Heritage Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents, (Resident 139) who was admitted with intact skin integrity (undamaged skin) did not develop a blood blister (fluid-filled pocket that forms when small blood vessels break under the skin, usually caused by pinching, crushing, or rubbing) on the left calf that deteriorated to a deep tissue injury ([DTI] (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) and later progressed to a Stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon [a tough cord of fibrous tissue that connects a muscle to a bone], ligament, cartilage, or bone) pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to:1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was accurately completed and obtained from the resident and/or responsible party for three of three sampled resident (Resident 35, 45, and 139). The facility failed to:1. Ensure Resident's 35's informed consent for psychotropic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) was signed by the physician.2. Ensure Resident 45's informed consent for psychotropic medication contained the correct medical diagnosis. These failures violated the residents' right to make an informed decision regarding the use of psychoactive medications.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a written copy of the bed hold notice was created and provided to one of three sampled resident's (Residents 1) responsible party (RP) within 24 hours of transferring Resident 1 to a General Acute Care Hospital (GACH). This deficient practice resulted in the incomplete status of Resident 1 bed hold availability and no documented notice provided to RP.

Inspectors wroteBased on interview and record review, the facility failed to the California Department of Public Health (CDPH) in two hours of an allegation for one of five sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for further abuse in the facility and had the potential for abuse for all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure by failing to do a complete investigation and remove a Certified Nurse Assistant (CNA) 1 during the investigation for an allegation of abuse for one of five sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 and all residents in the facility at risk of abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and treatment for four of six sampled residents (Resident 19, 14. 61 and 39). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 8, LVN 9 and Registered Nurse (RNS) 4 assessed and monitored Resident 19 when the resident had a change in condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, and understand] behavioral, or functional status which without immediate intervention, may result in complications or death) manifested by shivering and shaking on 6/8/2025 at 11:10 p.m., and every two hours thereafter. 2. Ensure LVN 8 informed LVN 9 of Resident 19's shivering and shaking on 6/8/2025 at 11:10 p.m. during change of shift handoff. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents, who were identified at risk for falls, did not fall and sustain injury for two of three sampled residents (Resident 50 and Resident 89). The facility failed to: 1. Ensure Resident 50's talking device (recordable voice alarm with a personalized message that plays when an alarm is triggered) was turned on as one of the interventions of fall risk prevention program for Resident 50. 2. Ensure the licensed nurses evaluated the effectiveness of interventions of Resident 50's care plan titled, At risk for falls, difficulty maintaining sitting/standing balance, history of falls/multiple falls initiated on 12/25/2024, after the resident's fall on 4/19/2025, to develop new interventions to prevent the resident's fall on 5/22/2025 with injuries. 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to store, handle and maintain food/food supplies with professional standard for food service safety for 125 residents who eat in the kitchen when : 1. Staff failed to wear a hair net while in the kitchen. 2. Food stored in the refrigerator had no label and open date. 3. The counter mounted can opener had a black tarry substance present. 4. One large dented can of jack pot brand 6 pounds 11 ounce of pineapple on the shelf. 5. Floor underneath the triple sink with small white particle and thick black tarry film. These failures had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA) failed to implement corrective action from the last re-certification survey in regard to the facility repeated deficient practices.

Inspectors wroteBased on observation and interview the facility failed to provide an effective pest control by: a. Preventing an infestation of tiny flies (Drain Flies) in the kitchen. This deficient practice had the potential to affect the residents by causing disease for the 127 residents who eat food in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to: 1. Ensure that the call light device was within easy reach for Resident 42 and Resident 45. 2. Provide a communication board (a visual aid often featuring pictures, symbols, or words to help individuals with aphasia express themselves and understand others when verbal communication is difficult) for Resident 120, who is aphasic. These deficient practices had the potential to result in a delay of care and the residents needs not being met.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident, who had unrelieved pain on his shoulder, neck, and legs, was provided with effective pain management (the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goal) for one of one sampled resident (Resident 55). The facility failed to: 1. Ensure Lidocaine patch (topical [applied to the surface of the body] pain relievers that work by numbing the skin) and Aspercrem (topical pain relief designed to relieve minor aches and pains associated with conditions like arthritis and backaches) were offered and given to Resident 55 in 4/2025, 5/2025 and 6/2025, as ordered by the physician. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Administer metformin ( a medication for treating high blood glucose), within one hour of its scheduled administration time according to the facility's undated policy and procedure titled Administering Medications. This affects one of the six sampled residents during medication administration (Resident 30). 2a. Ensure Resident 47's aspirin [a medication used to prevent heart attack (flow of blood and oxygen is blocked) and stroke (loss of blood flow to a part of the brain)] chewable tablet was administered as a chewable according to manufacturer formulation specifications instead of being swallowed without chewing, on 6/10/2025, affecting one of six sampled residents during medication administration (Resident 47). 2b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Maintain a clean and safe environment for medication storage by removing unsealed red biohazard containers filled with discarded medications in tablets, capsules and liquid form from three of the four inspected carts (Station B1, Station B2, and Station A). 2. Ensure that Resident 30 does not self-administer medications without facility supervision by safeguarding his medications during the medication pass, affecting one of six residents (Resident 30). 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide necessary dental services for four of four sampled residents (Resident 78,105, 6 and 10). This failure had the potential to lead to weight loss, inability to chew effectively, or infection of the mouth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS, resident assessment tool) assessments for one of six sampled residents (Resident 32) by failing to ensure Section GG 0115A was coded accurately to indicate functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) of Resident 32's both arms. This deficient practice had the potential to result in delayed or missed identification of joint range of motion (ROM, full movement potential of a joint) changes, inaccurate care planning, and inadequate provision of services and treatments for Resident 32.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the comprehensive care plan for two of four sampled residents (Resident 50 and 61) by failing to: 1. Revise and update Resident 50's care plan after a fall on 4/19/2025. 2. Revise and update Resident 61's care plan after Resident 61 pulled out her nasogastric tube (NG tube- a thin flexible tube inserted through the nose, down the throat, and into the stomach) and conduct an Interdisciplinary Team (IDT) conference. These failures resulted in Resident 50 falling on 5/22/2025 and Resident 61 pulling out her NG tube multiple times.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that facility staff did not administer Resident 120's benzonatate (a medication used to treat cough) capsules via gastrostomy tube ([G-tube] a soft tube surgically placed directly into the stomach for administration of medication and nutrition), for one of six sampled residents. This deficient practice failed to provide medication in accordance with professional standards of practice and had the potential to result in adverse effects and untreated cough for Resident 120.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide the necessary treatment and services to minimize the risk of development of pressure injuries (PIs, areas of damaged skin caused by staying in one position for too long) for one of three sampled residents (Resident 115) by failing to: a. Ensure the low air loss mattress (LALM - a pressure relieving mattress filled with air) remains inflated. This deficient practice had the potential for Resident 115 to develop new pressure injury and skin wounds to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to improve and/or prevent a decline in range of motion (ROM, full movement potential of a joint) for one of six sampled residents (Resident 39) by failing to provide Resident 39 with active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises to the left ankle per Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) physician's orders and in accordance with Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) recommendations. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two sampled residents (Resident 78 and Resident 95) were provided with a bowel and bladder retraining and/or toileting program ( aims to help individuals regain control over their bowel and bladder functions through a structured approach), to regain normal bowel and bladder function as much as possible and received appropriate treatment and services to restore continence. This failure had a potential risk for Resident 78 and Resident 95 to lose their ability to regain control of bowel and bladder function, which could result in loss of dignity.

Inspectors wroteBased on observation interview, and record review the facility failed to ensure one of one sampled resident (Resident 62) was provided with water at the bedside. This failure had the potential to put Resident 62 at risk for dehydration (occurs when your body loses more fluids than it takes in, leading to an insufficient amount of water for normal function.)

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for two of six sampled residents (Residents 30 and 47) by failing to: 1. Ensure administration of metformin (a medication used to treat high blood glucose) within one hour of its scheduled time of administration as per facility's policy and procedure (P&P) titled, Administering Medications, undated, affecting one of six sampled residents during medication administration (Resident 30). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for one (Resident 30) of six sampled residents during medication administration, by failing to administer Resident 30's metformin (a medication used to treat high blood glucose) within one hour of its scheduled time of administration as per facility's policy and procedure (P&P) titled, Administering Medications, undated. This deficient practice failed to provide medication in accordance with the physician's orders or professional standards of practice and had the potential to result in hyperglycemia (high blood glucose) for Resident 30.

Inspectors wroteDuring a review of Resident 19's admission Record, the admission Record indicated Resident 19 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), cardiomyopathy ( a long term condition that affects the heart muscle making it harder to pump blood), Covid -19 (highly contagious respiratory disease caused by Coronavirus which is transmitted thru coughing, talking , sneezing and touching contaminated surfaces ), and end stage renal disease (ESRD- irreversible kidney failure) with dependence on renal hemodialysis (procedure to remove waste products and excess fluids from the blood when kidneys [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA 5) wear proper personal protective equipment (PPE-clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and practice hand hygiene for one of two sampled resident ( Resident 119) who had Covid 19 ( highly contagious respiratory disease) before entering the room. This failure had the potential to transmit and spread infection among residents ,visitors and staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and 2) participated in care plan meetings to discuss her care and discharge goals. This deficient practice had the potential to violate Resident 1 and 2's right to be an active participant in her care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide 80 square feet of space per resident in multiple resident bedrooms (29 and 30). This failure to provide adequate space had the possibility for negatively affecting the residents' quality of life, safety, and plan of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) followed proper hand hygiene for contact isolation (the use of personal protective equipment [PPE - gown, mask, and gloves] for patients with diseases [illness or sickness characterized by specific signs or symptoms] caused by bacteria [germs] and viruses [a type of germ which causes disease] that are spread through direct and indirect contact) for Clostridioides difficile ([C. [...]

Inspectors wroteBased on interview, and record review, the facility failed to prevent the resident's unplanned severe weight loss (a weight loss greater than 5 % in one month, greater that 7.5% in three months and greater than 10 % in 6 months) of nine (9) pounds ([lbs.] 9.57 percent [%] in one month for one of two sampled residents (Resident 129). The facility failed to: 1. Ensure the Registered Dietician's ([RD] a health professional who has a special training in diet and nutrition) recommendation to increase Resident 129's enteral (form of nutrition that is delivered into the digestive system as liquid) feeding from 250 milliliter ([ml] unit of measurement) four times per day to 250 ml five times per day totaling 1500 calories ([kCal] energy people get from the food and drink they consume, and the energy they use in physical activity) were followed and provided. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident, who had a Stage 4 pressure ulcer (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joints}, and bones caused by prolonged pressure on the skin) to sacrum (tailbone area), did not experience unnecessary pain and suffering during pressure ulcer treatment and repositioning for one of five sampled residents (Resident 73). The facility failed to: 1. Ensure the Registered Nurse (RN 6) provided Resident 73 with effective pain relieve when Resident 73 loudly screamed and moaned during the sacral pressure ulcer treatment. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and observe infection control practices by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 and 2, performed hand hygiene in between residents when passing lunch trays. 2. Ensure Restorative Nursing Aide 1 (RNA 1) use the appropriate cleaning agent to effectively clean and disinfect a cloth gait belt (safety device worn around the waist that can be used help safely transfer a person from one surface to another or while walking) after completing RNA walking exercises with Resident 96. These deficient practices had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for the spread of infection. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure call light was within reach for two of four sampled residents (Resident 3 and Resident 22). This deficient practice had the potential for Resident 3 and 22 not to receive necessary assistance when needed, and experienced loss of self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for four of eight sampled residents (Residents 66 and 73, 9 and 103) by failing to: a. Develop a care plan for Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services for Resident 66. b. Develop a care plan for RNA services for Resident 73 These deficient practices had the potential to negatively affect the delivery of necessary care and services for Residents 66 and 73. c. Follow the care plan interventions for Resident 9 and 103 who were at risk for bleeding while on Coumadin (blood thinner) therapy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatments and services to five of eight sampled residents (Residents 23, 66, 84, 117, and 43) to prevent and/or limit a decline in joint (where two bones meet) range of motion ([ROM] full movement potential of a joint) and mobility (ability to move). a. For Resident 23, the facility failed to provide Restorative Nursing Aide ([RNA] nursing aide program that helps residents maintain their function and joint mobility) ROM exercises to Resident 23's both legs and assist with arm bicycle (stationary piece of equipment using a cycling motion for the arms to provide a cardiovascular and strength workout exercises, seven (7) times a week as ordered. b. For Resident 66, the facility failed to provide RNA ROM exercises to both arms and both legs, 7 times a week as ordered. c. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services. This deficient practice had the potential for 95 residents with physician's orders for RNA to experience a decline in range of motion (ROM, full movement potential of a joint) and mobility (ability to move).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to: 1. Ensure to keep a separate log of uses from the emergency medication supplies. 2. Ensure the licensed nurses would document inventory count (cycle count) of narcotics (medication used to moderate to severe pain) stored in the Cubex (an automated dispensing cabinet with a computer-controlled system that stores and dispense medications) at change of shift. Twenty-four of 124 shifts did not have nurses' signatures, and the existing signatures of the remaining 100 shifts had identical signatures for the performing and witnessing nurses. 3. Ensure there were administration record of narcotic medications for three (3) of 30 sampled residents (Residents 5, 43, 239). 4. Ensure the facility's consent policy is outdated and did not match with current regulations. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance ([QAA] a group which develops and implements appropriate plans of action to correct identified quality deficiencies) committee and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families) committee failed to: 1. Ensure on-going assessment and reevaluation of physical restraints' continuous use were conducted. 2. Identify, assess, and implement interventions on residents with severe weight loss. 3. Identify, assess, and implement interventions on residents with pain during wound care treatment. 4. Ensure Restorative Nurse Aide services were implemented to residents as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable room temperature on one of five sampled residents (Resident 25). This deficient practice had the potential to place Resident 25 at risk for disturbed sleep and can negatively impact resident's comfort and health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 73) was free of unnecessary physical restraints (any object or device that an individual cannot remove easily which restricts freedom of movement) by failing to: 1. Ensure on-going assessment and reevaluation of physical restraints' continuous use were conducted and documented. 2. Follow policy and procedure (P&P) regarding the use of restraints. These deficient practices had the potential to place Resident 73 at risk for unnecessary prolonged use of physical restraints, impaired blood circulation, skin injuries and contracture (permanent tightening of muscles that causes tissues and joints to become stiff and short).

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a preadmission screening and annual resident review (PASARR) I accurately for one of one sampled resident (Resident 50) who has a diagnosis of major depressive disorder (affects how you feel, think, and behave that can lead to a variety of emotional and physical problems). This deficient practice had the potential to result in inappropriate placement and delay of needed services for Resident 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the label of a bubble pack (unit-dose card that packages doses of medication within small, clear, or light-resistant plastic bubbles) reflected the current dosage, and/or a change in dosage, for one (1) of 30 sampled residents (Resident 239). This deficient practice had the potential for medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure two of two clean linen carts did not have unnecessary items such as a box of gloves, trash bags, assignment sheets, and container of perfumed body fragrance noted inside of the clean linen carts. 2. Ensure a box of clean gloves did not have soiled gloves inside for one of three resident rooms. These deficient practices had the potential to result in cross contamination (process by which germs are unintentionally transferred from one object to another) and the spread of infections in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1), who was transferred from the facility to a General Acute Care Hospital (GACH) for evaluation and treatment following a change of condition (COC) that Resident 1 experienced on [DATE], was readmitted to the facility after the seven-day bed hold expired, Resident 1 was cleared by the GACH to return to the facility and there were multiple female beds available. This deficient practice resulted in Resident 1's unnecessary stay in a GACH after the Resident 1 was cleared by the GACH to return to the facility. This had the potential for Resident 1's continuity of care to be interrupted and inconsistently provided.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident was placed securely in the sling (part of a lift system placed under and around patients who have mobility issues to assist them to be lifted and transferred safely from a bed, wheelchair, toilet, or shower) for a mechanical lift (a device used to ensure the safe transfer of patients from one location to another), prior to being transferred from a bed to a wheelchair, for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 falling from the mechanical lift onto his bed and sustaining a fracture (partial or complete break in the bone) of his clavicle (the collar bone) and his rib (chest bone). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement the care plans for two 6 out of 27 sampled residents (5, 32, 53, 69, and 95) to eliminate or decrease the risks by: a. Resident 5 and 95, who were receiving hemodialysis ([HD] a treatment that does some of the things done by healthy kidneys. It is needed when your own kidneys can no longer take care of your body's needs) the facility failed to ensure Resident 5 and 95 had a HD emergency kit in their room. b. Resident 32, 53, and 93 who were a fall risk, the facility failed to ensure Resident 32, 53, and 93 had a fall wrist band. C. Resident 69 who had a weight loss, the facility failed to ensure Resident 69 received Prostat (a supplement) to manage weight loss. [...]

Inspectors wroteBased on observation, interview, and review facility failed to revise the care plan for 4 out of 4 residents (20, 5, 87, 95) to reflect the individualized professional standards of care. This deficiency has the potential to harm by negating plans and care specific to the individual's needs.

Inspectors wroteBased on observation, interview and review, the facility failed to respond promptly to a bed alarm and provide a hazard-free environment for 4 out of 4 sampled residents (61, 87, 20, 157). These deficient practices had the potential to cause falls and injuries to Residents 61, 87, 20, 157 and other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a Hemodialysis ([HD] process of purifying the blood of a person whose kidneys are not working normally) emergency kit (E-kit) available at the bedside for two of three residents (Residents 5 and 95) who were receiving Hemodialysis treatment. The deficient practice had the potential to result in Residents 5 and 95 not receiving lifesaving interventions for HD emergencies such as severe bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed and unlicensed staff, in accordance with the nursing standards of practice, were able to identify residents requiring seizure (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements [stiffness, twitching or limpness], behaviors, sensations or states of awareness) precautions, monitored residents at risk for seizures, and demonstrated the ability to care for residents during and after a seizure. This deficient practice had the potential to place residents at risk for seizures to result in serious harm or inadequate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to dispose of controlled ([C], medications that have the potential for abuse and may also lead to physical or psychological dependence) and non-controlled (NC) medications in a manner that is not retrievable, in the one inspected pharmaceutical waste bin (bucket used for disposing medication) inside the Director of Nursing (DON's) office. As a result, control and accountability of C and NC medications awaiting final disposition (process of returning and/or destroying unused medications) did not follow the facility policy and procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five percent (%) due to two errors observed out of 26 total opportunities (error rate of 7.69 %). The medication errors were as follows: 1. Resident 606 received a form of calcium carbonate with vitamin D (a combination medication used to promote bone health, treat low blood calcium levels, and protect against osteoporosis [a condition where the bones become fragile and brittle from low calcium and vitamin D levels]) that was different than the one ordered by his attending physician. 2. Resident 610 received a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) that was different than the one ordered by his attending physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff accurately calculated and documented the total weekly intake and output (of fluids) for four out of four (4) sampled residents (Residents 7, 32, 53, and 76). This deficient practice resulted in inaccurate documentation of the residents' total weekly intake and output, and had the potential to place the residents at risk for inaccurate evaluation of the residents' progression or regression of the delivery of care services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal property was kept safe from loss or theft for one out of one (1) sampled residents (Resident 53). This deficient practice resulted in Resident 53 losing her diamond ring, which upset the resident, and had the potential to result in further loss of personal belongings.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Minimum Data Set ([MDS] a standardized assessment and care screening tool) assessment accurately reflected the discharge status of 1 out of 3 sampled residents (108). Resident 108 who was discharge to the community and the MDS indicated she was discharged to the General Acute Care Hospital (GACH). This deficient practice had the potential to put Resident 1 at risk of not receiving optimal care for a safety discharge.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of two residents (Resident 87) who received oxygen (a gas used by a person to increase the amount of oxygen the lungs receive and deliver to the blood) had the nasal cannula (device used to deliver oxygen) properly place consistent with professional standards of practice. Resident 87 who was a total care and was dependent on the staff to ensure he received oxygen. The deficient practice had the potential to cause Resident 87 to not receive the needed oxygen to maintain physiological function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor a certified nursing assistants (CNA 6) positions while feeding one of 27 residents, Resident 82. This failed practice had the potential to cause the resident to eat faster, have difficulty swallowing, and diminish the resident's dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three out of three (3) sampled residents (Residents 93 and 25) received treatment and care in accordance with professional standards of practice to meet the residents' physical, mental, and psychosocial needs as evidenced by: 1. For Resident 93, nursing staff failed to notify the physician of, create an SBAR (abbreviation for Situation, Background, Assessment, Recommendation - a communication tool) for, and update the resident's care plan to reflect the resident's complaint of burning with urination; 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow up with the facility's Registered Dietician (RD) recommendations for weight loss for one of 21 residents (Resident 69) who had 23 percent (%) significant weight loss in one month. This deficient practice had the potential to cause Resident 69 to experience dehydration, loss of caloric intake, and more serious complications that may lead to immediate death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Label one Oxycontin (a medication used to treat pain) package, in accordance with federal, state requirements, and current professional principals, affecting one of four observed residents (Resident 81) for medication administration. 2. Store one insulin (medication used to regulate blood sugar levels) vial for Resident 80, and one ophthalmic (medication used for the eye) bottle for Resident 44 in accordance with the manufacturer's requirements in one of two inspected medication carts (Medication Cart Station A). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two (2) sampled residents (Residents 7 and 32) received laboratory blood draws/tests as ordered by the physician. This deficient practice had the potential to delay necessary care and services.