Herman Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to include specific and resident-centered interventions in the post fall care plan in a timely manner for 1 of 2 sampled residents (Resident 1). This failure put Resident 1's at risk for potential fall and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety for one of nine sampled resident (Resident 1). Resident 1 was evaluated and identified at risk for elopement (unauthorized and unsupervised departure from facility), the facility failed to develop a person-centered care plan (an individualized, collaborative document that focuses on a resident specific needs, goals, interventions, and preferences) and failed to implement person-centered interventions with effective strategies to prevent elopement for Resident 1. This failures resulted in Resident 1 eloped from the facility on 12/14/2025 and unable to locate Resident 1 as of 3/9/26.

Inspectors wroteBased on interview and record review, the facility failed to ensure free from unnecessary antipsychotic medications (medications capable of affecting the minds, emotions, behaviors, and health conditions) for one of three sampled residents (Resident 1 and 2) when:There was no documented evidence of non-pharmacological (treatments and strategies that to manage health conditions without using antipsychotic medications) approaches attempted before administered antipsychotic medication to Resident 1 and 2. This failure had the potential to place above sampled residents at risk to receive unnecessary antipsychotic medications.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent one of 17 sampled residents (Resident 82) from multiple falls from August 2024 to May 2025 when:1. Resident 82 had a total of nine fall incidents as follows: a. Unwitnessed fall on 8/20/24 at 10:00 a.m. with no injuryb. Unwitnessed fall on 11/11/24 at 1:34 p.m. resulting to injury (abrasion-a superficial scrape or wound to the skin or other body tissue, caused by rubbing or friction against the surface) to right knee.c. Unwitnessed fall on 12/5/24 at around 11:00 a.m. with no injuryd. Unwitnessed fall on 4/12/25 at 12:30 a.m., with low spine back pain and swelling on the [NAME]. Two unwitnessed falls on 4/24/25 at 7:30 a.m. and 3:30 p.m. with no injuries notedf. Unwitnessed fall on 5/1/25 at 12:59 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean home-like environment, placing residents at risk for low self-esteem and living in an unkempt environment when: 1. Toilet room next to Resident 74 's Room, smelled feces and has feces on top of the toilet seat with smeared brownish substance around the toilet seat, toilet paper on top of the toilet seat and scattered small pieces of toilet paper on the toilet floor; and 2. Resident 73,74 and 76's window blinds were broken.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that 3 of 6 sampled residents (Residents 1, 15 and 37) were free from unnecessary medications, when:1. Resident 1 and Resident 15 were prescribed the psychotropic medication (medications that affect the mind, emotions, and behavior) Lorazepam without an end date; and2. Resident 37 was prescribed Haldol (antipsychotic medication, used to treat nervous, emotional, and mental conditions), but did not have the specific indication or behavioral manifestation for its use. These failures resulted in residents receiving unnecessary medications and had the potential to affect their clinical conditions negatively.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for four out of twenty-five sampled residents, (Residents 12, 36, 72, 73 and 76), when:1. For Resident 12, there was no care plan developed for her use of antibiotic;2. For Resident 36, Fall comprehensive care plan was not developed, and the short-term care plan was not person- centered;3. For Resident 72, the comprehensive Smoking Care plan was not initiated on time and was not person- centered;4. For Resident 73, the Fall comprehensive care plan was not initiated on time and the short-term care plan was not person centered; and 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post direct care staffing numbers, and nursing staff responsible for direct care to residents for two days (8/16/25-8/17/25) in the main entrance of the facility by the receptionist area and in each three halls of the facility. This failure resulted in residents and visitors not knowing the accurate number of hours of staff working and which staff were scheduled. During an initial tour of the facility on 8/18/25 at 8:40 a.m., observed there were no posting of direct care staffing numbers, and nursing staff responsible for direct care to residents in the main entrance of the facility for 3 days 8/16/25, 8/17/25 and 8/18/25. Last date posted was 8/15/25. During an observation on 8/18/25 at 8:45 a.m., in Hall BB. No staff schedule or direct patient care hours were seen posted. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure palatability and nutritive value of cooked foods were maintained when: 1. The pureed (smooth, thick liquid or paste made by crushing or grinding solid foods and often made using a food processor and has a consistency that's thicker than juice) and regular (no modifications to food texture or consistency) green beans tasted bland; and2. They cooked the yellow corn in the stove for an extended period (approximately 2 hours). These failures of decreased food palatability could lead to decrease in food consumed by residents, and the food cooked in the stove for extended period could lose nutritive value, that could lead to decreased nutrient intake for the ninety-four facility residents receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen equipment was maintained and food items were stored and prepared in accordance with professional standards for food safety when: 1. The outside of the ice machine had white deposits on the sides,2. The temperature log of the refrigerator and freezer were not filled out properly and3. The kitchen staff did not wear his face mask properly while helping with the tray line (a healthcare food service method where workers assemble food trays for residents on a moving assemble line) preparation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of infections when:1. The Housekeeping (HK) J was wearing a pair of gloves and was holding a wet floor mop in the hallway Infront of the opened food cart with lunch trays for the residents eating in the dining room;2. A licensed Nurse entered a contact precaution room without wearing gloves to administer medications;3. There was one fly flying around the dining area near the table of Residents 105 and 32 and 4a. Laundry staff R (LS R) did not perform hand hygiene (the process of cleaning and disinfecting one's hands to remove dirt, germs, and bacteria) between handling soiled and clean laundry. b. Certified nursing assistant K (CNA K) did not perform hand hygiene between resident care tasks. c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain resident's privacy or dignity for one of 25 sampled residents (Resident 76) when her back was halfway exposed from the Coccyx or tailbone (the last bone at the bottom (base) of the spine) up to the upper part of her back to public view in the hallway. This failure had the potential to affect Resident 76's self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse to the appropriate agencies, including the California Department of Public Health (CDPH), within the required timeframe involving two of six sampled residents (Residents 37 and 91). This failure to report allegations of abuse placed Residents 37 and 91 at risk of potential abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure, the resident's discharge minimum data set (MDS, a standardized assessment and care screening tool) assessment was transmitted within 14 days after the assessment reference date (ARD, the specific end point of look-back periods in the MDS assessment process) for one (Resident 43), out of twenty-five sampled residents. This deficient practice had the potential to result in delayed services for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate smoking assessment and complete smoking assessment were done every three months for two of 19 sampled residents who smoke (Residents 37 and 72). These failures had potential to cause accident/harm to these residents and potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident with Level 1 (involves completion of an evaluation to determine if the individual has, or is suspected of having serious mental illness, intellectual disability, developmental disability or related condition) preadmission screening and resident review (PASARR, federal requirement under the Medicaid program or public health insurance program that provides health care coverage to low-income individuals, families and people with disabilities, to screen all applicants and residents for serious mental illness, intellectual or developmental disabilities, and related conditions before they are admitted to the nursing facility) was coded accurately and those with positive Level 1 PASARR were evaluated for Level 2, for three of twenty-five sampled residents, (Residents 22, 92 and 72) when:1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the preadmission screening and resident review (PASARR, federal requirement under the Medicaid program or public health insurance program that provides health care coverage to low-income individuals, families and people with disabilities, to screen all applicants and residents for serious mental illness, intellectual or developmental disabilities, and related conditions before they are admitted to the nursing facility) was done and accurately implemented to two of twenty-five sampled residents, (Residents 85 and 6) when: 1. For Resident 85, there was no level 1 PASARR screening (involves completion of an evaluation to determine if the individual has, or is suspected of having serious mental illness, intellectual disability, developmental disability or related condition) and 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan (CP) was revised based on preferences and needs of the residents for two of 25 sampled residents (Resident 72 and 73. This failure had the potential for Resident 72 and 73 not to receive the necessary care and services to achieve the highest practicable well-being and communicate necessary interventions to the staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice for one of twenty-five sampled residents, (Resident 22), when for Resident 22: 1. The care plan for the risk of elopement was not followed;2. There was MDS assessment inaccuracy; and3. The care plan was not person-centered. These failures caused the resident to have an episode of elopement and potentially, not attaining or maintaining the highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of five emergency kits (e-kits; kits containing medications and supplies for immediate use during a medical emergency) was replaced in a timely manner. This failure resulted in two medications (a total of 16 tablets) expiring, which had the potential to make medications unavailable for use during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility had a 9.68 percent (%) medication error rate, with three medication errors out of 31 opportunities observed during the medication administration for three of the five residents (Residents 107, 41, and 55). when1. Resident 107's lactulose oral solution (a colonic acidifier that works by increasing stool water content and softening the stool) was not available during medication administration.2. Resident 41' polyethylene glycol 3350 powder was not available during medication administration.3. Resident 55's lactulose oral solution was not available during medication administration, and the nurse used another resident's medication instead. These failures had the potential to compromise the health and safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling when:1. Expired medications were not removed from the medication refrigerator to prevent medication errors.2. A bottle of lactulose oral solution (a colonic acidifier that works by increasing stool water content and softening the stool) was sticky in the medication cart.3. One tuberculin purified protein derivative (PPD) vial and five bottles of multi-dose medications were not labeled with an open date. These deficient practices had the potential to result in residents receiving medications with reduced potency or unsafe properties, as well as medication errors due to improper labeling or failure to remove expired medications from active stock.

Inspectors wroteBased on observation, interview, and record review, the following multi-resident rooms provided less than 80 square feet per resident.

Inspectors wroteBased on interview and record review the facility failed to implement their discharge planning process in including residents for their preparation to effectively transition them to post-discharge care for two of three sampled residents (Residents 1 and 2). Resident 1 and 2's records did not contain discharge care plans, interdisciplinary team (IDT, members of healthcare team that meets to discuss and plan resident care) meeting note addressing discharge planning, and referrals being sent to and accepted from shelters (temporary housing) and home health agencies (organization that provides skilled nursing and other therapeutic services to individuals in their homes). This failure resulted in unsafe discharges and placed residents at health and safety risks. Resident 2 after discharge was found sleeping outside a liquor store and admitted to a hospital.

Inspectors wroteBased on interview and record review the facility failed to timely notify a representative of the Office of the State Long-Term Care Ombudsman (an entity that serves as an impartial advocate for individuals or groups who have concerns or complaints about a particular organization) regarding discharges for two of two sampled residents (Residents 1 and 2). The facility faxed discharge notices on the day of discharge. This failure resulted in missed opportunities for an ombudsman to advocate if residents had concerns about their discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) was free from sexual abuse (sexual act that is committed or attempted by another person who is incapable of appraising the nature of the act or unable to give consent) when certified nursing assistant E (CNA E) did not separate female Resident 1 from male Resident 2. As a result of above failure, Resident 1's naked waist down body and Resident 1's private area were exposed to Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice for one of two residents investigated, (Resident 1), when Resident 1 was not provided with appropriate assistance with his activities of daily living (ADL, basic tasks individuals perform to take care of themselves on a daily basis) to prevent accident. This failure resulted in the safety of Resident 1, being compromised, thus having multiple falls.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from any type of abuse, including corporal punishment (type of physical punishment), and neglect, that could results in, or has the likelihood to result in physical harm, pain, or mental anguish for one of two sampled Residents (Resident 1), when Resident 1 was physically abused by Resident 2. This failure resulted in Resident 1 being physically abused by Resident 2 and sustaining a minor injury (bruising to back of head).

Inspectors wroteBased on an interview and record review, the facility failed to ensure medications were administered as ordered by the medical doctor (MD) for 1 of 2 sampled Resident (Resident 1). This failure had the potential to adversely affect the health and well- being of Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to ensure to follow psychiatric nurse practitioner (PNP: licensed as nurse practitioner or clinical nurse specialist, provides the full range of mental health care needs)'s recommendations and medication regimen review (MRR: a thorough evaluation of medication regimen for resident with the goal of promoting positive outcomes) for 2 of 2 sampled Residents (Resident 1 and 2) when; 1. Failed to follow up for PNP's recommendations for medication, and blood tests (common tests healthcare providers use to monitor overall health or help diagnose medical condition) for Resident 1; 2. Failed to follow up for MRR request for Resident 1; and 3. Failed to follow up for psychologist (a trained mental health professional who specializes in the study and treatment of mind and behavioral disorders)'s recommendations for Resident 2. [...]

Inspectors wroteBased on interview and record review the facility failed to follow it's Policy & Procedure (P&P) titled, Abuse Reporting and Investigation for three of four sampled residents (Resident 1, Resident 2, and Resident 3) when: 1. The facility failed to complete a 5-day investigative report for Resident 1's abuse allegation and send the report to the California Department of Public Health (CDPH). 2. The facility failed to complete a 5-day investigative report for Resident 2's abuse allegation and send the report to the CDPH. 3. The facility failed to complete a 5-day investigative report for Resident 3's abuse allegation and send the report to the CDPH. These failures had the potential for Resident 1, 2, and 3's abuse allegations to not be investigated thoroughly and resulted in CDPH being unaware of the outcome of each investigation by the facility.

Inspectors wroteBased on an interview and record review, the facility failed for 2 of 2 sampled residents (Resident 1 and 2): a) to ensure medications were administered as ordered by the medical doctor (MD) and b) to follow their policy and procedure (P&P) for administering medications. These failures had the potential to adversely affect the health and well-being of Residents 1 and 2.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary activities of daily living (ADL-skills required to independently care for oneself, such as eating, bathing, and mobility) for one of three sampled residents (Resident 1) when Resident 1's shower sheets was not available and not documented for a period of one month (3/4/24-4/4/24). This failure had the potential to negatively affect Resident 1's physical and mental health.

Inspectors wroteBased on interview and record review, the facility failed to provide care according to professional standards of practice for two of two residents (Resident 1 & Resident 2), when nursing staff failed to order two medications timely. This failure had the potential for negative health outcomes related to not receiving prescribed medications as ordered. During a review of Resident 1's Physician Orders dated March 2024, Orders indicated, Hydroxyzine [Antihistamine that can treat anxiety] HCL[hydrochloride] 25MG [milligrams] tablet. Give 1 tablet by mouth every 12 hours for anxiety. During a concurrent interview and record review on 3/19/24, at 2:32 p.m., with Licensed Vocational Nurse (LVN) A, Resident 1's Medication Administration Record (MAR) dated March 2024 was reviewed. The MAR indicated, Resident 1 did not receive Hydroxyzine on 3/18/24 for the AM dose or the PM dose. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for 40 (Residents 3, 6, 8, 10, 12, 14, 18, 20, 22, 24, 27, 28, 32, 41, 42, 45, 49, 50, 52, 55, 56, 58, 59, 64, 67, 69, 70, 74, 78, 91, 96, 98, 100, 103, 105, 113, 319, 320, 321, and 369) of 40 sampled residents (residents who used bed or side rails) when: 1. There was no documentation that indicated the facility conducted consistent routine maintenance of the facility's beds and side rails for 40 of 40 sampled residents; 2. There was no documentation of informed consents (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) were obtained prior to bed rail use for 40 of 40 sampled residents; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety when: 1. The kitchen refrigerator door has ice buildup in the rubber gasket (a flexible elastic strip attached to the outer edge of a refrigerator); 2. Three pieces of colored chopping board are stained and two cloudy and one cracked blender container in the kitchen sink; and 3 The snacks /nourishment in the unit refrigerator were outdated. These failures had the potential to cause food contamination and spread food-borne illness to residents who received their food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for seven of 24 sampled residents (Residents 28, 84, 55, 621, 46, 40, and 52) when: 1. Staff provided feeding assistance to Residents 28 and 84 while standing; 2. Staff failed to provide privacy bags for Residents 55 and 621's urinary bags; 3. Resident 46's privacy was not maintained during patient care; 4. Resident 40's dignity was not maintained by staff; and 5. Staff did not provide a privacy curtain inside Resident 52's room. These failures had the potential to affect the emotional and psychosocial well-being of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention in order to obtain agreement or permission for care, treatment, or services) was in place (or verified) prior to the initiation and administration of psychotropic medication (drugs that affects brain activities associated with mental processes and behaviors) for three of 24 sampled residents (Resident 58, 75, and 370). This deficient practice had the potential for the residents or the responsible party (RP) to not be informed of the risk and benefits of the psychotropic medications, and to make an informed decision, before receiving the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's needs were accommodated for five of 24 sampled residents when: 1. Residents 11, 2, and 18's call light button (a cord with a button used by residents to request assistance) were not within reach to use; 2. Resident 41's call light button was not within reach to use; and 3. Resident 52's call light was broken and unable to use. These failures had the potential to affect these resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit the Minimum Data Set (MDS, an assessment tool) discharge assessment and death tracking record in a timely manner for three of five residents (Residents 47, 82, and 15). These failures resulted in the resident's discharge assessment and death tracking record not being transmitted and received by the Center for Medicare and Medicaid System (CMS) within the time requirement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement individualized, resident-centered a care plans for five of 24 sampled residents (Residents 22, 28, 52, 369, and 79) when: 1. Staff did not follow Resident 22's care plan for wandering (when a person roams around and becomes lost or confused about their location) and elopement (an individual's behavior of leaving an area without permission or supervision); 2. Staff did not develop care plan for Resident 28's diagnosis of chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe) and use of oxygen for Resident 28; 3. For Resident 52, there was no care plan developed to address mood disorder (a mental health condition) or skin discoloration; 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing activity program that meet the resident's needs, interests, and preferences for five of 24 sampled residents when Residents 22, 61, 75, 70, and 41's activity care plan were not updated and followed. This failure had the potential to affect the residents' physical, mental, psychosocial well-being, and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure seven of 24 sampled residents (Residents 28, 34, 35, 56, 58, 369 and 370) received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, when: 1. Resident 56's antibiotic order from the hospital was not carried out. This placed the resident at risk for untreated and worsening infection; 2. For Resident 58, the facility staff failed to evaluate and report to the physician when the resident did not sleep for multiple days. The inability to have quality sleep may affect the resident's quality of life and lead to psychosocial outcomes (such as depression, anxiety, distress); 3. For Resident 34 and Resident 35's food tray ticket was not checked during food distribution . 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2) was provided for five of nine sampled residents (Resident 61, 28, 58, 369, and 1) when: 1. Staff did not follow the physician's order for Resident 61's oxygen therapy; 2. Staff did not post an Oxygen in use/No Smoking sign at Resident 28's door; 3. Staff did not post an Oxygen in use/No Smoking sign at Resident 58's door. 4. Staff did not post an Oxygen in use/No Smoking sign at Resident 369's door; and 5. Licensed vocational nurse (LVN) J failed to ensure oxygen (a colorless and odorless gas that people need to breath) was administered as specified in the physician's order and the nasal cannula (NC, flexible tubing inserted into the nostrils and attached to an oxygen source) was outdated for Resident 1; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff were competent in the use of the facility's charting system prior to their first shift. This failure had the potential for incorrect documentation of patient care, assessments, and medication administration.

Inspectors wroteBased on observation, interview and record review the facility failed to post direct care staffing numbers, and nursing staff responsible for direct care to residents for two days (2/14/24-2/15/24) in each three halls of the facility. This failure resulted in residents and visitors not knowing the accurate number of hours of staff working and which staff were scheduled.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide pharmaceutical services to meet the needs of three out of 24 sampled residents (Residents 56, 76, and 95). Also, the facility failed to ensure morning medication administration was given timely as per facility and procedures for two out of three halls (Hall CC) with the potential to affect 14 residents in this hall; and controlled medications (those with high potential for abuse and addiction) were fully accounted. These happened when: 1. Resident 56's Depakote (medication to treat mood disorder) was not available for administration. This had the potential for untreated medical conditions and withdrawal symptoms; 2. The morning medication administration in Hall CC was given late for two days during the survey. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR), and conducted an interim or immediate MRR (iMRR, an MRR when the medication regimen is thought to contribute to an acute change in condition or adverse effect, or when resident is not expected to stay less than 30 days), for three of 24 sampled residents (Residents 58, 75, and 370) when: 1. The facility did not request for an iMRR by the pharmacist to evaluate whether Resident 58's multiple falls were caused or contributed by medications; 2. The CP failed to make recommendations for Resident 75 who received four medications to control blood sugar (BS) without a hold order when the BS is too low; without hypoglycemia protocol (intervention instructions for when the BS is too low); [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 14.29% when five medication errors occurred out of 35 opportunities during the medication administration for one out of five residents (Resident 56). The failures resulted in medications not given according to the physician's orders and had the potential for Resident 56 to not receive the full therapeutic effects of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately when: - One of three medication refrigerators was identified unlocked when not in use; and its temperature was not being monitored and maintained twice daily as per professional standards of practice. This failure could lead to loss of medications and loss of drug potency due to unmonitored temperatures; - An opened multi-dose eye drop in the medication cart was not labeled with a resident name. The failure had the potential for the medication being used for the incorrect resident; - A package of expired blood sugar test strips was found in the medication cart. The failure could lead to the product being used past its effective date; [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure garbage was properly contained when one of the receptacles lid was not tight-fitting and cannot close. This failure had the potential to attract insects, rodents, and other pests to the facility.

Inspectors wrote2. During an observation on 2/12/2024 at 9:36 a.m., Resident 61 was lying in bed, with oxygen concentrator at bedside and the NC was on the floor. During a concurrent observation and interview with LVN E on 2/12/2024 at 10:19 a.m., in Resident 61's room, LVN E placed the NC back to Resident 61's nostrils and turned on the oxygen at 3 liters per minute (LPM). LVN E confirmed she did not clean the NC prior to application back to Resident 61's nostrils. LVN E stated she should have cleaned or changed the NC to prevent Resident 61 from having respiratory infection. Review of Centers for Disease Control and Prevention's (CDC) recommendations and reports titled, Guidelines for Preventing Health-Care-Associated Pneumonia, 2003, dated March 26, 2004, indicated, 1. General measures: a. Thoroughly clean all equipment and devices to be sterilized or disinfected .c. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy for one of 24 sampled residents (Resident 52) when staff did not report and investigate Resident 52's allegation of abuse timely. This failure had the potential to compromise Resident 52's safety and delay abuse investigations.

Inspectors wroteBased on interview and record review, the facility failed to ensure the hospital transfer information was documented in the medical record for one of 24 sampled residents (Resident 56). The facility did not document the date and time of transfer, where she was transferred to, how she was transported, and the summary of her condition when she was transferred. The failure resulted in lack of information regarding the resident's transfer, and the potential for not providing necessary care and services to the resident.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess and complete the Minimum Data Set (MDS, an assessment tool) for two of 24 sampled residents (Residents 12 and 46). This failure had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure to follow their Policy and Procedure for one of 5 sampled residents (Resident 1) Preadmission Screening and Resident Review (PASSR a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) to reopen and submit annual level I screening. These failures had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability, or related conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was safe and free of accident hazards for two of 97 residents in the facility (Residents 40 and 81). Resident 81's broken pieces of glass from the wall clock in his room were not cleaned up timely, posing a risk of injury for the residents and staff. For Resident 40, the facility staff placed a wet shower sheet blanket on the floor near the bed, presenting a fall risk for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate pain management in accordance with physician orders and resident needs for one of 24 sampled residents (Resident 370). This failure could result in ineffective pain management.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two of 24 sampled residents (Residents 75 and 370) were free from unnecessary medications when: 1. Resident 75 received two routine insulin (medication to lower blood sugar [BS]) and two other medications to control BS without a hold order when the BS is too low; without hypoglycemia protocol (intervention instructions for when the BS is too low); without staff monitoring for signs and symptoms of hypo/hyperglycemia (too low/too high blood sugar); and without a written care plan for diabetes; and 2. Resident 370 received Lovenox (an anticoagulant to prevent blood clots) and aspirin (an anti-platelet medication; the combined use increases the risk of bleeding) without staff monitoring for signs and symptoms related to anticoagulant use (such as bruising/bleeding); [...]

Inspectors wroteBased on interview, and record review, the facility failed to update and/or revised their policy and procedure in compliance with Federal regulations and with accepted professional standards and principles when the facility did not revise the facility's bed safety policy and procedure upon completion of the facility's recertification survey's plan of correction (POC). This failure had the potential to compromise resident's health and safety.

Inspectors wroteBased on interview and record review, the facility failed to offer, administer, and track Influenza vaccine (known as flu shot, immunization against infection by influenza viruses), pneumococcal vaccine (PV, immunization against bacterial that causes pneumonia, one type of lung infection), and COVID-19 vaccine (immunization against COVID-19 [Coronavirus, a severe respiratory illness caused by a virus and spread from person to person]) for three of 24 sampled residents (Residents 12, 52, and 370). This failure had the potential to cause the health complications for the residents.

Inspectors wroteBased on observation, interview, and record review, the following multi-resident rooms provided less than 80 square feet per resident:

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Laboratory staff (LS) was wearing gloves in the hallway; 2. COVID-19 (Coronavirus disease 2019); a highly contagious respiratory disease) screening process was not done properly; 3. The facility's COVID-19 screening logs were incomplete; 4. a. The nurse placed the glucometer (machine used to measure how much glucose or sugar is in the blood) on the unsanitized medication tray after the glucometer was disinfected; b. The nurse placed the syringe with medication in the unsanitized bedside table before administering it to the resident; c. The nurse did not sanitize the blood pressure apparatus after use; 5. The hospice aide (HA) did not perform hand hygiene after removing gloves; and 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safety for nine out of 22 sampled residents (Resident 17, 53, 73, 60, 46, 3, 10, 1, and 34) when: 1. For Resident 17, there was no fall risk assessment (tool, used to identify fall risk factors and to predict patients' chance of falling) completed on 3/21/22 after a fall and the bowel and bladder program fall intervention was not implemented; 2. Resident 53 was on oxygen and had a roommate who smoked, but No Smoking/Oxygen in Use sign was not posted on the resident's door. 3. For Resident 73, there was no quarterly fall risk assessment between 4/2021 to 11/2021; 4. One stall in the communal (shared by many residents) bathroom in building C (bldg C) had no call button; 5. For Resident 60, the facility did not develop and implement new and relevant interventions to prevent future falls; 6. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when: 1. The facility failed to ensure controlled medications (medications regulated by the government because they may be abused or cause addiction) for four out of five residents (Residents 39, 56, 72 and 82) were accounted for, and the consultant pharmacist (CP) did not identify this failure; and 2. The CP did not identify irregularities for two residents (Residents 87 and 27) who were receiving psychotropic medications (medications that cause changes in mood, feelings or behavior). Failure to account for controlled medications had the potential to result in diversion (transfer for illicit use) of the medications and lack of pain control for the residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nine of 22 sampled residents (Residents 1, 10, 16, 27, 30, 72, 76, 77 and 87) were free from unnecessary psychotropic medications (medications that cause changes in mood, feelings or behavior) when: 1. For Resident 1, the facility failed to ensure there was an indication for the use of Seroquel (medication to treat psychotic disorder); 2. For Resident 72, the facility failed to ensure there was an indication and a target behavior (behavior intended to be changed by the medication) for the use of Depakote (medication to treat seizures); 3. For Resident 77, the facility failed to ensure the order for as needed (PRN) Lorazepam (ativan, a medication used to treat anxiety) and Haloperidol (medication to treat psychotic disorder) was limited to 14 days; 4. [...]

Inspectors wrote2. During an observation and concurrent interview with the ADON on [DATE] at 9:12 a.m., in medication room A (Med Rm A), the medication refrigerator temperature was 29 degrees Fahrenheit (F, unit of temperature measurement). The ADON confirmed this observation and stated the medication refrigerator temperature should be between 36 and 46 degrees F. During an interview with the consultant pharmacist (CP) on [DATE] at 4:54 p.m., he stated the medication refrigerator temperature should be maintained between 36 and 46 degrees F. The CP explained that if the medication refrigerator temperature is too low, the medications could freeze or lose potency. Review of the facility's Medication Refrigerator Temperature Log, dated 4/2022, indicated the medication refrigerator temperature should be maintained between 36 and 46 degrees F. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when: 1. Several clear shallow pans and aluminum pans were stacked together and was not air dried; and 2. Dietary staff O (DS O) did not wear hairnet properly. These failures had the potential to cause foodborne illness (illness resulting from contaminated food ) for 93 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat three of 22 sampled residents (Residents 3, 48 and 57) with respect and dignity when staff were observed standing while feeding the residents. This failure resulted in not ensuring resident's rights to be treated with respect and dignity and could potentially affect the resident's self-worth.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for three of 22 sampled residents (Residents 60, 46 and 1). Failure to accurately assess the residents had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of ten residents observed for medication administration (Resident 39) and one of 22 sampled residents (Resident 30), when: 1. For Resident 39, the licensed nurse did not follow the physician's order for the administration of: a. pantoprazole (medication that decreases the amount of acid produced in the stomach); b. vitamin D3 (supplement for building and maintaining healthy bones); and 2. For Resident 30, the licensed nurse did not follow the proper timing of the administration of Amoxicillin (antibiotic used to treat bacterial infections). These failures had the potential to compromise the residents' health and well-being.

Inspectors wroteBased on observation, interview and record review, the following multi-resident rooms provided less than 80 square feet per resident: