Heritage Manor

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and appropriate discharge for two of 2 sampled residents (Resident 1 and 2) who required peritoneal dialysis (PD, a type of dialysis [a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed] that uses the lining of the abdomen [peritoneum] as a natural filter to remove waste, toxins, and extra water from the body]) service. The facility admitted Residents 1 and provided PD services to the residents without obtaining license and reporting to the State Agencies since 2/2026. The facility initiated Resident 1 and 2 to discharge to the hospital on 4/29/2026 which was not the choice of the residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to 2 of 2 sampled residents ( Residents 6 and 62) who required peritoneal dialysis (PD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed]that uses the lining of the abdomen [peritoneum] as a natural filter to remove waste, toxins, and extra water from the body) receive such services, consistent with professional standards of practice and the Federal and State Department requirements prior to providing PD Services to the residents. The facility failed to: 1. For Resident 6 failed to receive ongoing assessment and oversight before, during, and after PD treatments. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the accurate and current staffing data sheet (total number of actual hours worked by licensed [Registered Nurses (RNs), Licensed Vocational Nurses [LVNs], and unlicensed nurses [Certified Nurse Assistants (CNAs)] ) was posted on 4/25/2026 for the 7 AM - 3 PM shift when the annual recertification survey team entered the facility on 4/25/2025 at 8:30 AM. This deficient practice had the potential to delay recognition of inadequate staffing levels, which may lead to delayed response times, unmet resident needs, and decreased supervision, particularly for residents who require assistance with activities of daily living (ADLs), such as bathing, dressing, and toileting, or who require ongoing safety monitoring. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving anticoagulant or antiplatelet medications (blood thinner) were monitored for medication side effects, in accordance to the resident's care plan and failed to obtain the correct safe dose for a prescribed anti nausea medication, in accordance to professional standard of practice and pharmaceutical recommendation for four of six sampled residents (Residents 3, 40, 75, and 65) by failing to: 1. The facility did not monitor Resident 3 for signs and symptoms of bleeding while receiving Eliquis (a blood thinner medication).2. The facility did not monitor Resident 40 for signs and symptoms of bleeding while receiving Eliquis. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to store and serve food for 69 residents receiving food from the kitchen in accordance with professional standards for food service safety, and the facility's policy and procedure titled, Food Safety and Food Storage, revised 12/19/2022. This deficient practice had the potential for the residents to acquire food-borne illness (a life-threatening infection due to consuming contaminated food) from ingesting expired food.

Inspectors wroteBased on observation, interview and record review the facility failed to implement the facility's policy and procedure for infection control for 5 of 5 sampled residents Residents 43, 46, 62, 67 and 106. The facility failed to: 1. Resident 106's nasal canula (NC-a lightweight, flexible tube used to deliver supplemental oxygen) was properly stored when not in use to prevent contamination in accordance with Oxygen Administration facility policy. 2. Appropriately cohort Resident 62 who was on peritoneal dialysis (PD, a home-based treatment for kidney failure) with Resident 46 who had active infection with Escherichia coli Extended-Spectrum beta-lactamase (ESBL E. coli, bacteria resistant to many common antibiotics, making infection harder to treat) in urine in the same room. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain or enhanced a resident's dignity, in accordance with the facility's policy and procedure titled Promoting/Maintaining Resident Dignity, for two of six sampled residents (Residents 1 and 49) by failing to: 1. Cover Resident 1's urinary collection bag (a bag where urine drains from the bladder) with a privacy bag. 2. Provide privacy to Resident 49 while being assisted after a shower. Resident 49 was left in a shower chair with no clothes or covering from the waist down in the middle of her room while the door was open exposed to the facility hallway. These deficient practices had the potential for lowering the resident's self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure titled, Call Lights: Accessibility and Timely Response for three out of six sampled residents (Resident 1) to ensure that the residents had the call system within reach and were able to use it if desired. This deficient practice placed the residents at risk of not having their needs met timely, especially during an emergency or accident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform Physician 1 of the significant change in condition of one of three sample residents (Resident 38) on the morning of 4/25/2025 when Registered Nurse (RN) 3 assessed Resident 38, diagnosed with Diabetes Mellitus [DM, a disorder characterized by difficulty in blood sugar control and poor wound healing], with a blood pressure (the force blood pushes against the arteries; normal reading is 120/80 milliliters of mercury [mmHg, unit of measure]) of 85/50 mmHg and was drowsier than usual and RN 3 administered IV (Intravenous or administered into the vein) 5% Dextrose Normal Saline (solution with salt and glucose) without the physician's order. [...]

Inspectors wroteBased on interview and closed record review, the facility failed to ensure the required Notice of Proposed Transfer/Discharge (a written notification to the resident or responsible party (RP) was fully completed and sent to the Long Term Care Ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities) for two of two sampled residents (Resident 7 and Resident 101). The required notice, which provides written information to the resident or responsible party regarding the reason for the transfer or discharge, was not completed in full before being sent to the Ombudsman. This deficient practice failed to ensure the residents' rights to have the Long Term Care Ombudsman notified and able to advocate on behalf of Resident 7 and Resident 101 regarding their proposed transfer/discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services based on Professional Standard of Practice for two of two sampled residents (Residents 38 and 43). The facility failed to: 1. For Resident 38 with diabetes (a condition of having high blood sugar) Registered Nurse (RN) 3 transcribed in a physician order to administered IV (intravenous or administered into the vein) 5% Dextrose Normal Saline (solution with salt and glucose) to the resident without a physician order. This deficient practice had the potential to result in inaccurate treatment and inappropriate IV fluid administration and result in serious complications that included hyperglycemia (high blood glucose levels) fluid overload (the body retaining and unable to remove excess fluids) or need of hospitalization. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, sufficient fluid intake to maintain proper hydration and health to two of two sampled residents (Residents 6 and 65) by failing to: 1. For Resident 65, who has had weight loss, the staff failed to monitor and document the percentage of intake of nourishments/snacks to indicate if the snacks were consumed or not as ordered by the physician and recommended by the Registered Dietician. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store drugs and destruct biologicals in accordance with the facility's policy and procedure titled Medication Storage and Destruction of Unused Drugs when unknown white medication tablet was found on the floor in one of the two medication rooms. This deficient practice resulted in unsafe storage of the medication and had the potential to result in medication errors and misuse. During an observation Medication Room (MR) and concurrent interview with Licensed Vocational Nurse (LVN) 2 on [DATE] at 5:22 AM, a white round unknown medication tablet was found on the floor. LVN 2 stated she did not know what medication it was and why the tablet was on the floor. LVN 2 stated nurses should check the MRs for any loose tablets and discard medication tablet into the Medication Disposable bin to prevent medication errors. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the arbitration agreement (AA, a written contract where parties agree to settle disputes privately through a neutral third party [an arbitrator] rather than in a public courtroom) was adequately explained so the resident or their responsible party (RP) could understand its terms for one of three sampled residents (Resident 65) by failing to inform Resident 65's RP that he had 30 days after signing to fully review the agreement and rescind any agreement if it was not understood at the time of admission. This deficient practice has the potential to affect Resident 65's and the resident's RP's right to make informed decisions and choices about important aspects of the resident's health, safety and welfare.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call light was within reach for five of five sampled residents (Resident 46, . The deficient practices had potential for Resident 46 not being able to call the facility staff to ask for help or assistance, especially during emergencies. During a review of Resident 46's admission Record (AR), the AR indicated the facility admitted Resident 46 on 3/22/2026 with diagnoses that included displaced fracture of base of neck of right femur (right hip fracture) and Parkinson's disease (a progressive condition that affects movement). During a review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 3/26/2026, indicated Resident 46's had moderately impaired cognition (ability to understand and make decisions) and memory. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food production practices were implemented by failing to: Dispose of one sandwich, with a use by date of 2/23/26, stored in the facility's refrigerator in the conference room. Ensure kitchen towels used to wipe food contact surfaces were stored in the sanitizer solution bucket and ensure hair nets were readily available in the conference room where food was served. Ensure temperature of Time/Temperature control for safety food (TCS foods that can support bacterial growth that can result in food borne illness unless stored, prepared and served safely) foods were not above 41 degrees Fahrenheit (F). The temperature of milk held for cold storage served during lunch service was measured at 52.5F. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a QA/QAPI (Quality Assurance/Quality Assurance and Performance improvement, a date driven proactive approach to improvement used to ensure services are meeting quality standards) plan was developed on how to monitored interventions put in place related to the inoperable elevator from and to the kitchen and food service in the conference room by failing to: 1. Safe and sanitary food storage and distribution practices in the conference room. 2. Staff received ongoing training and evaluations of their skills and knowledge to ensure safe food receipt and delivery procedure, safe and sanitary food distribution to residents and reduced risk of injury. 3. Food items were received and handled in a safe and sanitary manner from suppliers. [...]

Inspectors wroteBased on observation, interview and record review, facility failed to maintain safe and functional environment by ensuring the elevator from the kitchen was maintained in functioning condition to maintain sanitary and safe food service for all residents in the facility and staffs. As a result, resident food was carried by the staff from basement through the stairwell, food distribution and service is relocated to the conference room, food vendors leave food deliveries in the parking lot to be carried by kitchen staff through the stairwell. This deficient practice had the potential to result in unsafe and unsanitary food storage and distribution practice and place staff at risk of injuries.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary diabetic care and services for one of three sampled residents (Resident 1), who had a diagnosis of type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control), by failing to coordinate services for diabetic care and management for Resident 1 that included checking blood sugar with an accu-check machine (checking blood sugar level with the use of a machine, by pricking the finger and collecting a small blood sample on a test strip, which would be read by the machine) in accordance with Physician 1's H&P treatment plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive resident centered care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) in accordance with the facility's care plan policy for one of three sampled residents (Resident 1), by failing to ensure the diabetes mellitus care plan initiated on 7/15/2025 was appropriate. This deficient practice had the potential to result in delay or lack of delivery of care and services to Resident 1, which could affect the resident's overall wellbeing.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Minimum Data Set Nurse (MDSN, a licensed nurse who specializes in the assessment and documentation of patient health data in long-term care) 1 completed the annual licensed nurse competency for 2023 and 2024. This deficient practice caused an increased risk for improper resident assessments, inadequate documentation, and could negatively impact the quality of care to the residents which could lead to hospitalization or death.

Inspectors wroteBased on interview and record review, the facility failed to perform a comprehensive medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) in accordance with the facility's policies and procedures (P&P) for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 not having medication for the diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control) since admission on [DATE], which lead to Resident 1's hyperglycemia (high blood sugar) on 8/9/2025.

Inspectors wroteBased on interview, and record review, the facility failed to provide the necessary respiratory care and interventions in accordance with the resident's respiratory care needs, care plan, facility policy and professional standards of practice, the physician's order and facility's policy and procedure for one of three closed record sampled residents (Resident 98) diagnosed of acute respiratory failure with hypoxia (a life-threatening condition where the lungs fail to deliver enough oxygen to the blood, leading to dangerously low oxygen levels in the body), chronic obstructive pulmonary disease exacerbation (worsened COPD, sudden severe symptoms of a lung disease characterized by poor airflow to the lungs that results in shortness of breath, difficulty breathing and respiratory distress) and pulmonary hypertension [a condition characterized by high blood pressure (BP, the measurement of [...]

Inspectors wrote3. During a review of Resident 94 ' s AR, the AR indicated the facility admitted Resident 94 on 1/31/2025, with diagnoses including hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and dysphagia (difficulty or discomfort in swallowing). During a review of Resident 94 ' s H&P, dated 2/2/2025 indicated, Resident 94 had the mental capacity to make medical decisions. During a review of Resident 94's MDS, dated [DATE], indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and dependent on staff for the activities of daily living. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the two of two dietary staff (Dietary Manager and Facility Cook) had appropriate competencies and skills sets to carry out the functions of the food and nutrition service based on resident assessments, individual plans of care of the 30 residents who were prescribed with pureed diet (diet with food that has been blended, mashed, or strained until it's smooth and free of lumps, like applesauce or mashed potatoes, often used for those with difficulty chewing or swallowing) and were served pureed food that was pasty and thick in texture by failing to: 1. Ensure the Facility [NAME] reviewed and followed the recipe to ensure adequate measurement of thickener powder (powder like starch used to thicken the texture of food) were mixed when preparing the pureed food on 3/26/2025. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow proper sanitation and safe food handling in accordance with the facility ' s policy and procedures by failing to ensure: 1. The scoop used for scooping flour was not on the top of the flour container and was stored in a plastic bag when not in use to limit exposure to potential contamination. 2. The dietary staff correctly conduct the calibration (correlating the readings of an instrument with those of a standard to check the instrument's accuracy) of the food thermometer used to readily identify the proper temperatures of the food being served. [...]

Inspectors wrote2. On 3/26/2025 at 3:09 PM, while onsite at the facility, the California Department of Public Health (CDPH) an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) was identified and called regarding the facility ' s failure to notify the physician regarding significant changes in Resident 98 ' s respiratory conditions and provide the necessary respiratory care and monitoring. 3. LVN 1 who was in charge of Resident 98 on 2/12/25 to 2/13/25 did not implemented Resident 98 ' s Physician Orders for Life-Sustaining Treatment (POLST, a portable medical order that communicates a patient's wishes for end-of-life care and treatment interventions) according to the resident ' s preferences. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat resident with dignity and respect by ensuring one of five sampled residents (Resident 78) by receive meal at the same time as other residents who were dining in the dining room during lunch time on 3/25/2025. The deficient practice resulted in Resident 78 reported feeling disrespected and frustrated when watching other residents eating and completing their meals in front of him.

Inspectors wroteBased on interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Notification of Changes, revised [DATE], its professional standards of practice and the physician ' s order for one of one sampled resident (Resident 98), who had a diagnosis of acute respiratory failure with hypoxia (a life-threatening condition where the lungs fail to deliver enough oxygen to the blood, leading to dangerously low oxygen levels in the body), chronic obstructive pulmonary disease exacerbation (COPD, sudden severe symptoms of a lung disease characterized by poor airflow to the lungs that results in shortness of breath, difficulty breathing and respiratory distress) and pulmonary hypertension [a condition that affects the blood vessels (the network of tubes through which blood is pumped around the body) in the lungs] by failing to ensure LVN 1 immediately notified [...]

Inspectors wrote2. During a review of Resident 27's AR, the AR indicated the facility admitted Resident 27 on 2/25/2016 and readmitted on [DATE] with diagnoses that included aphasia (a language disorder that affects a person's ability to communicate) following cerebral infarction (or ischemic stroke, occurs when the blood supply to part of the brain is blocked or reduced), and type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood). During a review of Resident 27's History and Physical, dated 11/20/2024, indicated Resident 27 did not have the capacity to understand and make decision. During a review of Resident 27's MDS, dated [DATE], indicated Resident 27's cognition (ability to think, remember, and reason with no difficulty) was severely impaired and was dependent (helper does all of the effort) in the ability to walk at least 10 feet in the room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS-a federally mandated resident assessment tool) entries were accurate and reflects resident's status for one of three sampled residents (Resident 99) who was discharged home with home health services. The MDS was incorrectly coded as a transfer to a hospital, which does not reflect the actual discharge disposition of the resident who was discharged to home. This failure resulted in inaccurate documentation in the resident's medical record could impact continuity of care, facility reporting accuracy, and regulatory compliance. Incorrect discharge coding may also affect quality measures, reimbursement, and tracking of resident outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of four sampled residents (Resident 10) who had an impaired vision and needed eyeglasses to improve his vision and to meet the residents ' needs, resident ' s goals, and preferences. The deficient practices have the potential to delay necessary care and services to assist with the Resident 10 ' s vision that and affect resident ' s quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled resident (Resident 11) was provided care and services to prevent skin pressure injury (PI-pressure injury skin damage due to unrelieved pressure or sheer or friction to the skin). Resident 11 developed Stage 2 PI (partial-thickness loss of skin, presenting as a shallow open sore or wound) on left first metatarsal (big toe) that developed in the facility and on 12/31/24 that progressed to Stage 3 P1 (Full-thickness loss of skin. Dead and black tissue may be visible) on 3/4/25. Resident 11 ' s new footwear was not assessed and evaluated to determine if the shoes was effective to prevent worsening or development of new or old pressure injury. This deficiency had the potential for Resident 11's left first metatarsal pressure injury to worsen and experience pain and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent or (5%) or less during medication pass for one of four observed residents (Residents 52) in which three (3) medication errors were identified out of 29 opportunities that yielded a cumulative error rate of 10.34 %. The facility failed to ensure: 1. Licensed Vocational Nurse 2 (LVN 2) checked the heart rate of Resident 52 prior to the administration of Metoprolol tartrate (medication that lowers blood sugar level) and Amlodipine (medication ordered to manage hypertension [HTN - elevated blood pressure]). 2. Licensed Vocational Nurse 2 (LVN 2) provided food during medication administration of Metoprolol and Metformin HCL (medication given to lower blood sugar level) ordered by the physician. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one out of four residents (Resident 52) was free from significant medication errors as indicated in the physician ' s order, pharmacy recommendation and facility's policy and procedures by failing to ensure Licensed Vocational Nurse (LVN) 2 failed to check the heart rate of Resident 52 prior to the administration of Metoprolol tartrate (medication given to lower the blood pressure) and Amlodipine (medication ordered to manage Resident 52's hypertension [HTN - elevated blood pressure]). This failure places the resident at risk for adverse effects, including bradycardia (low heart rate), hypotension (low blood pressure), dizziness, increasing the risk of falls, and cause the heart to stop that could lead to hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for one of two sampled residents (Resident 47) who had difficulty swallowing was served pureed diet (a food item that has been blended, mixed, or processed into a smooth and uniform texture) that was too thick in texture. This deficient practice resulted in Resident 47 and other residents with difficulty swallowing to be at increased risk for choking (happens when something blocks the airway, preventing a person from breathing properly, often due to food or other objects getting stuck in the throat) and aspiration (accidentally inhaling food, liquid, or other material into the lungs instead of the stomach, which can lead to complications like pneumonia [a severe lung infection]) that could lead to death. Finings: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean and sanitary environment for six out of 20 sampled residents(Residents in room [ROOM NUMBER] and 5) when a rusty and dirty commode was found in shared bathroom of room [ROOM NUMBER] and 5. This failure resulted in unsanitary environment and potential to lower the residents' quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances verbalized by one of two sampled residents' (Resident 1) responsible party (RP) apprised of progress towards resolution. In addition, the facility failed to issue a written grievance decision to the resident and RP, in accordance with the facility's policy on Grievance/Concern. This deficient practice increased the risk for negative psychosocial impact on Resident 1's quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure one (1) of five (5) sampled residents (Resident 1), who was assessed at risk for falls and diagnoses of dementia (a progressive state of decline in mental abilities) and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) was free from falls and injury in accordance with the resident ' s care plan by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 prevented Resident 1, who was assessed as totally dependent to staff for bathing/showers, from falling in the Shower Room while sitting on the shower chair. On 11/30/2024, Resident 1 fell on her left side when the resident opened the arm rest of her shower chair while CNA 1 bent over to fix the hem (an edge that is folded over and stitched down to prevent threads coming loose) of her [CNA 1] pants. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to report an injury of unknown source, immediately, but not later than two (2) hours after the allegation was made at 8:30 AM and reported the allegation to the Department of Public Health (DPH) at 1:23 PM (five [5] hours after the allegation), when Resident 2 was found having ecchymosis (a bruise) to both arms and a skin tear to the left forearm, for one (1) of five (5) sampled residents (Resident 2), in accordance with the facility's policy and procedure [P&P] titled Abuse, Neglect, and Exploitation. This deficient practice had the potential to result in placing the resident at risk for undetected elder neglect or abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the facility ' s policy and procedure titled Clean Dressing Change to prevent infection during wound care of the pressure ulcer (a skin injury resulting from prolonged unrelieve pressure in the body). Licensed Vocational Nurse (LVN 1) failed to change gloves and wash hands after touching a soiled wound dressing during wound care for one of three sample residents (Resident 2) who had Stage 4 pressure ulcer (skin injury that involves full-thickness tissue loss that exposes bone, tendon, or muscle). This deficient practice had the potential for Resident 2 to develop severe wound infection, pain and could lead to delayed healing process and a decline in the resident ' s wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the facility ' s infection surveillance tracking and heighten the facility ' s surveillance activities for coronavirus illness during periods of transmission to prevent and control the spread of Covid-19 (Coronavirus, a severe respiratory illness caused by a virus and spread from person to person) in accordance with current standards and the facility ' s policies and procedures. The facility failed to develop an effective line listing (a table/list that summarizes information about cases [possible, probable or confirmed] associated with an outbreak) for 20 out of a facility census of 98 who tested positive for Covid 19. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient monitoring and supervision to one of two sampled residents (Resident 1) who eloped (the act of leaving a facility premises or a safe area without notifying anyone) from the facility. The facility found out that Resident 1 was missing on 4/20/24 at around 8 PM when a family member (FAM 1) called the facility to inform a staff that the resident went home. This deficient practice had the potential for Resident 1 and other residents who are at risk for elopement to be exposed to danger or harm that could lead to injury or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Certified Nurse Assistant (CNA) 3 was seated during meals times while assisting feeding for three of three sampled residents (Residents 25, 33, and 388). This failure had the potential for Residents 25, 33 and 388 to experience loss of dignity, self-esteem and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for three of three sampled residents (Resident 12, 2, and 31). 1. Resident 12 who had oxygen therapy in accordance with the facility's protocol for Oxygen Administration. 2. Resident 2 who was admitted with diagnoses of sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and pneumonia (a severe infection in your lungs). 3. Resident 31's preference to receieve prescribed medication at different times from the usual medication scheduled times at the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 81) was assessed, monitored, and evaluated for skin breakdown related to MASD (Moisture-associated skin damage caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion [gradual destruction of tissue] or skin infection) and fungal infection (irritation or swelling of the skin cause by overgrowth of fungus) in accordance with the facility's policy and procedure and resident's plan of care. The facility failed to ensure: 1. Resident 81's plan of care was implemented to assess and document status of wound perimeter; wound bed and healing progress and report improvements and declines to medical doctor and resident. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 81), was assessed, provided pain management and interventions to relieve severe pain in the perianal (body area near the anus), perineal (body area between the anus and vaginal area) area due to severe MASD (Moisture Associated Skin Damage characterized by skin inflammation and damage of the outer layer of the skin resulting from prolong exposure moisture from to feces, urines and perspiration) and fungal dermatitis (irritation or swelling of the skin due to overgrowth of fungus) during wound care, hygiene care or when sitting on the chair for a long period of time as indicated in the facility's policy and procedure and as ordered by the physician. [...]

Inspectors wroteBased on interview, and record review, the facility failed to complete a performance review for eight of nine (9) Certified Nurse Assistants (CNAs) based on the outcome of the review for each of the CNAs. The CNAs did not have a completed Annual Core Clinical Competencies (ACCC, an assessment and training on the CNAs the ability to perform clinical nursing care). This failure had a potential to result in the facility ' s CNAs not able to provide quality care to the resident ' s population based on the Facility Assessment (an assessment to make decisions about direct care staff needs, as well capabilities to provide services to the residents).

Inspectors wroteBased on observation and interview and record review the facility failed to implement the facility's policy and procedure on food storage and in accordance with professional standards of practice for food service safety by failing to: 1. Label and date of when it was opened or used by a brown powder in a clear plastic container, the chicken bouillon (ingredients used for seasoning). 2. Label a clear plastic container containing rice found in the refrigerator, with the use-by-date (the date the food product could be safely consumed). 3. Label a clear plastic container containing sliced peaches found in the refrigerator with the use-by date. 4. Label a clear plastic container containing tofu found in the refrigerator with the use-by-date. 5. Label a clear plastic container containing green peas found in the refrigerator with the use-by date. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Complete the facility's Surveillance Data Collection Form (SDC - a form used by the facility to indicate if the resident met the criteria for the use of antibiotic [medication used to treat infection]), a part of the facility's Antibiotic Stewardship Program (protocols and a system in the facility to monitor antibiotic use) prior to the administration of antibiotic for one of three sampled residents (Resident 30). 2. Implement the facility's Antibiotic Stewardship Program (a facility policy that uses protocols and a monitoring system for antibiotic [medication used to kill bacteria and to treat infections]) use by not conducting a surveillance (close observation) and monitoring prior to antibiotic use. for one of three sampled residents (Resident 2). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: provide reasonable accommodation of needs for two of two residents (Resident 30 and 81). 1. Provide reasonable accommodation of needs for one of two sampled residents (Resident 30) by failing to ensure to place resident's call light within reach. 2. Use a communication board, tool or ask assistance from a translator when communicating to one of one sampled resident (Resident 81), who speaks a foreign language. These deficient practices had the potential for Resident 30 not to receive or have a delay in provision of care and necessary services for the resident's well-being, and resulted in Resident 81's verbalized feeling confused and frustrated when the staff communicated in a language that she did not understand. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the physician and responsible party was notified for one of one resident (Resident 81) with significant change of condition (COC) related to severe MASD (damage of the skin caused by prolonged exposure to various sources of moisture) and fungal skin infection (skin disease irritation, swellingness caused by an overgrowth of a fungus) in the perineal (the area extending from the anus to the vulva in the female and to the scrotum in the male) and perianal (the tissues surrounding the anus) area. This deficient practice Resident 81 developed worsened skin breakdown, fungal infection that led to more pain, discomfort and recurrent sepsis (a life threatning infection of the blood). Crossed reference with F684 and F697.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 76) receives appropriate care and services to prevent urine in the Foley catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) from entering back into the bladder and cause urinary tract infections (an infection due to a disease causing organisms that enters the bladder and the kidney). Resident 76 was observed with Foley catheter tubing kinked (sharp twist or bent) on the bedrail and causing the urine to flow back to the bladder and not flow freely into the drainage bag as indicated in the facility's policy and procedure and Resident 76's plan of care. This deficient practice had the potential for Resident 76 to experience recurrent urinary tract infection and negatively affect Resident 76s quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy and procedure on Care and Treatment of Feeding Tubes, for one of one sampled resident (Resident 72). The facility failed to ensure: 1. Resident 72's gastrostomy tube (tube inserted through the belly that brings nutrition directly to the stomach) was labeled with the date when the tubing will be changed and/or the last time it was changed. This failure had the potential to cause complications to Resident 72's gastrostomy tube.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of three sampled residents (Resident 12) had nasal canula and humidifier bottle dated and changed weekly in accordance with the facility's protocol for Oxygen Administration. 2. Ensure one of three residents (Resident 59) had a plastic storage bag for oxygen equipment changed weekly per facility's standard of practice. This failure had a potential to result in Resident 12 and Resident 59 using contaminated (the presence of an infectious agents- bacteria, viruses, microbes) oxygen equipment leading to a possible respiratory infection (an infection of parts of the body involved in breathing, such as the sinuses, throat, airways or lungs), sepsis (severe infection in the blood) including pneumonia (an infection that affects one or both lungs).

Inspectors wroteBased on observations, interview and record review, the attending physician failed to take an active role in supervising the total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident's current medical regimen for one of one sample resident (Resident 81), in accordance with the facility policy and procedure on Physician Visits and Physician Delegation. The facility failed to ensure Resident 81's attending physician: 1. Physically assess, evaluate and document the resident's skin condition during admission and during other physician ' s visits for Resident 81 with severe MASD (damage of the skin caused by prolonged exposure to various sources of moisture), fungal infection (skin disease caused by an overgrowth of a fungus) and dermatitis (irritation or swelling of the skin). 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that two of two sampled residents (Residents 2 and 50), who were at risk for bleeding and bruising were free of unnecessary medication while receiving blood thinners by failing to ensure: 1. Resident 2 had adequate monitoring for bleeding and bruising while receiving Plavix (a medication that prevents platelets [a type of blood cell] in your blood from clumping together to form unwanted blood clots). 2. Resident 50 had routine laboratory test ordered to monitor the resident for complications of Aspirin (used to prevent blood cells called platelets from clumping together to form unwanted blood clots) and Eliquis (medication that decreases the clotting ability of the blood and helps to prevent harmful clots from forming) such as bleeding. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that medication error rate was less than five percent (%). During the medication administration observation, four medications out of 30 total medications administered and opportunities contributed to an overall medication error rate of 13.33 % affecting three of eight residents observed for medication administration (Resident 37, 28, and 69). The medication errors noted were as follows: 1. The medication nurse attempted to administer Calcitriol (medication to treats low calcium level) and Folic Acid (medication is used to treat low blood level) without checking the expiration date on the bottle for Resident 37. 2. The medication nurse administered Metoprolol Tartrate (medication used to lower blood pressure) without offering food as ordered by the physician for Resident 28. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed provide documented evidence that two of three sampled residents (Residents 53 and 390) were offered or declined (refused) the influenza (flu- results in severe infection of the lungs) vaccine (a substance used to stimulate immunity to a particular infectious disease administered via injection) annually (every year). This deficient practice placed Residents 53 and 390 at a higher risk of acquiring and transmitting the flu to other residents and staffs that could result in a widespread infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure that employee's personal item was not stored in the one of two medication rooms (Med room [ROOM NUMBER]) at Nursing Station 2. 2. Ensure one of three sampled residents (Resident 6), was maintained with sanitary environment by failing to timely clean up Resident 6's bedside commode with feces and urine. These deficient practices had the potential for cross contamination leading to infection and had a potential to result in a negative effect on Resident 6's overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed implement the facility ' s policy and procedure for infection control by failing to ensure the facility staffs performs hand hygiene (hand washing or use sanitizing agent to eliminate disease causing organisms) for five of 5 sampled residents (Residents 5, 6,7,8 and 9). 1. After contact and caring for Resident 5 and Resident 8. 2. Before and after dispensing the fresh and old water in a water pitcher between Resident 6, 7 ,8, and 9. These deficient practices had the potential to result in the wide spread of infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) in the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection control surveillance tracking log to ensure that facility staff members who were possible close contacts (one who has shared the same indoor airspace with someone with COVID-19 for a total of 15 minutes or more over a 24-hour period) while they were infectious to 13 of 13 sampled residents with confirmed Coronavirus 2019 (COVID-19; an infectious disease) infection for the facility's current COVID 19 outbreak that started with the first positive resident on 11/8/2023. This failure had the potential to result in the further spread of COVID-19 amongst the facility's residents and staff. allows for the facility to become quickly and efficiently aware of other positive residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five sampled residents (Resident 6) out of the 92 residents residing at the facility, was educated, and offered a Coronavirus 2019 (COVID-19; an infectious disease) vaccine, in accordance with the facility's policy and procedure. This failure resulted in the resident contracting COVID-19 during his stay at the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow and implement the resident ' s fall risk care plan that indicated to follow facility fall protocol (system of rules or accepted behavior that staff should follow in certain situations) to prevent further accidents and injury for one of three sampled residents (Resident 1), who had a recent fall in 10/22/2023, when facility staff failed to: 1. Report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident, in accordance with the facility ' s policy and procedures titled Incidents and Accidents. There was no report endorsed from the previous night shift to the morning shift licensed nurse on 10/22/2023, when Resident 1 was found with a swollen right eyelid with bluish discoloration and swollen cheek. [...]