Hemet Hills Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to reassess and revise the resident's person-centered care plan to include effective interventions after repeated incidents of inappropriate sexualized behavior for one of four residents (Resident 1). This failure placed residents, staff, and visitors at risk for unwanted sexual contact, physical altercations, and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the environment free of accident hazards when the toilet seat in a resident-accessible restroom was not securely fastened. This failure had the potential to cause a resident to lose balance while transferring on or off the toilet, placing the resident at risk for a fall with injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food stored in the Unit 1 refrigerator was properly labeled, dated, and discarded when no longer safe for use. This failure had the potential to increase the risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention protocols were followed when a nebulizer treatment mask (a medical accessory that fits over the nose and mouth, delivering aerosolized liquid medication directly into the airways and lungs) was stored uncovered on top of the nebulizer (a medical device that converts liquid medication into a fine mist, allowing patients to inhale it directly into their lungs), for one of eleven residents, (Resident 12). This failure had the potential to expose the nebulizer mask to environmental contaminants before its next use, increasing the risk of introducing microorganisms into the resident's respiratory tract.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eleven residents, (Resident 12), had a call light pad. This failure had the potential for Resident 12 to have unmet needs due to difficulty with using the call light.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's medical records were accurate and complete in accordance with the accepted professional standards and practices, for two of three sampled residents (Residents 3 and 5) when: 1. For Resident 3, nursing weekly summaries and skin evaluations did not reflect changes in skin condition; and 2. For Resident 5, progress notes regarding the resident's status were not completed in accordance with facility protocols. These failures could negatively impact resident care and prevent staff and responsible parties from recognizing potential deterioration in residents' conditions.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the plan of care (POC) was updated to reflect changes in condition, for one of two residents reviewed for care planning (Resident 6), who had repeated episodes of pulling out her G-tube (a surgically implanted tube needed for feeding when unable to swallow) from October 11, 2025, to November 12, 2025. This failure had the potential to place the residents at risk for further harm and complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of three residents reviewed for quality of care (Resident 3) the resident was monitored every shift for a change in condition involving left upper extremity bruising (skin discoloration) as ordered by the physician. This failure had the potential to result in a delay of the implementation of appropriate interventions to address the care and treatment for Resident 3. In addition, this failure had the potential to place Resident 3 at risk for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented, when an outside vendor ultrasound technician (UT) was observed providing care at the bedside to a resident on contact precautions (infection prevention precautions) without wearing appropriate PPE (personal protective Equipment - a gown and mask) according to the facility protocol. This failure had the potential to result in transmission of infectious illnesses to the vulnerable residents.

Inspectors wroteBased on interview and record review the facility failed to ensure Levothyroxine was administered for one of one resident (Resident 6) reviewed for quality of care, when Resident 6 did not receive the scheduled dose of Levothyroxine on November 30, 2025 and December 4, 2025. This failure had the potential for Resident 6 not to receive the desired benefit of the medication and may cause adverse reactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, for one of nine resident reviewed for infection control (Resident 8), proper infection control measures were implemented when Certified Nursing Assistant (CNA) 1 did not wear personal protective equipment (PPE - equipment, such as gloves and gown, used to protect against infection or illness) upon entering Resident 8's room, who was on contact isolation precautions (an infection control intervention to reduce transmission of multidrug-resistant organisms (bacteria that have become resistant to multiple antibiotics)). The failure had the potential to result in cross contamination and increasing the spread of infection among a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to ensure blood glucose meters (glucometer - a blood sugar meter measures the amount of sugar in a small sample of blood) were calibrated and documented according to the facility protocol and current professional standards of practice on multiple days on November 2025. This failure had the potential to result in inaccurate blood glucose readings for residents requiring routine monitoring.

Inspectors wroteBased on interview and record review, the facility failed to assess and verify the resident's history of obstructive sleep apnea (OSA - person's breathing repeatedly stops and starts during sleep due to a blocked airway) and coordinate necessary CPAP (Continuous positive airway pressure - a machined use to treat OSA) treatment with the physician, for one of five sampled residents (Resident A). This failure had the potential to result in untreated sleep apnea for Resident A, placing the resident at risk for respiratory complications, hypoxia (low oxygen), and sleep disruption.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions for fall prevention were implemented for two of seven residents, (Resident 1 and Resident 7). This failure had the potential for Resident 1 and Resident 7 to fall and sustain serious injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed for two of six sampled residents (Residents 1 and 2) to ensure: 1. The call light was placed within reach for Resident 1; and 2. The call light was answered timely for Resident 2. These failures had the potential to compromise the timely delivery of resident care.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported to the California Department of Public Health within two hours for one of five sampled residents (Resident 1). This failure had the potential to leave Resident 1 unprotected, result in further abuse, and delay the initiation of an investigation.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician timely when one of eight sampled residents (Resident 1) had an oxygen saturation (measures of how effectively the body is transporting oxygen from the lungs to the tissues) of 35%. This failure caused a delay in provision of appropriate interventions resulting in prolonged discomfort and hypoxemia (abnormally low concentration of oxygen in the blood) for Resident 1, requiring transfer to the general acute care hospital (GACH). Resident 1 had an emergency endotracheal intubation (insertion of a flexible plastic tube called an endotracheal tube (ET) into the mouth or nose and then into the airway to hold it open and provide oxygen) upon arrival at the GACH, where the resident expired.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight residents, (Resident 3), was safe from a fall, when the Certified Nursing Assistant, (CNA 1), repositioned Resident 3 away from her while changing Resident 3's briefs. This failure caused discoloration to the top of the head accompanied with 4/10 pain, discoloration to the left side of cheek, and skin tear to the left elbow. Resident 3 was transferred to the hospital for evaluation.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) quarterly assessments were completed within 14 calendar days, as required by Center for Medicare and Medicaid Services (CMS - an agency that administers the nation's major healthcare programs), for 19 of 27 residents reviewed for resident assessment (Residents 3, 14, 25, 30, 41, 45, 76, 81, 83, 86, 89, 106, 124, 127, 128, 129, 130, 131 and 141). This deficient practice resulted in late completion of quarterly assessments in Residents 3, 14, 25, 30, 41, 45, 76, 81, 83, 86, 89, 106, 124, 127, 128, 129, 130, 131 and 141, potentially resulting in delay in updating and creating residents' care plan affecting residents' quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS - an assessment tool) annual and quarterly assessments were transmitted timely for 21 of 27 residents (Residents 3, 14, 25, 30, 41, 45, 70, 76, 81, 83, 85, 86, 89, 106, 124, 127, 128, 129, 130, 131 and 141) reviewed for resident assessment. This failure had the potential to cause gaps in the development or implementation of the resident's care plan, potentially affecting the quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food with appetizing taste for 10 of 177 sampled residents (Residents 102, 104, 124, 130, 123, 6, 253, 140, 27 and 85). This failure had the potential to decrease the nutritional intake and affect Residents 102, 104, 124, 130, 123, 6, 253, 140, 27 and 85's nutritional status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Eight out of twelve storage shelves in the dry storage room had brown grime, corrosion, and chipped coating. 2. Seven out of seven storage shelves in the walk-in refrigerator had white buildup, brown grime, and dirt. 3. Seven out of seven storage shelves in the freezer had brown grime and chipped coating. 4. Two electric fans mounted on the wall above the preparation sink and dishwashing area had white debris on the blades and covers. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a vulnerable population of 168 out of 177 residents who received food prepared in the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to provide Advance Directive (AD-a written instruction related to the provision of health care when the resident is no longer able to make decisions) education, materials, and follow-up for two of three residents reviewed for AD (Residents 73 and 130) and/or their resident representatives (RP). This failure had the potential in Residents 73 and 130's medical preferences not being honored during critical healthcare decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the annual comprehensive assessment for two of 27 residents reviewed for resident assessment (Residents 70 and 85) were completed within 14 calendar days, as required by the Center for Medicare and Medicaid Services (CMS - an agency that administers the nation's major healthcare programs). This failure had the potential for Residents 70 and 85 to not receive resident centered care (care focusing on the needs of individuals).

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician when the resident missed a follow-up visit for a surgical wound to the spine for one of six residents reviewed for skin conditions (Resident 24). This failure had the potential to delay the care and treatment of Resident 24's skin condition which could result in skin infections and worsening of the wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of six residents (Resident 104) reviewed for pressure injuries: 1. The care plan interventions for the right heel pressure injury (PI - localized damage to the skin and underlying soft tissue over a bony prominence or from a medical device) were implemented. 2. The Registered Dietitian (RD) nutritional recommendations for wound healing were communicated to the physician. These failures had the potential to result in Resident 104 not receiving the necessary nutrition and devices needed to heal and prevent the worsening of the pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order for oxygen therapy, for one of six residents reviewed for respiratory care (Residents 49). This failure had the potential to place Resident 49 at risk of respiratory distress and a decline in medical condition.

Inspectors wroteBased on interview and record review the facility failed to ensure for one of six residents (Resident 152), a pain assessment and evaluation was conducted before and after the administration of narcotic (controlled drug that induces stupor, coma, or insensibility to pain) pain medication from December 2024 through January 2025. This failure had the potential to result in unrelieved or ummanaged pain, which could lead to a decline in Resident 152's overall health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the PRN (as needed) narcotic (controlled drug that induces stupor, coma, or insensibility to pain) pain medications that were signed out were properly administered and recorded in the Medication Administration Record (MAR), for one of six residents (Resident 152). This failure resulted in delays in identifying medication discrepancies and increased the risk of controlled substance diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented when: 1. Resident 290's oxygen humidifier (a medical device used to humidify oxygen) was found on the floor. 2. Resident 291's nasal cannula (a device used to deliver oxygen) was found on the floor. These failures had the potential to result in cross-contamination, increasing the spread of infection to an already vulnerable population of residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent fingernail care to maintain grooming was provided, for four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4). This failure resulted in poor hand hygiene and had the potential to result in infections and skin injury.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate care and services to prevent urinary tract infection (a bacterial infection that affects the urinary tract, which includes the bladder, uretha, and kidneys) for one of six sampled residents, when: 1. Foley catheter (flexible tube that drains urine from the bladder into a collection bag) care was not consistently provided in accordance with the care plan. 2. Urinary output was not consistently monitored in accordance with the physician order. These failures could have contributed to the recurrent UTI which led for Resident 5 to be transferred to the general acute care hospital (GACH), where the resident was diagnosed with sepsis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented when multiple staff did not perform hand hygiene during donning (putting on gloves and gown) of PPE (Personal Protective Equipment - mask, gown, gloves, face shield or goggles) and failed to don a face shield or goggles to go inside Droplet Isolation (droplets from coughing, sneezing, or talking may contain viruses or bacteria and generally travel no more than three feet from the patient) rooms when providing care. This failure had the potential to result in the transmission of infection to an already vulnerable population of residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment in accordance with the facility policy and procedures for one of two residents (Resident 2) reviewed for oxygen treatment. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the residents ' health condition.

Inspectors wroteBased on interview and record review, the facility failed to prevent medication errors, as resident 's medications were administered outside of the physician's ordered parameters, for two out of seven sampled residents (Residents 3 and 4). The failure had the potential to cause harm to residents, such as adverse reactions, side effects, or ineffective treatment.

Inspectors wroteBased on interview and record review, facility staff failed for one of seven sampled residents (Resident 2) to follow-up on the resident's blood pressure (BP) to assess the effectiveness of the as needed (PRN) BP medication. This failure had the potential to result in not knowing whether the blood pressure medication effectively lowered the resident's blood pressure or if the blood pressure dropped too low after taking the medicatiion.

Inspectors wroteBased on interview and record review, the facility failed to verify accuracy of the prescribed parameters for a blood pressure (BP) medication, for one of seven sampled residents (Resident 2). This failure had the potentially to cause harmful side effects from the blood pressure medication for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that hospice services for two of three residents, (Resident 1 and Resident 3) ' s were properly coordinated, as two hospice companies did not provide a monthly schedule indicating when hospice staff would be visiting. This failure had the potential to disrupt the continuity of coordinated, quality care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified, for one of six residents (Resident 1), when Resident 1 refused to come back inside the facility and had an aggressive behavior including threatening to hurt himself on July 9, 2024. This failure had the potential for the physician to be unaware of Resident 1 ' s condition and delayed provision of possible treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a home like environment was provided, for two of six residents (Resident 2 and Resident 4), when: 1. The wall on the left side of the entry door had horizontal black scuff marks along the whole surface of the wall inside Residents 2 and 4's rooms; 2. There was a one inch by one inch dent, with the wallpaper peeling away from the wall surface on the same wall adjacent from Resident 4 ' s bed (closest to the entry door), above the base board; and 3. There were 14 dried orange, brown droplet-like smudges on the wall, baseboard, and the edge of the floor; and approximately six-inch black vertical scuff mark on the same wall, adjacent from Resident 2 ' s bed, (furthest from the entry door). These failures placed the residents at risk for low self-esteem and living in an unkempt environment.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a plan of care was developed and/or implemented, for one of six residents (Resident 1) when Resident 1 had episodes of aggressive behavior. This failure had the potential to result in staff not providing care and interventions not being implemented that would affect the residents' highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services for activities of daily living (ADLs), for one of six sampled residents (Resident 2), when the resident failed to receive showers as scheduled. This failure had the potential to negatively affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure physician order was followed, for one of six residents (Resident 3), when Midodrine (a medication used to increase blood pressure) was not held when the systolic blood pressure, (SBP) was greater than 120. This failure had the potential for Resident 3 to have dangerously high blood pressure.

Inspectors wroteBased on interview, and record review, the facility failed to ensure, for one of six residents (Resident 1), was free from unnecessary psychotropic medications (medications used to treat mental illness), when there was no appropriate indication for use for Ativan (medication used to treat anxiety) and Seroquel (medication to treat mental disorders). In addition, an informed consent was not obtained from Resident 1's responsible party for the use of Ativan and Seroquel. These failures had the potential for Resident 1 to receive unnecessary antipsychotic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to display direct care daily staffing information (DHPPD-Direct Care Service Hours Per Patient Day) in a prominent location, readily accessible to the residents and visitors. This failure had the potential to result in residents, visitors, and staff not being fully informed of staffing levels in the facility based on resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment for self-administration of medication was conducted, for one of eight residents (Resident 2). This failure had the potential to result in an unsafe self-administration of medication by Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's equipment are kept clean and sanitary, for one of eight residents reviewed (Resident 1), when Resident 1's wheelchair safety belts contained layers of dry crusted food. This failure has the potential for Resident 1 to continue to have an unclean environment and further develop infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent oral care and personal grooming was provided, for one of eight residents (Resident 1). This failure resulted in poor oral hygiene and had the potential to affect Resident 1's dignity and diminish his quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers twice per week for one of three residents (Resident 1). This failure had the potential to result for Resident 1 to develop body odor, skin breakdown and had the potential to affect Resident 1 ' s overall wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to address one of three sampled residents' (Resident 2) multiple episodes of poor meal intake and refusal of meals. In addition, Resident 2 was not consistently provided with food substitutes, during episodes of poor intake and refusals of meals. These failures increased Resident 2's risk for inadequate nutrition and hydration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure new interventions were initated to prevent fall incidents, for one of three residents (Resident C) when Resident C had fall episodes on March 6, 9, 15, 18, 20, and 26, 2024. This failure resulted to Resident C experiencing multiple falls and had the potential for further falls with injury and could compromise overall health condition.

Inspectors wroteBased on interview, and record review, the facility failed to ensure transportation services were provided timely for residents receiving dialysis (the process of removing waste products in the blood), for four of six residents reviewed (Resident A, B, C, and D). This failure resulted to Residents A, B, C, and D, to arrive late at the dialysis center and received incomplete dialysis run time. This failure had the potential for the dialysis residents to experience complications related to incomplete dialysis treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was developed, for one of three residents (Resident C), when: 1. Resident C had an order for a brace (restricting movement and relieving pressure to promote healing) to be applied to the right arm due to fracture (broken bone); and 2. Resident C had a diagnosis of congenital deafness (hearing loss that is present at birth) and required the use of white board for communication. These failures had the potential to have a delay in treatment and services to maintain or improve the highest practicable physical, mental, psychosocial well-being of Resident C.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided, for one of three residents (Resident A) who required close monitoring and supervision, when Resident A was left unsupervised during care. This failure resulted in Resident A to have wandered into Resident B's room and hit Resident B multiple times while she was lying in bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure showers and/or bed baths were provided, for three of three residents reviewed (Residents 2, 3, and 4). This failure had the potential to decrease the quality of living for Residents 2, 3, and 4, and could potentially contribute to skin conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate care and treatment was provided to promote wound healing, for one of three residents reviewed (Resident 2), when: 1. The facility staff failed to consistently monitor and evaluate Resident 3 ' s pressure injuries (PI - Injury to skin and underlying tissue resulting from prolonged pressure on the skin); 2. The facility did not provide the low air loss (LAL - a type of mattress equipped with small air-filled cells that allow constantly circulating air flow to prevent and treat pressure injuries) as ordered by the physician; 3. The facility did not refer to the physician a new PI on Resident 2's sacrococyx area (sacrum an coccyx - tailbone) when the resident was re-admitted from the acute hospital on February 15, 2024, for appropriate treatment; and 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the California Department of Health (CDPH) was notified of an allegation of financial abuse immediately or within two hours after knowledge of the allegation of abuse, for one of three residents reviewed (Resident 1). This failure had the potential in a delay in the investigation of abuse and could subject Resident 1 to further financial abuse by the alleged abuser.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment was provided, for one of three residents reviewed (Resident 5), when there was no medication treatment initiated for Resident 5's rash on the groin. In addition, there was no follow up assessment to monitor the status of the rash on the groin. These failures had the potential for a delay in the care and treatment of Resident 5 rash on the groin and could potentially affect the overall condition of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free of verbal abuse, for one of four residents reviewed (Resident 1), when a Certified Nursing Assistant (CNA) yelled at Resident 1. This failure resulted to Resident 1 being subjected to verbal abuse which could negatively affect the emotional and psychosocial wellbeing of Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Resident 1 ' s urinary catheter, (a hollow tube inserted into the bladder to drain or collect urine), was secured in place for one of four residents, (Resident 1). This deficient practice caused skin erosion on the penis and pressure injuries, (injury to skin and underlying tissue resulting from prolonged pressure on the skin), on the testicles.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician Orders for Life Sustaining Treatment (POLST), for one of six residents (Resident 1) was signed by the physician to indicate the resident's request for a do not resuscitate measures (DNR - no code). This failure resulted in Resident 1 receiving an unwanted treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment for pressure injuries (P/Is - localized damage to the skin and underlying soft tissue over a bony prominence or from a medical device) were provided, for five of five residents reviewed for pressure injuries (Residents 98, 92, 18, 357, and 49), when: 1. The facility staff did not assess or evaluate the staging of pressure injuries in accordance with standards of practice. In addition, there was a delay in providing further interventions/treatment of the P/Is; and 2. The facility did not have a process in the timely notification of the Interdisciplinary Team (IDT - a group of healthcare professionals), which included the Registered Dietitian (RD). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate foot care was provided, for five of 32 residents reviewed for foot care, (Residents 98, 47, 84, 14 and 26). The facility did not consistently trim the residents' toenails, kept the residents' toenails clean and initiate referral to podiatrist for evaluation and further care. This failure resulted in the residents developing long, yellowed, and hypertrophied (thickened) toenails causing pain and discomfort, and did not promote the maximum ADL (activities of daily living) potential for Residents 98, 47, 84, 14 and 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the garbage bin lid was securely closed. This failure had increased the potential to attract rodents and spread infection affecting 121 medically compromised residents.

Inspectors wroteBased on interview and facility record review, the facility failed to have a written Quality Assurance Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety, quality of care, and quality of life of the residents) plan in place to address the facility's systemic process issues related to pressure injuries (PIs) and foot care. These failures resulted in multiple residents to not receive appropriate care and treatment for pressure injuries and foot care. In addition, these failures had the potential to place other residents residing at the facility to be at risk for not achieving their highest physical, mental, psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was available in the residents' records, for eight of 12 residents reviewed for AD (Residents 457, 83, 61, 99, 308, 54, 92, and 311.) This failure had the potential for Residents 457, 83, 61, 99, 308, 54, 92 and 311's AD to not be readily retrievable by the staff and the physician, making them unaware of, and unable to honor the residents' wishes regarding their medical treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. The physician evaluated the overall condition, for three of five residents reviewed for pressure injuries (Residents 92, 98, and 18). This failure resulted in Residents 92, 98, and 18 to not receive prompt and appropriate care and treatment for their pressure injuries; and 2. The physician evaluated the overall condition, for three of five residents reviewed for foot care (Residents 98, 84, and 47). This failure resulted in Residents 98, 84, and 47 not to receive prompt and appropriate foot care and necessary podiatry services (medical care and treatment of the human foot and their ailments).

Inspectors wroteBased on interview and record review, the facility failed to ensure annual performance reviews were conducted, for three of five Certified Nursing Assistants (CNAs [CNAs 2, 3, and 4) employee file reviewed for sufficient and competent staffing. This failure had the potential for facility staff to not develop and maintain the necessary skills and competencies in order to provide adequate and safe care and services to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when: 1. Discontinued medications in the medication cart that were no longer used were stored along with active medications for resident use. This had the potential for residents to receive wrong, and ineffective medications; and 2. The thermometer in the medication refrigerator displayed 32 °F (degree Fahrenheit; unit of measurement). This had the potential for residents to receive ineffective medication therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were receiving pain medications according to the physician orders with adequate indications, for two of five residents reviewed for unnecessary medications (Residents 92 and 311), when the residents received oxycodone/acetaminophen (potent Schedule II narcotic pain medication combined with Tylenol) with documented pain level below 3 (mild pain in pain rating scale). This resulted in the two residents unnecessarily receiving narcotic pain medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were stored, prepared, and served under sanitary conditions, when two containers of sour cream were found inside the walk-in refrigerator past the used by date (the last date recommended for the use of the product while at peak quality). This failure had the potential to result in food borne illnesses to medically vulnerable residents who are on oral feeding in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures were implemented when: 1. Multiple staff who provided resident care were observed to not perform hand hygiene; and 2. One resident (Resident 78) was not placed on Enhanced Barrier Precautions (EBP - infection control intervention designed to reduce transmission of resistant organisms that required use of gown and glove during high contact resident care activities) when the resident had VRE (Vancomycin Resistant Enterococcus [MDRO - multi-drug resistant organism; a type of infection which is resistant to more than one antibiotic]) in the urine. These failures had the potential to increase the spread of pathogens (germs) and infections by staff to residents.

Inspectors wroteBased on interview and record review, the facility failed to provide initial and ongoing wound care training, for five of five Licensed Nurses (LNs) (Licensed Vocational Nurse [LVN]s 1, 7, 8, 6, and Registered Nurse [RN] 2), who provided wound care to residents with pressure injuries (PI - localized damage to the skin and underlying soft tissue over a bony prominence or from a medical device). This failure resulted in inaccurate assessment and a delay in the care and treatment for the residents who had pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident was treated with dignity and respect, for one of five residents reviewed for dignity (Resident 13), when the resident waited to be fed while the other resident seated at the same table (Resident 14) had been eating for 15 minutes, and Licensed Vocational Nurse (LVN) 1 was observed standing while feeding Resident 13. These failures had the potential for Resident 13 to not attain her highest practicable physical and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents needs were accommodated, for one of six residents reviewed for environment (Resident 4), when the call light was observed not within the resident's reach. This failure had the potential for Resident 4 not to be able to notify staff of necessary assistance she needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Resident Representative (RR) was notified when the resident returned to the facility from the hospital, for one of one resident reviewed (Resident 17). This failure resulted for Resident 17's RR to not be notified of the resident's current status in the facility after coming back from the hospital.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, clean, and homelike environment, for three rooms (rooms [ROOM NUMBER]). These failures could potentially placed residents residing in rooms [ROOM NUMBER] at risk for accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an individualized baseline care plan (specific interventions to provide effective and person centered care to meet the resident's needs) was initiated within 48 hours after admission to address bowel and bladder needs, for one of eight newly admitted residents reviewed (Resident 359). This failure had the potential to cause inadequate management of Resident 359's toileting needs and could affect the overall condition of Resident 358

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided meet professional standards of practice, for two of 25 sampled residents (Residents 457 and 85) when medications brought in by the residents were stored on top of the bedside table. In addition, Residents 457 and 85's medications did not have a physician's order. These failures had the potential for Residents 457 and 85 to receive medications unsafely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain or improve hearing difficulty, for one of one resident reviewed for communication-sensory (Resident 5). This failure had the potential for Resident 5 to not effectively communicate and express her needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of seven residents reviewed for nutrition (Resident 83) when the Registered Dietician's (RD) recommendations were not referred to the physician to address Resident 83's significant weight loss of 12.30% in six months. This failure had the potential for a delay in the care and treatment which may result in further weight loss and worsening of Resident 83's overall condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of five residents reviewed for unnecessary medications (Resident 92), antipsychotic medications (for treatment of schizophrenia, mental illness characterized by disordered thinking, hallucinations, and/or delusions) were not started unless: 1. Non-pharmacological interventions were attempted and failed; 2. Documentation was made in the resident's record the targeted behaviors presented danger to themselves and others, and caused a significant distress; and 3. The resident's behaviors were monitored for responses to and effectiveness of the medications. This had the potential for Resident 92 to receive unnecessary psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure vials and pens of insulin (hormone used to control blood sugar) were stored in the medication refrigerator as specified by the manufacturer's guidelines when the insulin vials and pens were stored in the medication cart at room temperature instead of refrigerated. This had the potential for less effective, expired medications to be administered to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified timely, for one of 25 residents reviewed (Resident 78), when the resident had a low potassium (electrolyte for muscles and nerves) level. This failure resulted in Resident 78 not to receive appropriate treatment and evaluation to address the resident's low potassium level and placed the resident at risk for further health complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of five Certified Nursing Assistants employee file reviewed (CNA 4), received the federally mandated annual trainings for CNAs. This failure had the potential for residents to receive inadequate or unsafe care.

Inspectors wrote2. On February 25, 2020, at 9:23 a.m., Resident 357 was observed awake and lying in bed. A clear plastic medicine cup containing a round orange-pink colored tablet was observed on the over bed table by the right side of her bed. There was no score (groove), symbol, or label observed on either surface of the tablet. In a concurrent interview, Resident 357 stated she was not aware there was a medication by her bedside. She stated she did not recall who placed it there or if she was offered this medication to take. She stated she did not know what kind of medication it was. On February 25, 2020, at 9:27 a.m., Resident 357 and the items at her bedside were observed with LVN 4. LVN 4 stated the tablet looked like a vitamin. She stated she did not give this medication to the resident. She stated she gave two medications to Resident 357 for the morning medication pass. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the plan of care (POC) was updated, for two of 27 residents reviewed (Residents 6 and 255), when: 1. For Resident 6, the IDT (Interdisciplinary Team) recommendation for the bed height and the decline in bowel and bladder status were not addressed in the POC; and 2. For Resident 255, the POC did not address the resident's preference to not be woken up for blood sugar (BS) checks before breakfast. These failures had the potential to result in a delay of the implementation of appropriate interventions to address the care and treatment for Residents 6 and 255.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' fingernails were cleaned and trimmed, for six of eight residents reviewed for activities of daily living (Residents 33, 105, 8, 80, 42, and 154). These failures had the potential to result in injury and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the necessary care and treatment were provided, for four of 28 residents reviewed (Residents 33, 22, 255, and 21), when: 1. For Resident 33, the facility failed to identify, assess, and monitor the wound on her left forearm; 2. For Resident 22, the facility failed to notify the physician after she had five episodes of diarrhea (loose stool) in one shift; 3. For Resident 255, the facility failed to ensure the resident's blood sugar (BS) was checked before breakfast as ordered by the physician; and 4. For Resident 21, the facility failed to monitor the edema (swelling caused by excess fluid) on both her lower extremities. These failures had the potential to result in a delay of care and treatment for Residents 33, 22, 255, and 21.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR, process by which a consultant pharmacist reviewed a resident's medications) recommendations were acted upon timely, for two of five residents reviewed for unnecessary medications (Residents 80 and 18). This failure had the potential to resulted in a delay in the provision of treatment for Resident 80 and the monitoring for the effectiveness of Atorvastatin (medication to treat high cholesterol level) for Resident 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed, when the appropriate portion size was not served, for 34 of 34 residents with a diet order of cardiac (diet for residents with heart related diseases) and cardiac/controlled carbohydrate (CCHO [diet for residents with heart related disease and abnormal blood sugar]). In addition, spiral pasta was not served as indicated in the menu, for nine of nine residents with renal (kidney) diet. These failures had the potential for 41 residents to not receive adequate nutrition which could further compromise their medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the therapeutic diet was served to residents as ordered by the physician when the appropriate portion size was not served, for 34 of 34 residents with a diet order of cardiac (diet for residents with heart related diseases) and cardiac/controlled carbohydrate (CCHO [diet for residents with heart related disease and abnormal blood sugar]). In addition, spiral pasta was not served as indicated in the menu, for nine of nine residents with renal (kidney) diet. These failures had the potential for 41 residents to not receive adequate nutrition which could further compromise their medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control was implemented when multiple staff who provided patient care were observed to have long and/or artificial fingernails. This failure had the potential for the residents to acquire infections due to harmful bacteria harbored underneath the artificial fingernails, and for resident/s to acquire injury due to the length of staff's fingernails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a scheduled eye appointment was followed up, for one of two residents (Resident 154) reviewed for vision. This failure had the potential for Resident 154 to not receive the necessary treatment timely to maintain effective vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment was conducted and care and treatment were provided, when a resident had a decline in bowel and bladder status, for one of 28 residents reviewed (Resident 6). This failure had the potential for a delay of treatment to restore Resident 6's bowel and bladder function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' fluid intake were being monitored while on fluid restrictions, for two of two residents reviewed (Residents 55 and 140). This failure had the potential for the residents to have fluid overload and complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the use of Lasix (medication to treat edema [swelling]) was monitored related to the indication of edema, for one of five residents reviewed for unnecessary medications (Resident 18). This failure had the potential for Resident 18 to receive unnecessary medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician's order for comprehensive metabolic panel (CMP - blood test that measured the levels of sugar and electrolytes in the body and kidney function) and lipid panel (blood test to monitor the fatty substances in the blood) were completed as ordered by the physician, for one of 27 residents reviewed (Resident 18). These failures had the potential for medical condition/s to not be identified timely and/or a delay in the care and treatment for Resident 18.