, Smoking Policy-Residents, dated 8/2022, to ensure eight of eight sampled residents (Residents 2, 3, 9, 14, 18, 56, 67 and 136) who were smokers (residents who smoked cigarettes) had an environment free of accident hazards (risk) by failing to: 1. Provide supervision while smoking to Residents 2, 3, 9, 14, 18, 56, 67 and 136 when Resident 2, 3, 14, 18, 56, 67 and 136, were assessed by the facility as unsafe smokers, and when Resident 9 ' s smoking assessment was not completed by the facility. 2. Ensure Resident 9 was assessed for the level of supervision while smoking. 3. Ensure Resident 3 did not store cigarettes and lighters in Resident 3 ' s drawer. 4. [...]

Inspectors wrote2. During a review of Resident 14's admission Record (Face sheet), the facility admitted Resident 14 on 1/13/2020 and readmitted him on 9/7/2023 with diagnoses of bipolar (a mental illness that causes extreme mood swings that range from lows of depression to elevated periods of emotional highs) schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and nicotine (a highly addictive substance found in cigarettes, cigars, and e-cigarettes) dependence. During a review of Resident 14's Letter of Conservatorship (when a judge appointed another person to act and make decisions for a person who needs help), dated 2/22/2021, this document indicated that Resident 14 was still gravely disabled and was reappointed a conservator. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to address Resident 45's refusal to treat the long nails with [NAME] infection and for podiatric (a physician specialized in foot treatment) treatment on 10/7/2024. This deficient practice had a potential result in Resident 45's inadequate and incomplete provision of care and result in worsened foot infection. Cross Reference to F687.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the facility had sufficient staffing to monitor and supervise 8 out of 23 sampled residents (Resident 2, 3, 9, 14, 18, 56, 67 and 136) while smoking during the scheduled and nonscheduled smoking time in the patio and monitor for residents that are at risk of elopement (leaving the facility without permission) from 1-2 PM on 10/21/2024. These failures could result in the residents to be at risk for accidental burn, fire and accidents that could result in major injuries and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy and procedure by ensuring to store all drugs and biologicals in a safe, secure, and orderly manner, under proper temperature, light, and humidity controls and controlled medications are stored in separately locked, permanently affixed compartments for four of five sampled residents (Residents 3, 66, 69 and 76). The facility failed to: 1. Store Glargine (a medication to treat diabetes [a group of disease that result in too much sugar in the blood]) Pen for Residents 3, 69, 76. 2. Store Lorazepam (a controlled medication to treat anxiety) oral (given by mouth) concentrate in a sanitary environment inside the medication refrigerator at the Medication room [ROOM NUMBER] for Resident 66. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food were stored prepared and distributed of food under sanitary conditions to all the residents in the facility in accordance with the facility ' s policy and procedure by failing to: 1. Monitoring and documenting Sanitization Sink Solution Log. 2. Monitoring and documenting Cold Storage temperature Log. 3. Monitoring and documenting Sanitization Solution Log. These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wrote2. During a concurrent observation and interview on 10/23/2024 at 9:15 AM with the Maintenance Supervisor (MS), there was no documentation that the facility tested their water management system for Legionella. The MS stated, the facility conducted their own testing for Legionella with a minilab test kit. The MS stated, the water system was tested for Legionella, and the results were recorded in the previous administrator's phone. The MS stated the previous administrator was no longer employed by the facility and had been out for about two months. The MS stated, it was important to test for Legionella because Legionella can survive in water and grow in human-made water systems. The MS stated residents, staff, and visitors were at risk for developing Legionella because everyone uses the water system. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program by ensuring the supply room containing enteral nutrition (a form of nutrition delivered through a tube into the digestive system as a liquid) and other food products did not have any cockroaches and pests. This failure had the potential for the residents to contract illnesses, including food borne illnesses [an illness that comes from eating contaminated (containing disease causing organism) food] brought in by the pest and cockroaches.

Inspectors wroteBased on interview and record review, the facility failed to provide care that meets the professional standards of quality for one of five sampled residents (Resident 72) by failing to: 1. Document - Morphine Sulfate a controlled medication (a drug whose manufacture, possession, or use is regulated by a government) on the Control Drug Record on 10/10/2024 as administered to Resident 72 on her in accordance with the facility's policy and protocol. 2. Document the wrong physician order and wrong volume of receiving medication vial on Resident 72's Control Drug Record. These deficient practices had the potential to result in medication errors, which could lead to adverse reactions (any unexpected or dangerous reaction to a drug) for Resident 72, and undetected diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper footwear for one of two sampled residents (Resident 76). This deficient practice had the potential to result in Resident 76's discomfort and placed Resident 76 at risk for falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were at risk for skin breakdown and pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) received treatment and services to prevent skin breakdown for one of three sampled residents (Resident 21) with pressure injury by failing to ensure the low air loss mattress (LAL Mattress -air filled mattress used to relieve pressure) was set according to resident's weight. Resident 21's LAL mattress was set for 320 pounds (lbs.) body weight instead of 200 lbs. body weight since Resident 21's weigh was 185 lbs. As a result of this deficient practice Resident 21 was at a potential risk for developing pressure injury and/or worsened pressure injury to both heels.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide foot care for one of three sampled residents (Resident 45) with long nails and [NAME] infection and was documented by the facility as the resident refused podiatric (a physician specialized in foot treatment) treatment and no alternative services were offered or provided to ensure foot care was provided. Resident 45 stated he was never asked and provided foot and nails care by the facility's staff. This deficient practice resulted in Resident 45's feeling pain and uncomfortable when his feet were being touched and had a potential to result in worsened foot infection. Cross Reference to F656.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 28), was administered with the correct feeding formula (nutritional formula) delivered via gastrointestinal tube (GT- a tube surgically inserted into the stomach to deliver liquids and medications) as ordered by the physician. This failure had a potential to result in Resident 28's weight loss, intolerance (not able to absorb formula effectively) to GT feeding formula, such as having increased GT residual, vomiting, diarrhea, and stomach pain/discomfort.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sample residents (Resident 55) was provided respiratory care was consistent with professional standards of practice and facility's policy and procedure for by failing to ensure Resident 55's nebulizer mask (changes medication from a liquid to a mist so you can inhale it into your lungs) was kept in a plastic bag when not in use. The deficient practice had the potential to spread bacteria and infection to the residents and resulted in contamination of Residents 55's oxygen equipment and can place the resident at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately and safely provide pharmaceutical services, in accordance with the facility ' s policy and procedure (P&P) titled Controlled Substances and Discarding and Destroying Medications, by failing to: 1. Properly discard and destroy the remaining Morphine Sulfate (MS, a controlled medication [a drug whose manufacture, possession, or use is regulated by a government] is used to treat moderate to severe pain) for Resident 72. 2. Document the MS administered to Resident 72 on her Control Drug Record on 10/10/2024 in accordance with the facility ' s P&P. 3. Document the correct instruction and the correct volume of the MS to start on Resident 72 ' s Control Drug Record. 4. Maintain a record of the receipts of Resident 72 ' s MS that was delivered by the hospice pharmacy. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one out of 23 sampled residents (Residents 62) with meals that accommodated the resident's food preferences. Residents 62 received tomato products and milk with her meals, despite her dislikes for tomato products and allergy to milk. This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility's Quality Assessment and Assurance committee (QAA, committee established for the purpose of improving the safety and quality of health services) failed to establish and implement written policies and procedures to address noncompliance to the facility's smoking policy for 8 out of 28 residents (Resident 2, 3, 9, 14, 18, 56, 67 and 136) who were smokers, by failing to: 1. Identify quality deficiencies related to noncompliance with the facility's smoking policy. 2. Ensure effective oversight of the facility's smoking area. 3. Ensure effective system to obtain input from the Activity Director (AD) 1 to develop and implement appropriate plan of action to address noncompliance with the facility's smoking policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and maintain a functioning call light (a device that allows residents to communicate with their care providers when they need assistance) for one of 23 sampled residents (Resident 10). This deficient practice had the potential to result in a delay in meeting the resident's needs for assistance and can lead to falls and accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean and sanitary environment for four of four sampled residents (Residents 58, 60, 66, and 74) by failing to: 1. Ensure Resident 66's oxygen concentrator machine (a medical device that supplies oxygen and it can help people with breathing difficulties breathe more easily) was clean. 2. Ensure the facility maintained an effective pest control in the facility. Three of three residents (Resident 58, 60, and 74) were observed in the dining room with flies while eating their meals. These deficient practices had the potential for Resident 66 to have an allergic reaction from the dust and had a potential to result in Resident 58, 60, and 74's food contamination transfer of disease-causing organism from the flies from one contact area to another that could result in infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five (5) out of thirty (30) resident's rooms (room [ROOM NUMBER], 32, 33, 34, and 35) accommodated no more than four residents in each room. All 5 resident rooms consisted of six (6) bed capacity. This deficient practice had the potential adversely affect the delivery of care, quality of life, safety and violate the resident's rights for privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident for five (5) out of thirty (30) resident rooms (room [ROOM NUMBER], 32, 33, 34, and 35). This deficient practice had the potential to negatively impact the quality-of-care and the ability of the nursing care to safely provide care and privacy to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent and respond to the elopement (an act of leaving a care facility or safe area independently without notifying anyone) of one of three residents (Resident 1), who had severely impaired cognition (a condition that significantly impacts a person's ability to learn, remember, think, and communicate, making it difficult or impossible for them to live independently), by failing to implement the facility's policy and procedures by: 1. Not assessing and identifying Resident 1 as at risk for unsafe wandering (aimlessly going to places) and elopement when the facility observed the resident wandering to other resident ' s room and front lobby as indicated in the facility ' s policy and procedure titled Wandering and Elopement. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three facility staffs had appropriate competencies and skills sets necessary to provide nursing related services related to residents with wandering behavior (walking or going to places aimlessly) and at risk for elopement (running away or leaving the facility without proper permission) as indicated in the facility's policy and procedure titled Staffing, Sufficient and Competent Nursing. The facility failed to ensure: 1. Licensed Vocational Nurse (LVN) 1 attended in-services for elopement and Code Green (the code used to alert all facility staff that a resident is missing or has eloped). 2. Director of Staffing Development (DSD) evaluate the competencies of staff after in-services and when Resident 1 eloped. 3. DSD did not have specific clear instructions in the in-services provided about Code Green. 4. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), was appropriately transferred/discharged on 4/11/24 at 9 pm, in accordance with the facility ' s policy and procedure titled Discharging the Resident. As a result, Resident 1 was inappropriately discharged to Law Enforcement and then to home with Family (FAM) 1 on 4/11/24 at 9 pm, without a physician ' s order, discharge medications, and appropriate discharge planning. This deficient practice had resulted to Resident 1 not getting any of the prescribed and routine medications from 4/12/24 to 4/17/24 (6 days). This deficient practice may further result to medical complications due to inability to receive routine medications and the unsafe/unplanned discharge back to home.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), had a developed comprehensive care plan that addressed refusal to medications, specifically the risperidone (antipsychotic medication). This failure had a potential to result in not meeting the resident ' s needs and could lead to medical complications.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), had behavior monitoring related to schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), in accordance with the facility ' s policy and procedure titled Behavior, Mood and Cognition. This failure had a potential to result in a delay in physician ' s notification, interventions, and treatment of the resident ' s psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to supervise one of four sampled residents (Resident 1) who walked out of the facility ' s premises without the facility ' s knowledge on 2/8/24. As a result, Resident 1 was found on the street by the local police and was transferred to a general acute care hospital (GACH) with no injury. This deficient practice placed Resident 1 at risk to cold exposure, dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake) and other medical complications, and being struck by a motor vehicle.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient monitoring and supervision for one of three sampled residents (Resident 1) who eloped (the act of leaving a facility premises or a safe area without notifying anyone) or was absent without official leave (AWOL) from the facility. Resident 1 left the faciity on an approved out on pass order from his physician on 11/30/23 at 5:30 am. The resident had not returned and his whereabouts were unknown until he returned to the facility on [DATE]. This deficient practice had the potential for Resident 1 and other residents with out of on pass orders to be at risk to be in danger or harm from the environment and extreme weather conditions, which could lead to accidents, dehydration (when the body doesn't have enough water and other fluids to carry out its normal functions), and injuries.

Inspectors wroteBased on interview and record review, the facility failed to provide behavioral health care and services to maintain physical, mental and psychosocial wellbeing for one of two sampled residents (Resident 1). Resident 1 is a parolee (a person released from prison) wearing an ankle tracking device (an ankle monitor used to track location and is monitored 24 hours a day around the clock). On 10/2/23, Resident 1 had a decrease in dose of Haloperidol (Haldol) an antipsychotic medication. There was no individualized plan of care developed to address the resident's immediate needs and standard of care to reflect changes in approaches, as needed, that could result in significant changes in the resident's mental and psychosocial condition or needs. This deficient practice had the potential to negatively affect the Resident 1's emotional and psychosocial well-being.

Inspectors wroteBased on interview, observation, record review, the facility failed to ensure the maintenance of a safe, clean, and home-like environment for twelve of twelve sample residents as evidenced by: 1. Soiled curtains in rooms for Residents 2, 7, 23, 26, 34, 50, 54, 63, 70, and 78. 2. Residents 12 and 60's restrooms had damaged and peeling paint. This deficient practice placed the residents at risk for physical discomfort and had the potential for the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quarterly Minimum Data Set (MDS-a resident assessment and care-screening tool) was performed timely and transmitted to the Centers for Medicare and Medicaid Services (CMS) system for 5 of 11 sampled residents (Residents 46, 49, 53, 82, 83). This deficient practice had the potential for the residents not to receive the care and services to achieve their highest potential.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a resident assessment and care-screening tool) was transmitted (a process of transferring report) Transmittal requirements within 14 days after a facility completes the resident's assessment, into the Centers for Medicare and Medicaid Services (CMS) system information for 7 of 11 sampled residents (Residents 8, 19, 46, 49, 53, 82, 83). This deficient practice had the potential to result in confusion regarding the care and services provided to Residents 8, 19, 46, 49, 53, 82, and 83. It also had a potential to affect the facility's quality of care monitoring system that measures the effective, safe, efficient, patient-centered, equitable (fair), and timely care.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure titled, Arbitration Agreement, for three of three sampled residents (Resident 4, 40 and 86) by not ensuring that they were informed and understood any proposed binding arbitration agreement (resolving disputes with a neutral third party instead of the court) before having them enter into one. This failure resulted in Resident 4,40 and 86 unknowingly giving up their right to resolve any disputes with the facility through a court of law before a jury.

Inspectors wroteBased on, observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 63 and Resident 42) had the right to be informed and make treatment decisions. 1. Resident 63 refused care that included diaper change and nail care, had an interdisciplinary (IDT) plan of care to determine the cause of the refusal, in accordance with the facility's policy and procedure on Requesting, Refusing and/or Discontinuing Care or Treatment. 2. Resident 42 was prescribed Lorazepam (medication used to treat anxiety [a mental disorder that result in having the fear of the unknown]) without informed consent. This failure violated Resident 42's and Resident 63's rights to be informed when choosing the type of care or treatment to be received, and make decisions on alternative measures the resident or responsible party preferred.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (an alerting device for residents to call nurses or other nursing personnel to assist when they are in need) was accessible for one of ten sampled residents (Resident 20). This failure had the potential to result in Resident 20 not being able to call staff for assistance and result in delayed or no emergency care when needed.

Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedure titled, Physician Orders for Life Sustaining Treatment (POLST; a person's treatment wishes during a medical emergency), for one of 18 sampled residents (Resident 23) by not ensuring the revised POLST form showing the resident's code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) as Do Not Resuscitate (DNR; no medical measures to maintain life) was in Resident 23's medical chart. This failure had the potential to result in Resident 23's wishes not being met during a medical emergency.

Inspectors wroteBased on interview and record review, the facility failed to provide Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNF ABN, CMS-10055 form to notify beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services) to one of three sample residents (Resident 62), who was discharged from Medicare skilled service and continued to stay at the facility under custodial care (non-medical care that helps individuals with their activities of daily living, such as eating and bathing). This failure resulted in Resident 62 not knowing about the financial liability for services provided by the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that facility staff prevent abuse by implementing the facility's abuse policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating during the provision of care and services for one of four sampled residents (Resident 63). The facility failed to: 1. Identify an allegation of physical abuse which was reported by Resident 63 to the Social Services Director (SSD) on 10/31/2023, when Certified Nurse Assistant (CNA) 4 allegedly got on top of Resident 63, pulled the resident's right arm down, put CNA 4's knee on the resident, and cut the resident's nails, approximately about two to three weeks ago, as verbalized by the resident. 2. Start the investigation of Resident 63's allegations of abuse to CNA 4 to determine if abuse had occurred on 10/31/2023. 3. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to report a suspected abuse immediately to the Administrator immediately (within two hours of an allegation involving abuse or result in serious bodily injury) to the administrator and to other officials [state agency, adult protective services (a social services program serving older adults and adults with disabilities)] according to state law and in accordance with the facility's policy and procedure on Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one of four sampled residents (Resident 63). The facility did notify the appropriate agencies within two hours when the Social Services Director (SSD) was informed of Resident 63's allegation of abuse towards Certified Nurse Assistant (CNA) 4, on 10/31/2023. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a Preadmission Screening and Resident Review (PASRR - a federally required screening for mental health; Level I screening identifies suspected mental illness, intellectual/developmental disability or related condition; Level II screening determines if the individual would benefit from specialized mental health services) Level II evaluation for two of three sampled residents (Resident 20 and 78). This failure had the potential to result in Resident 20 and Resident 78 not receiving necessary mental health services.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline and comprehensive care plan for one of four sampled residents (Resident 3), who was receiving Eliquis (an anticoagulant or a medication that thins the blood or blood thinner which makes the blood flow through veins and arteries more easily). This deficient practice had the potential for Resident 3's not to receive the assessment and monitoring or other interventions needed to prevent or intervene when complications such as bleeding and bruising occurs while receiving anticoagulant.

Inspectors wroteBased on interview and record review the facility failed to revise the plan of care for one of 18 sampled residents (Resident 23) to reflect the new physician's order for Life-Sustaining Treatment (POLST-a person's treatment wishes during a medical emergency) from full code (all medical measures will be taken to maintain life) to Do Not Resuscitate (DNR-no medical measures to maintain life). This failure had the potential for Resident 23 not to receive the emergency treatment and intervention according to the resident's wishes.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice (a team of health care professionals that focuses of end-of-life pain and symptoms and attend to the emotional and spiritual needs at the end of life) for the development, implementation of, and revision of the coordinated plan of care for two of two residents (Resident 9, 77) reviewed for care plans by failing to ensure Resident 9, 77 had coordinated care plans with the hospice providing end of life care. This deficient practice had the potential to negatively affect the delivery of care and services related to the end-of-life status of Resident 9, 77.

Inspectors wroteBased on observation and interview, the facility failed to ensure 1 of 10 sampled residents (Resident 7) environment remained free of exposed electrical wiring. This deficient practice had the potential to result in Resident 7 sustaining an electrocution or burn injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff to follow physician order to provide correct amount of feeding formula for one of two sampled residents (Resident 78) who was on tube feeding (a therapy where a feeding tube supplies nutrients to people who cannot get enough nutrition through eating) by giving more feeding formula amount than physician ordered. This failure had the potential to result in putting Resident 78 at risk for aspiration (when food, liquid or some other material enters the airway or lungs by accident) and unplanned weight gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy and procedure related to respiratory care, titled Departmental (Respiratory Therapy) Prevention of Infection by ensuring the oxygen humidifier bottle (a device used to make supplemental oxygen moist) was labeled with the accurate the date of when first used for one of 3 sampled residents (Resident 77). This deficient practice has the potential for Resident 77 and other potential residents to develop an infection associated with unlabeled humidifier bottle.

Inspectors wroteBased on observation, interview, and record review, the facility failed to arrange dental service for to one of one sample resident (Resident 86) in a timely manner after Resident 86 was re-admitted to the facility. This failure has the potential to put Resident 86 at risk for oral infection and pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's room accommodates no more than four residents. The facility had 5 out of 30 residents' rooms (room [ROOM NUMBER], 32, 33, 34, and 35) that had six residents' beds in the room. This had the potential to have inadequate space for resident care and mobility for daily activities.

Inspectors wroteBased on observation and interview, and record review, the facility failed to ensure 5 of 29 resident rooms (Rooms 31, 32, 33, 34 and 35) met the required 80 square feet (sq. ft.) per resident area as indicated in the federal regulation or the CMS (Centers for Medicare and Medicaid Services). The rooms were occupied by residents or consisted of six resident beds in each rooms, a total of 24 residents occupied the 5 rooms. This deficient practice had the potential to result to inadequate space for resident care, mobility, and privacy of the resident that affects the health and safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a permit from the Department of Healthcare Access and Information (HCAI - the State agency having jurisdiction that reviews and approves plans for construction, repairs, renovations, and remodeling made to buildings to comply with State codes) for the replacement of the sprinklers throughout the facility. This deficient practice does not ensure that the installation of the sprinklers complies with the appropriate safety codes and regulations and could potentially pose a risk to the residents, staff, and visitors at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services for one of three sampled residents (Resident 1) with diagnosis of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and wandering (moving from place to place without a fixed plan; roaming; rambling) behavior by entering to other resident ' s room and nursing stations, and episodes of angry outburst (sudden violent and explosive behavior). Resident 1 was not monitored and supervised, and no plan of care developed to address behaviors related to dementia in accordance to the facility's policy and procedure. [...]