Harbor Villa Care Center

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for two of three final sampled residents (Residents 10 and104) reviewed for pressure injuries. * The facility failed to offload Resident 10's heels, as ordered by the physician and failed to provide a pressure relieving mattress with a pump as ordered by the physician. * The facility failed to offload Resident 104's heels as ordered by the physician. These failures had the potential for the residents to result in new pressure injuries, worsening of existing wounds, or other complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one two of four residents (Residents 6 and 44) observe for the medication administration were free from the significant medication errors. * LVN 1 administered the furosemide (medication to treat fluid retention) medication outside the physician's ordered parameter for Resident 6. * LVN 3 administered the heparin (blood thinner) medication without a physician's order for Resident 44. These failures posed the risk of adverse complication to the residents.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure to prepare food by methods that conserve nutritive value and at safe and appetizing temperature for 11 residents that consumed pureed food and 45 residents on Regular Diet Texture. * The prepared pureed vegetables were left in the oven for more than one hour before the lunch food tray line. * The ham temperature was at 98 degrees Fahrenheit. These failures had the potential for the residents not to eat the food served and could affect the residents nutritional status.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed for 81 of 87 residents who eat in the kitchen. * Food items used for residents' food were not properly stored, labeled and dated. * One expired bottle of opened ground ginger spice was not discarded. * The kitchen equipment and utensils were not maintained in a sanitary condition. * One cutting board was observed heavily marred and fuzzy with knife marks. * The pitchers were stored wet. * The hair restraint was not worn by one staff member preparing food in the kitchen. * Nonfood contact surfaces were not clean or in a cleanable condition. These failures had the potential to contaminate the food which could lead to foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on interview, medical record review, and facility's P&P review, the facility failed to ensure the residents or their representatives were informed in advance of the proposed treatment regarding the use of psychotropic medications (medications affecting brain activity) for two of five residents (Residents 3 and 4) reviewed for unnecessary medications. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 87 residents (nonsampled resident, Resident 91) was assessed to self-administer of medication. The facility failed to ensure there was a physician's order and self-administration assessment for the Vicks VapoRub (cough suppressant and topical analgesic) ointment medication found at the resident's bedside. This failure had the potential to impact Resident 91's safety and well-being and an increased risk of improper medication use.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe environment for the residents, staff, and visitor was provided in one of four hallways. * One of four hallways was observed with a handrail that was sharp to the touch. This failure posed the risk of injury to the residents, staff, and visitors.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 3 and 4) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure Resident 3 was properly monitored for orthostatic blood pressures (measure the blood pressure while laying down or sitting and again upon standing up) as ordered by the physician. * The facility failed to ensure Resident 3's monthly behavior summary for the use of olanzapine (a medication for mental disorders including schizophrenia and bipolar disorder) and mirtazapine (antidepressant medication) were completed. * The facility failed to ensure a gradual dose reduction (GDR) was attempted for Resident 4 when the facility failed to follow the psychiatrist's order to discontinue the clonazepam medication. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the PASARR recommendations were followed up and incorporated into the resident's care for one of seven final sampled residents (Resident 8) reviewed for PASARR. * The facility failed to ensure the PASARR Level II recommendations were followed and incorporated into Resident 8's care. This failure had the potential for Resident 8 not to receive the adequate care that was recommended by the PASARR Level II evaluation report that completed by an appropriate state-designated authority.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the treatment and care in accordance with the professional standards of practice for one of four final sampled residents (Resident 10) reviewed for unnecessary medications and one nonsampled resident (Resident 87). * The facility failed to ensure the insulin injection site was rotated for Resident 10. * The facility failed to ensure the insulin injection site was rotated for Resident 87. The facility failed to ensure Resident 87's insulin was administered accurately as ordered by the physician. The insulin Regular Human injection (medication to lower blood sugar levels) solution was not administered to Resident 87 when the sliding scale (amount of insulin to be administered based on the blood sugar results) showed to administer 1 unit of insulin Regular Human injection solution. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four final sampled residents reviewed for nutrition (Resident 8) received the appropriate services needed to maintain acceptable parameters of nutritional status. * The facility failed to follow up when Resident 8 refused CNA Helping Hands assistance, as recommended by the dietician and as ordered by the physician, after the resident experienced a weight loss of more than 5 (five) pounds in one month. This failure had the potential to result in inadequate monitoring and evaluation of the effectiveness of nutritional interventions and increase the risk for further weight loss and nutritional decline.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the PICC line assessments were performed and documented for one of one final sampled resident (Resident 58) reviewed for the IV management. * The facility failed to obtain and document the external catheter length measurement upon admission for Resident 58's PICC line. This failure posed the risk for the resident developing complications related to PICC line displacement, malfunction, or infection.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure necessary respiratory care and services were provided for one of three sampled resident (Resident 44) reviewed for respiratory care. * The facility failed to ensure Resident 44 received the correct amount of oxygen via nasal canula per the physician's order. This failure had the potential to negatively affect Resident 44's medical conditions.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of the residents. * One of four LVNs (LVN 4) observed for medication administration discarded the liquid medication in the medication cart's trash bin. This failure had the potential for the medications to be administered in error and opportunities for drug misuse.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the drugs, biologicals, or medical supplies were stored in a safely for one of 19 final sampled residents (Resident 6) and one nonsampled resident (Resident 91). * The facility failed to ensure Resident 6's Inhaler medication (ciclesonide) was not left at unattended at the resident's bedside. * The facility failed to ensure a packet of Vitamins A&D (skin protectant) ointment was properly stored for Resident 91. These failures had the potential to result in medications being contaminated, misused, or accidentally administered to the wrong resident.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu and recipes were followed for one of 81 residents (Resident 14) who consumed food prepared in the kitchen. * The facility failed to ensure Resident 14 was served the braised cabbage as per the menu. This failure posed the risk of negatively impacting Resident 14's satisfaction and dietary compliance.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed. * The facility failed to conduct a facility-wide risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in facility water system. This failure posed a risk of exposure and potential illness to the residents, staff, and visitors by allowing unidentified and uncontrolled areas within the water system where Legionella and other opportunistic waterborne pathogens could grow.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer and provide required education on the benefits and potential side effects for the seasonal influenza and pneumococcal immunizations for two of five residents (Residents 8 and 14) reviewed for the immunizations. * The facility failed to ensure Resident 8 was offered pneumococcal and seasonal influenza vaccinations and provided with education regarding their benefits and potential side effects. * The facility failed to ensure Resident 14 was offered seasonal influenza vaccination and provided with education regarding its benefits and potential side effects. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the residents were offered and provided education regarding the benefits and potential side effects of seasonal COVID-19 vaccine for two of five residents (Residents 8 and 14) reviewed for the COVID-19 immunization. * The facility failed to offer and provide education regarding the benefits and potential side effects of seasonal COVID-19 vaccine for Residents 8 and 14. This failure placed the residents at risk for increased risk of infection and transmission of COVID-19 and had the potential for the residents and/or their representatives not being informed of the seasonal COVID-19 vaccines.

Inspectors wroteBased on observation and interview the facility failed to ensure the residents' care equipment was maintained in a safe operating condition. * One of four LVNs (LVN 1) observed for medication administration used a non-facility issued BP automatic machine to obtain Resident 6's BP prior to medication administration. The facility failed to ensure the calibration for the personal BP machine was conducted. This failure had the potential for the essential equipment not to function in the way it was intended and the risk of resulting in inaccurate resident BP measurements.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive person centered care plan to reflect the individualized care needs of one of 19 final sampled residents (Resident 3). * The facility failed to develop a care plan to address the skin discoloration on Resident 3's bilateral hand. This failure had the potential to result in Resident 3 not receiving appropriate, consistent, and individualized care and monitoring.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure an environment free of accident hazards was provided for two of three sampled residents (Residents 1 and 2). * Resident 1 used a razor to self-inflict harm. * Resident 2 had two razors and two scissors in an unlocked bag inside Resident 2's closet, easily accessible to other residents. * The razors used to shave the male residents were unlocked and unsecured at Nurse Station A and inside a supply closet. These failures posed the risk of the residents accessing the sharp devices and resulting in injuries to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for three of six sampled residents (Residents 1, 2, and 3). * The facility failed to ensure the risks of leaving the facility unsupervised without informing the staff were explained to Resident 1. * The facility failed to ensure Resident 1's smoking assessment was accurate and complete. * Resident 2 and 3's post fall neuro checks were not completed per their care plans. These failures had the potential to negatively affect Resident 1, 2, and 3's health condition and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement their P&P on Abuse Investigation and Reporting by failing to report an allegation involving the resident to resident physical altercation between two sampled residents (Residents 1 and 2) when Resident 1 alleged Resident 2 had hit him on the right cheek and Resident 1 had allegedly hit back Resident 2. This failure had the potential to put Residents 1 and 2 and other residents at risk of not being protected against the alleged abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P reviewed, the facility failed to thoroughly investigate an alleged incident involving the resident to resident physical altercation between two sampled residents (Residents 1 and 2) when Resident 1 alleged Resident 2 had hit him to the right cheek and Resident 1 had allegedly hit back Resident 2. This failure had the potential to put Residents 1 and 2 and other residents at risk of not being protected against the alleged abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for residents (Residents 1 and 2). * The facility failed to develop a comprehensive person-centered care plan for Residents 1and 2 addressing the incident when Resident 1was grazed to his right cheek by Resident 2who was confused. This failure had the potential risk of not providing the appropriate, consistent, and individualized care to the residents.

Inspectors wroteBased on interview, medical record review, and the facility P&P review, the facility failed to ensure the discharge process was properly followed for Resident 1. * Resident 1's closed medical record failed to show the physician's documentation to show Resident 1 was ready for discharge. This failure had the potential for Resident 1 to unsafely discharge from the facility.

Inspectors wroteBased on observation, interview, medial record review, and facility P&P review, the facility failed to provide an environment free from the physical restraint (physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) for one of three sampled residents (Resident 2). * The facility failed to obtain the orders to place a soft mitten on Resident 2's left hand. * The facility failed to ensure the appropriate assessment was completed prior to placing a soft mitten restraint on Resident 2. * The facility failed obtain the consent for the application of the soft mitten restraint for Resident 2. * The facility failed to monitor Resident 2 for the use of restraints. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for two of three sampled residents (Residents 1 and 2). * The facility failed to assess the resident for the use of supplemental oxygen and failed to obtain a physician's order for Resident 1's use of the oxygen as per the facility's P&P. * The facility failed to follow up with the pharmacy services for Resident 1's delivery of the breathing treatment medications. * The facility failed to ensure Resident 2's humidifier was labeled, dated, and changed when it was empty. These failures had the potential to negatively affect the resident's well-being as the necessary care and services were not provided.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained the highest practicable physical well-being. * The facility failed to ensure the physician was timely notified when Resident 1 had a change in condition to theright leg. This failure posed the risk for Resident 1 to not receive the necessary care and services timely to maintain the resident's highest physical well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to treat and prevent the development of pressure injuries for one of three sampled residents (Resident 2). * The facility failed to provide the skin treatment to Resident 2 as ordered by the physician and developed a care plan to address Resident 2's Stage 3 pressure injury to the lumbosacral spine. These failures had the potential for Resident 2 to not receive the appropriate care and services to promote healing of the pressure ulcer.

Inspectors wroteBased on interview, medical record review, and facility P& P review, the facility failed to ensure five of five final sampled residents (Residents 5, 19, 64, 84, and 745) reviewed for unnecessary medications were free from the unnecessary psychotropic medications. * There was no evidence of non-pharmacological interventions for Resident 745's use of quetiapine (antipsychotic medication), Ativan (antianxiety medication), duloxetine (antidepressant medication) and divalproex sodium (mood stabilizer medication). Additionally, the facility failed to monitor behavior and side effects for the use of Ativan and failed to reassess the resident for use of quetiapine as needed more than 14 days. * The facility failed to show the Xanax (antianxiety medication) medication was only limited to 14 days for Resident 84. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the facility had monthly Infection Prevention and Control Surveillance logs for July, September, and December 2024. * The facility failed to ensure the facility's infection surveillance log for August through November 2024 included if the resident met the Loeb's criteria for true infection. * The facility failed to ensure the October and November 2024 Infection Prevention and Control QA Reports were accurate. * The facility failed to ensure the facility had a surveillance log to show the residents who met and not met the Loeb's criteria. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 19 final sampled residents (Residents 24 and 394) and one nonsampled resident (Resident 74) were safe to self-administer the medications found at bedside. * Resident 394 was observed with a bottle of dorzolamide (medication used to treat glaucoma) eyedrops at bedside. Resident 394 stated she administered the eyedrops herself. Resident 394 did not have the assessment and physician's order addressing the resident's self-administration of medication. * Resident 74 was observed with a medication cup containing a gabapentin (anticonvulsant medication) capsule at bedside. Resident 74 stated the charge nurse left the medication for her to self-administer the medication later. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for two of 29 final sampled residents (Residents 5 and 48) and four nonsampled residents (Residents 9, 29, 35, and 38). * The facility failed to ensure the call lights were within reach and accessible for Residents 5, 9, 29, 35, 38, and 83. This failure had the potential to result in a delay in the provision of care and the potential to negatively impact the residents' psychosocial well-being.

Inspectors wroteBased on interview, facility document review and facility P&P review, the facility failed to respond to the concerns brought up by the residents during the Resident Council meetings. * The facility failed to show what facility administrative actions were taken to address the concerns from the Residents Council meetings on 7/11, 9/12, and 10/10/24, regarding the medications, snacks, and CNA interactions with the residents. This failure had the potential for the residents' identified issues to not be resolved, a delay in the provision of care, and a decline in quality of life for the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests for two of 19 final sampled residents (Residents 5 and 22) and two nonsampled residents (Residents 9 and 35). * The facility failed to provide the activities for Residents 9 and 22 which met the residents' identified interests. * The facility failed to ensure the bingo game was not cut-off by the activity department to supervise the smokers as per the concerns of Residents 5 and 35. These failures had the potential for the residents to experience feelings of social isolation and depression.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure one of 19 final sampled residents (Resident 64) was provided with the prescribed liquid consistency diet per the physician's order. This failure had the potential to negatively affect Resident 64's health condition and well- being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of 19 final sampled residents (Residents 44 and 20) and two nonsampled residents (Residents 97 and 99) reviewed for respiratory care. * The facility failed to ensure Resident 44's nasal cannula was applied properly. * The facility failed to ensure the oxygen cannula for Resident 97 was stored in a set-up bag when not in use, and ensure a physician's order was obtained prior to administering oxygen to the resident. In addition, the facility failed to ensure a No Smoking/Oxygen in Use sign was posted outside the resident's door per the facility's P&P. * The facility failed to ensure the nebulizer mask and canister for Resident 99 was stored in a set-up bag when not in use. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to accurately monitor the fluid intake and output for one final sampled resident (Resident 394) reviewed for hemodialysis care. This failure had the potential for Resident 394 to experience life threatening conditions associated with fluid deficit/overload.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the IP had specific competencies and standard of practice skill sets needed to provide the safe and efficient nursing services to the residents as evidenced by: * The IP failed to identify the six moments of EBP. * The IP failed to document the meeting minutes on the Infection Control Committee Meeting Minutes form. * The IP failed to correctly identify HAI and CAI. * The IP failed to identify what the infection onset date was for. * The IP failed to provide accurate information on the Antibiotic Time Out to Resident 694's physician. * The facility failed to ensure CNA 8 and LVN 6 were competent about EBP. CNA 8 and LVN 6 were not able to identify when to use EBP and were not provided with training on EBP. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Residents 84) reviewed for unnecessary medications was properly monitored related to the use opioid medication. * The facility failed to ensure Resident 84 was monitored for the side effects of receiving Norco (narcotic) medication. This failure had the potential for Resident 84 to receive unnecessary medications and develop significant side effects.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. * The facility's medication error rate was 23.33%. Three of three licensed nurses (LVNs 1, 2, and 3) were found to have made errors during the medication administration observation for one sampled resident (Resident 745) and two non-sampled residents (Residents 29 and 32). This failure had the potential to negatively impact the resident's heal outcomes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (final sampled resident, Resident 745) was free from the significant medication errors. This failure placed Resident 745 at risk for medical complications.

Inspectors wrote2. On 1/7/25 at 0834 hours, during the initial tour of the facility, a bag containing several wound dressings, a tube of CalProtect topical ointment and two tubes of Triad hydrophilic wound ointment was observed on Resident 82's nightstand. Resident 82 stated she did not know anything about the wound dressing and wound care ointments, and the nurse applied those to her right leg wound. Medical record review for Resident 82 was initiated on 1/7/25. Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's Order Summary Report dated 1/8/25, showed the following physician's orders: - dated 12/13/24, for the left lower leg with dry and scaly skin, cleanse with normal saline, apply with moisturizing cream and leave open to air; - dated 12/13/24, for the right lower leg with dry and scaly skin, cleanse with normal saline, apply with moisturizing cream and leave open to air; [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure two coffee pots were not stored wet. * The facility failed to ensure the kitchen equipment and utensils were maintained in a sanitary condition. * The facility failed to ensure the food preparation sink had a back flow prevention in place. These failures had the potential to result in foodborne illnesses for residents receiving kitchen services in the facility.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure one of one resident (final sampled, Resident 52) reviewed for hospice services had received the necessary care and services. * The facility failed to ensure the hospice visit calendar was available in Resident 52's residents' medical record. * The facility failed to ensure for an accurate documentation of the hospice staff visits were available for Resident 52. * The facilty failed to ensure the hospice staff visited the resident as scheduled in the hospice calendar for Resident 52. These failures posed the risk for the delay in communication and provision of hospice care between the hospice provider and facility .

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to implement their Antibiotic Stewardship Program when the IP was not able to show the documentation she notified the physician of the residents who were prescribed antibiotics and did not meet the Loeb's Criteria. This failure had the potential for inaccurately identifying for true infections and potentially inhibited residents from receiving the appropriate treatment and care.

Inspectors wroteBased on observation, interview, and medical record review the facility failed to provide the clean, sanitary, and homelike environment for one of 19 final sampled residents (Resident 64). This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify one of two residents (final sampled resident, Resident 44) reviewed for hospitalization of their right to a bed hold (holding or reserving a resident's bed while the resident in the acute care hospital) policy upon transfer to the acute care facility. This failure had the potential for Resident 44 and/or his representative to be unaware of their rights to request a bed hold upon transfer.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the PASARR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level 1 assessment was coded accurately for one of three final sampled residents reviewed for PASARR (Resident 52). This failure had the potential for having residents that were not appropriate in the facility and for Resident 52 not to receive the appropriate services.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive person-centered care plan for one of 19 final sampled residents (Resident 75). This failure had the potential to negatively impact the health of the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs for one nonsampled resident (Resident 794). * The facility failed to ensure Resident 794's order for methylphenidate (stimulant) was administered as ordered by the physician. This failure had the potential to negatively affect the residents' health and well-being.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the Pharmacy Consultant followed up on the monthly MRR for one of five sampled residents reviewed for unnecessary medications (final sampled resident, Resident 19). This failure had the potential to cause unsafe medication doses and adverse medication reactions that can jeopardize medically compromised residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food served to the residents was palatable. * The cooked broccoli was mushy in texture. This failure had the potential for the residents to not eat the food served and could affect their nutritional status.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for one of 19 final sampled residents (Resident 24) and one of three closed record residents (Resident 92) were complete and accurately documented. * The facility failed to ensure Resident 24's POLST was signed by the legal decisionmaker. * The facility failed to ensure Resident 92's Vital Signs Summary was accurate. These failures had the potential for the residents' needs not being met as the medical information were incomplete and inaccurate.

Inspectors wroteBased on observation and interview, the facility failed to ensure the frozen storage area inside the residents' refrigerator, located in Station B was free of ice buildup. This failure had the potential for the food stored in the freezer area to not maintain the proper temperature.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to protect the resident's rights to be free from physical abuse by a staff for one of two sampled residents (Resident 1). * CNA 2 was observed by her colleague slapping Resident 1 on the face,resulting in redness to Resident 1's face. Resident 1 stated the incident made him feel embarrassed. This failure had the potential to cause serious injury and physical and/or psychological harm to the resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three closed record sampled residents reviewed for discharges (Resident 1) was properly discharged from the facility after his elopement. * Resident 1 was found after his elopement from the facility and transported to an acute hospital for evaluation. Resident 1 was cleared to transfer back to the facility; however, the facility denied Resident 1's readmission. This failure had the potential to place Resident 1 at risk for decline in his health condition if placed inappropriately.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents reviewed for elopement (Resident 1) was provided adequate supervision and necessary services to prevent elopement. * The facility failed to monitor Resident 1's whereabouts, resulting in Resident 1 leaving the facility undetected twice. * The facility failed to reassess Resident 1 for elopement risk as per the IDT's recommendations after an elopement episode. * The facility failed to monitor Resident 1 for his exiting behaviors. These failures placed Resident 1 at risk to not receive the appropriate care and services and placed the resident at risk for harm or injury.

Inspectors wroteBased on interview and medical record review, the facility failed to coordinate the transportation for one of two sampled residents (Resident 1)'s ortho surgery appointment. * Resident 1's physician ordered an ortho surgery appointment; however, the facility failed to coordinate the transportation services in a timely manner. This failure resulted in Resident 1 having missed his ortho surgery appointment, which had the potential to delay Resident 1's plan of care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs for two sampled residents (Residents 1 and 4). * The facility failed to ensure Residents 1 and 4 were provided with assistance in a timely manner. This failure had the potential to negatively impact the resident's physical and psychosocial well-being or would result in delayed provision of care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one sampled resident (Resident 1) remained free from accident hazards. * The facility failed to ensure Resident 1's smoking materials were not stored at the resident's bedside. This failure had the potential for the resident to sustain accidents and/or injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide a safe environment free from potentially serious accident hazards for 15 of 15 residents (Residents 2, 10, 11, 24, 37, 39, 43, 53, 56, 63, 71, 76, 79, 92, and 394) who smoked in the facility. * The facility failed to ensure the safe smoking practices were followed for 15 residents who smoked in the facility as evidenced by: - The residents were not accurately and thoroughly assessed to determine if they required supervision or any adaptive safety equipment while smoking, nor if they could safely store their own cigarettes or lighters. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the sanitary condition in the kitchen as evidenced by: * The facility failed to ensure safe storage of food items. * The facility failed to ensure the kitchen equipment was maintained in sanitary condition. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented as evidenced by: * The facility failed to ensure eye protection was worn by the staff as PPE during all resident care in accordance with the Orange County Health Care Agency's Guidance on COVID-19 in long-term care facilities. This failure posed the risk of a COVID-19 outbreak at the facility. * The facility failed to ensure LVN 5 performed hand hygiene and changed gloves when administering the eye drops for one of 19 final sampled residents (Resident 16) as per the facility's P&P. This failure had the potential for the resident to acquire an eye infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure the staff provided care in a manner that promoted dignity and respect for one of 19 final sampled residents (Resident 54). CNA 1 was observed standing over Resident 54 while assisting the resident with her meal. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 19 final sampled residents (Resident 16) was assessed to determine if the resident was safe to self-administer the medications. This failure had the potential for medication interactions and inappropriate use of medications. * Aspercreme Lidocaine dry spray (pain reliever medication) with an expiration date of 08/2021 and Icy Hot Max-maximum strength/Lidocaine roll on (pain reliever medication) with an expiration of 12/2023 were unlabeled and observed at Resident 16's bedside table.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the call light was kept within reach for one of 19 final sampled residents (Resident 73). This failure resulted in Resident 73 not being able to use the call light to call for assistance, which had the potentail to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to offer assistance to formulate an advance directive, and/or maintain a copy of the resident's advance directive in the medical records for five of 19 final sampled residents (Residents 18, 29, 38, 54, and 595). This failure put the residents at risk of not having their wishes for treatment known and had the potential for the residents' decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 19 final sampled residents (Resident 594) was provided with comfortable and homelike environment. This failure had the potential to prevent Resident 594 from getting a restful sleep and be free unwanted noise in his room.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to develop a plan of care to reflect the individual care needs for two of 19 final sampled residents (Residents 74 and 78). * The facility failed to develop a care plan problem to address Resident 74's risk for developing pressure ulcers. * The facility failed to ensure a care plan problem was developed to address Resident 78's use of the PRAFO boots for wound management. These posed the risk of not providing appropriate, consistent, and individualized care to the residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to maintain the highest physical well-being for two of 19 final sampled residents (Resident 74 and 78). * The facility failed to ensure the PRAFO boots was applied to Resident 78 as per physician's order. * The facility failed to ensure Resident 74's right arm sling was applied when he was out of bed as ordered by the physician. These failures had the potential to affect Residents 74 and 78's well being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure ulcers for one of 19 final sampled residents (Resident 74). * The facility failed to offload Resident 74's heels from pressure as ordered by the physician. This had the potential of Resident 74 not receiving the appropriate care and services to promote healing or prevent the development of the pressure ulcers.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 19 final sampled residents (Resident 594) was provided appropriate pain management. This created the risk of not effectively manage pain for this resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to complete a comprehensive bed/side rail assessment for one of 19 final sampled residents (Resident 44). This failure had the potential to cause physical harm to Resident 44.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of one of 19 final sampled residents (Resident 16). * The facility failed to ensure the physician's orders were obtained for the use of the topical analgesics found at Resident 16's bedside table. This failure had the potential to cause Resident 16's pain not to be managed completely and could lead to the resident's decreased concentration or sleep disturbance.

Inspectors wroteBased on observation, interview, and medication prescription inserts review, the facility failed to ensure the medications were stored and labeled properly in one of four medication carts (Medication Cart 1); and failed to ensure an expired medication was not stored at the bedside for one of 19 final sampled residents (Resident 16). * Three inhalers with no opened dates were stored in Medication Cart 1. * An expired medication was observed at Resident 16's bedside table. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medical records for two of 19 final sampled residents (Residents 16 and 54) were accurate and complete. * Resident 54's POLST was incompletely filled out. * Resident 16's medical record contained Resident 56's Order Summary Report. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure two glucometers (Glucometers A and B) from one of four medication carts (Medication Cart 1) were maintained in safe operating condition. This had the potential for residents requiring glucose checks to have inaccurate readings.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage and refuse were properly stored in one of one garbage dumpster. * The lid of the facility's garbage dumpster was left open. This failure had the potential to harbor pests or rodents which carry diseases.