Huntington Drive Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and privacy for one (1) of three (3) residents (Residents 2) based on the facility's policy and procedure (P&P) titled Dignity. On 7/24/2026, Certified Nurse Assistant 1 (CNA 1) was transferring Resident 2 along the hallway from the shower room going to the resident's room while sitting on the shower chair with the resident's back and buttocks exposed. This deficient practice had the potential to affect Resident 2's sense of self-worth and self-esteem which could result in problems with emotional and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to inform about one of three sampled residents (Resident 1) the resident's rights and responsibilities to participate in her care and treatment in accordance with the facility's policy This deficient practice has resulted in Resident 1 feeling disrespected and has a potential effect on Resident 1's sense of self-worth and self-esteem which could result in problems with emotional and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide Foley catheter (F/C- a hollow tube inserted into the bladder to drain or collect urine) care (includes daily cleaning of a F/C and the surrounding genital area to prevent infection, often using mild soap and water) for one of two sampled residents (Resident 3), in accordance with the care plan. This failure had the potential to result in preventable foley catheter complications including discomfort, urine leakage, infection, or decreased quality of life for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) care was provided for one of two sampled residents (Resident 1) as indicated on the physician's order and facility's colostomy policy. This failure had the potential to result in colostomy complications including discomfort, stool leakage or decreased quality of life for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure concerns were addressed for two (2) of 2 sampled residents (Resident 1 and 2) when the facility was informed of a resident (Resident 3) not allowing Certified Nursing Assistants (CNAs) to take water from the shared restroom in Room C to provide care for Resident 3's previous roommates and for the previous roommates to use the restroom. This deficient practice violates Resident 1 and 2's rights to be heard and for the resident's previous roommate to have the same access to services/ facility's amenities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accident hazards for one (1) of 2 sampled residents (Resident 3) when three (3) oxygen tanks (a metal canister storing compressed, 100 percent pure oxygen for people with breathing difficulties) was found inside the resident's restroom and two (2) oxygen tanks outside the resident's restroom located close to the wall by the left side of the resident's room were not removed when not in use as indicated in the facility's policy. This deficient practice had the potential to result in injuries and serious harm in the event of a resident fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support).

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to promote dignity and respect for five (5) of six (6) sampled residents (Residents 37, 51, 79, 24 and 47 ) reviewed for dignity by failing to:1. Close the curtain while providing care to Resident 37 on 2/23/2026 and 2/24/2026. Resident 37's body was visible to other residents and staff in the room during care.2. Address Resident 51 by the resident's preferred name rather than using the term Mama on 2/25/2026.3. Knock on the door before entering Resident 79's room on 2/26/2026.4. Ensure Resident 24's pants were not wet with urine while Resident 24 sat on his wheelchair in the hallway on 2/23/2026 and did not ensure Resident 24 did not smell like urine in the hallway on 2/24/2026.5. [...]

Inspectors wroteBased on observation interview and record review, the facility failed to provide reasonable accommodation of resident needs by ensuring 2 of four (4) sampled residents (Residents 29 and 43) call light device (one of the major communication technologies that links nursing home staff to the needs of residents) was within reach and answered timely. This failure had the potential to cause a delay in care for Resident 43 and 29 and prevent the residents from receiving the necessary care and services, which could lead to illness or serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of four (4) sampled residents (Residents 104 and 107) reviewed for activities of daily living (ADL) were provided care and services to maintain good grooming and personal hygiene by failing to:Provide toileting assistance to Resident 104 when residents asked to use the restroom and and was instructed by facility staff to urinate in the resident's diaper. 2.a. Provide toileting assistance to Resident 107 when resident needed to urinate and was instructed by facility staff to urinate in the resident's diaper.2b. Give Resident 107 a bath from 2/18/2026 to 2/23/2026. These deficient practices have the potential for Residents 104 and 107 to develop skin issues/complications and affect the residents' quality of life and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents bed were at the lowest position for two (2) of four (4) residents (Resident 81 and 86) reviewed for accidents, as indicated on the care plan. This deficient practice has the potential to cause injury and/or fall to Resident 81 and 86.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary proper care and services for two (2) of two sampled residents (Resident 24 and Resident 47) reviewed for indwelling catheter (a tube that allows urine to continuously drain from the bladder) as indicated in the facility's policy and procedure (P&P) by failing to ensure: Resident 47's indwelling catheter drainage bag (a bag used to collect urine from an indwelling catheter) was not touching the floor. This deficient practice resulted in contamination of Resident 47's care equipment and placed Resident 47 at risk for infection. 2a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) as indicated on the physician's order for two (2) of two sampled residents (Resident 71 and 15) reviewed for respiratory/oxygen. This deficient practice had the potential to place Resident 71 and 15 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which could lead to irreversible damages of health and/or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure competencies and skills sets to provide nursing and related services were completed for two (2) of four (4) nursing staff in accordance with the facility assessment and policy and procedures (P&P). This deficient practice had the potential to cause increased risk for improper resident assessments, and inadequate documentation which could negatively impact the quality of care provided to the residents.

Inspectors wroteBased on observation, staff interviews, and review of facility records, the facility failed to correctly measure the calorie and sugar content of breakfast meals for 14 of 14 residents who were ordered to receive a fortified diet (an enhanced meal meant to provide extra protein, calories, and nutrients). This deficient practice had the potential for residents on fortified diet to not receive the increased nutrients, protein and calories required which could result in malnutrition or weight loss.

Inspectors wroteBased on observation, interview, record review, facility failed to provide food that accommodated food preferences and offer meal substitutes of the same nutritive values for two (2) of two sampled residents (Resident 107 and Resident 75) reviewed for food. This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition (when the body does not get the right amount of nutrients, either too little or too much, causing health problems).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and store food in a sanitary manner in accordance with facility policy by failing to ensure:Soaps and cleaning solutions were not combined with food items. Kitchen equipment and surfaces were free from food debris and cleaned after use. Food items stored in the refrigerator were labeled and dated. Opened food item in the freezer was properly sealed. Multiple clear bags of brown bread in the dry storage room were labeled. Dietary [NAME] (DC) changed gloves and performed hand hygiene in between documentation, checking the food temperature during the tray line assembly, food preparation, and before serving the residents' meal trays. DC's apron did not come in contact with the residents' clean plates and DC did not touch the center of the clean plates during tray line assembly. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home-like environment for three (3) of four (4) sampled residents (Resident 15, 29 and 37) reviewed for environment by failing to ensure: 1.a. Resident 15's room was free of soiled diaper and a used cup containing chocolate on the floor.1.b. Resident 15's electric fan was free of sticky gunk (any thick, sticky, greasy, or slimy substance, often representing unwanted, dirty, or unidentifiable residue). 2. Resident 29's floor was free of used wet wipes. 3. Resident 37's curtain was free of brownish colored stains. These deficient practices caused an unsanitary environment for Resident 15, 29 and 37 and had the potential to result in the spread of diseases and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform one (1) of 22 sampled residents (Resident 86) the risks and benefits of the use of bilateral bedside rails (a metal or plastic bars attached to the sides of the bed) in accordance with the facility's policy. This deficient practice had the potential for Resident 86 not to be able to exercise their right to choose his treatment plan.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASRR, initial screening for all applicants to Medicaid-certified nursing facilities [meets federal and state standards for care and is approved to receive payment from Medicaid {a government health insurance program that provides free or low-cost coverage to eligible low-income individuals and families} for services provided to eligible residents] for possible serious mental disorder [MD, a health condition characterized by clinically significant alterations in thinking, mood, or behavior associated with distress and/or impaired functioning], intellectual disability [ID, a condition characterized by significantly subaverage intellectual functioning and substantial limitations in adaptive behavior] or a related condition, which is completed prior to admission to a [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to keep one (1) of six (6) sampled residents (Resident 37) reviewed for Activities of Daily Living (ADLs, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) face and blanket clean and free of food particles on 2/26/2026, as indicated on the facility's dignity policy. This deficient practice had the potential to result in a negative effect on Resident 37's quality of life and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit (E-Kit, an emergency supply kit used for residents who received hemodialysis) was readily accessible at the bedside for one (1) of two (2) sampled residents (Resident 29) reviewed for dialysis. This failure may result in the inability to manage Resident 29's bleeding from hemodialysis access site in the event of complications such as uncontrolled bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for two (2) of 22 sampled residents (Residents 89, and 2) in accordance with the facility's policy and procedure (P&P) by failing to ensure: 1. Resident 89's Bactrim double strength ([DS] type of antibiotic medication used to treat infection) tablet 800-160 milligrams (mg-unit of measurement) and Prevymis oral (medicine used to prevent viral infection) tablet 480 mg were not left at bedside. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the use of anticoagulant therapy ( a medical treatment using drugs, called blood thinners, to prevent or treat dangerous blood clots [thrombi] by slowing down the blood's clotting process, stopping existing clots from growing, and preventing new ones from forming) for one (1) of five (5) sampled residents (Residents71) reviewed for unnecessary medications, in accordance with the facility's policy and the resident's care plan by failing to monitor resident for side effects of anticoagulant medication, bruising, bleeding, and hematoma (localized collection of blood outside a blood vessel that has leaked into surrounding tissues and clotted). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of one trash can was covered with a lid while not in use in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to spread odors and bacteria (germ), cause contamination (presence of a germs, chemicals, or dirt in a place making it unsafe) and attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects) which may cause disease and other health issues to residents residing in the facility, staff, and the community.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two (2) of 22 sampled residents (Resident 37 and Resident 4) on Enhanced Barrier Precautions (EBP, refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) by failing to ensure:Certified Nursing Assistant 2 (CNA 2) was wearing a gown while providing bed bath and dressing to Resident 37. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of screening, education, offering and current Influenza (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) vaccination status for one (1) of four (4) sampled staff member (CNA 1) reviewed for infection prevention, control, and immunizations. This deficient practice had potential to miss potential gaps in identifying, tracking, implementing strategies to increase vaccination rates among staff, which helps to protect vulnerable residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of screening, education, offering and current Coronavirus disease (Covid-19, an infectious disease caused by the SARS-CoV-2 virus that causes respiratory illness primarily affecting lungs and breathing) vaccination status for one (1) of four (4) sampled staff member (CNA 1) reviewed for infection prevention, control, and immunizations. This deficient practice had potential to miss potential gaps in identifying, tracking, implementing strategies to increase vaccination rates among staff, which helps to protect vulnerable residents.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) bed rails (are adjustable metal or rigid plastic bars that attaches to the bed) are safe, functional and in good working condition in accordance with the facility's policy. This deficient practice has the potential for Resident 1 to be at risk of injury when getting in and out of bed.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat two (2) of 2 sampled residents (Resident 1 and 2) with respect and dignity when:1) Resident 1 was left sitting on the wheelchair for 2 and half hours while waiting for the resident's clothes and personal belongings left on the resident's bed to be put away on 12/11/2025 when resident was transferred to a new room. Resident 1 was also not provided with a functional television (TV) remote control since 12/11/2025.2) Resident 2 was provided with a TV without the channel of resident's choice since 12/15/2025. These deficient practices had the potential to negatively affect Residents 1 and 2's psychosocial well-being and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide Restorative Nursing Assistant (RNA- responsible for providing restorative and rehabilitation care for residents/patients to maintain or regain physical, mental, and emotional well-being) services on 12/22/2025, 12/26/2025, and 1/2/2026 for one (1) of 1 sampled resident (Resident 1) with limited range of motion (ROM - movement of the joints) in accordance with the physician's order. This deficient practice had the potential to cause complications such as pain, swelling, and contractures) to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care services for two (2) of two sampled residents (Resident 1 and 2) in accordance with the facility's policy and procedure by failing to ensure: 1. Resident 1 received oxygen on 11/18/2025 as ordered via nasal cannula (NC, device used to deliver supplemental oxygen placed directly on a resident's nostril). 2. Resident 2's oxygen saturation (level of oxygen found in a person's blood, normal reference= 95-100 %) which was below 92% on 10/4/2025, 10/11/2025 and 10/15/2025 was reported to the physician per physician's order. These deficient practices have the potential to place Resident 1 and 2 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which could lead to irreversible health damages and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the physical environment in a safe and sanitary condition by failing to ensure there was no water leak in the facility ceiling from 11/15/2025 to 11/18/2025 by failing to:Ensure there was no water leak in the ceiling at the hallway in front of the oxygen room from 11/15/2025 to 11/16/2025. Ensure there was no water leak in the ceiling of Resident 4's room. This deficient practice had the potential to cause harm by creating slip hazards, increase the risk for mold growth and compromise the safety and comfort of residents, staff and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff followed the facility's policy and procedures (P&P) titled Indwelling (Foley) Catheter Insertion, Female Resident for one (1) of three (3) sampled residents ( Resident 1) by not documenting the indication for Foley catheter (tube that drains urine from the bladder (organ that collects and stores urine ) into a drainage bag) use as required by the P&P. This failure had the potential to cause harm by increasing the risk of infection, improper catheter use, and inadequate monitoring of the resident condition.

Inspectors wroteBased on interviews and record review, the facility failed to document an episode of dizziness for one (1) of two (2) sampled residents (Residents 1) who experienced change with condition in the resident's nurses' progress notes (nurses detailed, day-to-day journal about patient care) in accordance with the facility's policy and procedure (P&P) titled, Charting and Documentation. This deficient practice resulted in the medical records inaccurate representation of care provided and placed Resident 1 at risk of complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for two (2) of 3 residents (Residents 2 and 3) based on the facility's policy by failing to: 1. Ensure Resident 2's privacy curtain was closed and the resident's (a movable fabric barrier designed to provide a private enclosure and block views, commonly used in healthcare settings like hospitals and nursing homes to create patient seclusion) inner thighs were covered and were not exposed while the resident was lying on his bed on 8/11/2025.2. Accommodate Resident 3's request to be gentle when providing perineal care (cleaning the private areas of a resident) from Certified Nursing Assistant 1 (CNA 1). This deficient practice had the potential to affect Resident 2 and 3's sense of self-worth and self-esteem which could result in problems with emotional and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe and sanitary environment for two (2) out of three (3) sampled residents (Residents 1 and 2) in accordance with the facility's Infection Control and Pet Programs policies. This deficient practice had the potential to put Resident 1 and 2 at risk of being exposed to potential health and safety risks which include infection. During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 Diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), and liver cancer. During a review of Resident 1's History and Physical (H&P) dated 7/21/2025, the H&P indicated that Resident 1 has the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) was free from unnecessary drugs (medications used in situations where they are not providing adequate benefit to the patient/ reisdent, or may even be causing harm) by failing to monitor Resident 1's hours of sleep for the use of Ambien (drug used to treat [insomnia-inability to sleep]) 5 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) the physician ordered for insomnia. This deficient practice had the potential to result in unnecessary use of the Ambien for Resident 1 and could cause delayed provision of necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to document assessment, notify attending physician (MD), do a Change of Condition (CoC) and monitor the CoC for one of two sampled residents (Resident 1) in accordance with the facility's Change in a Resident's Condition policy after Resident 1 reported that the resident hit her head while in the bathroom to the Director of Staff Development (DSD) on 6/30/2025. This deficient practice had the potential to cause Resident 1 to have delayed treatment, untreated injury and worsening injury.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-centered comprehensive care plan (a care plan developed and implemented to meet his or her preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs) to prevent falls (unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an external force) for one of three residents (Resident 1). [...]

Inspectors wroteBased on interview and record review, the facility failed ensure one of two sampled residents (Resident 1) was treated with respect and dignity in accordance with the facility policy by failing to allow the resident to voice grievances (statement of complaint over something believed to be wrong or unfair) without discrimination (to treat that person differently or less favorably) or reprisal (the act of retaliation). This deficient practice has the potential for Resident 1 to not voice future grievances and affect the resident's self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 10 of 43 resident rooms (Rooms: A, B, C, D, E, F, G, H, I, and J) were free of chipped/ peeling paint and unpainted patched areas in accordance with the facility policy. This deficient practice had the potential for unsafe and unclean resident's environment with the potential to place residents at risk for physical discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to ensure: 1. Opened food items were labeled with used by date. 2. To discard expired food in the kitchen. These deficient practices have 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 observation, interview, and record review, the facility failed to ensure staff followed the facility's enhanced barrier precautions (EBP- refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs-bacteria that have become resistant to certain antibiotics and these antibiotics can no longer be used to control or kill the bacteria] that employs targeted gown and glove use during high contact resident care activities) and standard precautions (a set of infection control practices used to prevent the spread of diseases), and perform handwashing/hand hygiene (cleansing your hands with soap and water or alcohol based hand sanitizers) in accordance with the facility's policy for four of 19 sampled residents (Residents 6, 18, 28 and 88) by failing to ensure: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 49) was treated with respect and dignity in accordance with the facility policy by failing to ensure by failing to keep the resident's clothes clean and free of food particles. This deficient practice has the potential to affect the resident's self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 88) was informed in advance, of the risks and benefits of proposed care by failing to obtain an informed consent prior to the use of psychoactive medication (a drug that changes brain function and results in altercations in perception, mood, consciousness, or behavior) in accordance with the facility policy. This deficient practice had the potential for Resident 88 not to be able to exercise the right to choose the resident's treatment plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 77) who were unable to carry out activities of daily living (ADL) received the necessary care and services to maintain good personal hygiene. This deficient practice had the potential for unmet resident's needs, which can result to a decline in physical and emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 88) was free of accident hazards by failing to provide a wheelchair with tires that were not torn. This deficient practice has the potential to cause injury and/or fall to Resident 88.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care services for one of one sampled resident (Resident 294) by failing to ensure oxygen (O2, a colorless, odorless gas necessary for most living organisms to breathe and function properly) was administered according to the physician's orders. This deficient practice placed Resident 294 at risk for experiencing complications such as respiratory distress (a condition that occurs when the body needs more oxygen, resulting in difficulty breathing, rapid breathing, and low blood oxygen level) that can lead to serious illness and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the physician's order for fluid restriction of 1200 cubic centimeters (cc - units of volume on liquids) a day by ensuring accurate monitoring of the resident's fluid intake for one of 2 sampled residents (Resident 38) with a diagnoses that included end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) with dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). This deficient practice had the potential to place the resident at risk for fluid overload (a condition where the body has too much fluid).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 19 sampled residents (Resident 15) was assessed for the use of bedside rails (adjustable metal or rigid plastic bars that attaches to the bed) in accordance with the facility's policy. This deficient practice placed the Resident 15 at risk for potential accident such as a body part being caught between the bedside rails, falls if a resident attempts to climb over, around, between, or through the bedside rails, which could result in injury, harm, and/or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure a coordination of care between facility and hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) staff for one of one sampled resident (Resident 76) in accordance with the facility's hospice program by failing to ensure: a. Certified Home Health Agency (CHHA) staff followed physician's order to visit and provide care to Resident 76 twice (2) per week. b. Hospice care plan was developed for Resident 76. These deficient practices have the potential for Resident 76 to not receive the required hospice care and services necessary to promote comfort and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within the resident's reach (arm's length) for one (1) of 19 sampled residents (Residents 15) as indicated on the facility's call light policy. This deficient practice had the potential for Residents 15 not being able to call the facility's staff for help or assistance especially during an emergency.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide pain management (the process of alleviating pain) for one of four sampled residents (Resident 1), after Resident 1 verbalized experiencing pain. This deficient practice resulted in a delay in pain relief for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a resident centered comprehensive care plan (a plan of care that summarizes a resident ' s health conditions, specific care needs, and current treatments) to address a resident ' s behavior of refusing care from certain Certified Nursing Assistants (CNA) for one out of two sampled residents (Resident 1). This deficient practice had the potential to deliver inappropriate care for Resident 1 due to miss communication of staff and may result in continuity of inappropriate care and interventions for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) for one (1) of three (3) sampled residents (Residents 1) who had a left hip hemiarthroplasty (a surgical procedure that replaces the femoral head of the hip with a prosthetic component) due to a left hip fracture (a partial or complete break in the upper part of the thigh bone [femur] where it meets the pelvic bone), as indicated on the facility policy. This deficient practice had the potential to not meet Resident 1's specific needs, which could result to harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and treatment for one (1) of three (3) sampled residents (Resident1) who had undergone a left hip hemiarthroplasty (a surgical procedure that replaces the femoral head of the hip with a prosthetic component) due to a left hip fracture (a partial or complete break in the upper part of the thigh bone [femur] where it meets the pelvic bone) when: 1. Licensed Nursing staff did not monitor the resident for signs of hip dislocation such as uneven leg/hip length. 2. There was no documented evidence that the Resident 1 ' s bilateral hips/ legs were assessed on 7/23/24 during the Nurse Practitioner ' s visit. 3. Failing to complete a Change of Condition on 7/21/24 when Resident 1 was assessed as having asymmetrical hips/legs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one (1) of three (3) sampled residents (Resident 1 from verbal abuse (a type of mental abuse [the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation] with (the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) based on the facility's policy and procedure. This deficient practice had resulted to Resident 1 experiencing verbal abuse from Resident 2 which could affect Resident 1's emotional and psychosocial wellbeing.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of verbal abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one (1) of three sampled residents (Residents 1) within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement. This deficient practice had the potential to compromise or impede the protection of Resident 1, which could affect the resident's emotional and mental wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (a device used by patients to call for assistance from hospital staff) was within reach (an arm's length) of one of 6 sampled residents (Resident 1). This deficient practice had the potential to result in delayed provision of services, delay in care and not receiving assistance with activities of daily living (ADLs).

Inspectors wroteBased on interview and record review the facility failed to implement their policy for abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish and includes verbal abuse [a range of words of behaviors used to manipulate, intimidate, and maintain power and control over someone]) for one (1) of four (4) sampled residents (Resident 1) by failure to report to the state agency (CDPH; California Department of Public Health), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement (Police Department) and failed to investigate an allegation of verbal abuse by two Certified Nursing Assistants (CNAs). [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the attending physician regarding the left sided chest pain for one (1) of four (4) sampled resident (Resident 1) in accordance with the facility's policy. This deficient practice had the potential to result in delayed provision of necessary care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the STAT (urgent) electrocardiogram (EKG, measures the hearts electrical activity) test was promptly acted on for one (1) of four (4) sampled resident (Resident 1) as indicated with the physician's order and EKG results was not relayed to the physician as soon as the result was available in accordance with the facility's policy. This deficient practice resulted in delay in conducting the EKG test which could potentially lead to a delay in diagnosis and treatment for Resident 1's abnormal EKG result of Sinus Rhythm with first degree atrioventricular block (a heart rhythm disorder that causes the heart to beat more slowly than it should).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse (intentionally inflicting bodily injury such as slapping, hitting, kicking, and punching). On 4/17/2024, Resident 2 hit Resident 1 on the right cheeks. This deficient practice has the potential for Resident 1 to have psychological distress. In addition, it placed Resident 1 and other residents in the facility for being abused.

Inspectors wroteBased on interview and record review, the facility failed to report immediately not later than two hours of the allegation of physical abuse (intentionally inflicting bodily injury such as slapping, hitting, kicking, and punching) to the State Survey Agency (SSA) for one of four sampled residents (Resident 1) in accordance with the facility's policy and procedure. This deficient practice had the potential to place the residents at risk for elder abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to monitor the progress of a skin rash for one of two sampled residents (Resident 1). 1. The facility did not obtain a physician ' s order for Resident 1 to see a dermatologist after continued complaints and non- healing rash since November 2023. 2. The facility did not obtain a skin scraping test to identify the cause of Resident 1 ' s skin rash. This deficient practice had the potential to negatively affect the resident ' s physical comfort and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from unnecessary medication. This deficient practice resulted in Resident 1 receiving medications that did not appropriately treat Resident 1 ' s skin rash.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Advanced Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them) Acknowledgement Form was clearly filled out & readily available in the residents' medical chart for three of four sampled residents (Residents 46, 65 and 14) for Advance Directives care area, in accordance with the facility's policy and procedure. This failure had the potential to result in nursing staff not knowing if Residents 46, 65 and 14 had specific resident wishes to follow in case of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 46 and Resident 82) for Activities of Daily Living (ADLs) care area was provided the following: 1. For Resident 46, the facility failed to ensure a communication board was provided with the language they are able to understand as indicated in the facility policy. This deficient practice had the potential to result in Resident 46 experiencing a delay in receiving appropriate care and treatment due to the staff not being able to properly communicate with the resident. 2. For Resident 82, the facility failed to ensure care and services was provided to maintain good grooming and personal hygiene when Resident 82's fingernails were left dirty and untrimmed. This deficient practice had the potential to result in injuries from scratching, and spread of germs when eating.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions by: 1. Facility failed to ensure that conventional oven temperature is accurate since conventional oven knob had no temperature settings. 2. Facility failed to ensure dirty utensils were not left on top of conventional oven and grease tub left inside sink was disposed of correctly. 3. Facility failed to ensure that vegetables and fruits were labeled with a received date and expiration date, and expired vegetables were discarded and not mixed with other foods. 4. Facility failed to ensure Sani Tech testing paper chlorine precision strips (to measure the concentration of free available chlorine in sanitizing solutions) are not expired to make sure the dishwasher was sanitized properly. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow transmission-based precautions (additional protection measures that are focused on the particular mode of infection transmission) to prevent spread of infection for three of five sampled residents (Residents 29, 47 and 86) for infection control care area, by not properly donning (to put on) or doffing (to take off) personal protective equipment (PPE, a barrier precaution which includes use of gloves, gown, mask, face shield, shoe covers, head covers, respirators, etc., when you anticipate contact with blood or body fluids or other communicable toxins or agents) prior to entering or exiting the resident's room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) for dignity care area, was treated with respect and dignity by failing to ensure resident's shirt was clean and free from stains. This deficient practice had the potential to affect Resident 1's self-worth, self-esteem, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) within 48 hours after resident admission for one (1) of 1 sampled resident (Resident 82) for care plan care area, in accordance with the facility's policy. This deficient practice had the potential for delayed provision of necessary care and services.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure resident specific care plans (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) were developed and implemented for two (2) of twenty (20) sampled residents (Resident 47 and 61) in accordance with the facility policy. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physicians order not to use straw with liquids for one (1) of 20 sampled residents (Resident 1). This deficient practice could potentially result to Resident 1's higher risk of choking incidents and aspiration (when foods or fluids gets into the airway which can lead to trouble breathing or lung infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accident hazards for one (1) of 1 sampled resident (Resident 53) for accident care area by failing to ensure the residents bed was placed on the lowest position while the resident was on bed as indicated on the care plan. This deficient practice had the potential to result in injuries in an event of a resident fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one out of three sampled residents (Resident 51) for food care area, with meals that accommodated the resident's food preferences. This deficient practice had the potential to alter Resident 51's nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a functioning heating, ventilation (movement of fresh air around a closed space), and air conditioning (HVAC) system (use of various technologies to control the temperature, humidity, and purity of the air in an enclosed space. It's goal is to provide thermal comfort and acceptable indoor air quality) for three (3) out of 20 sampled residents (Residents 12, 26, and 67) as indicated on the facility policy. This deficient practice had the potential to result to inadequate indoor air quality through adequate ventilation with filtration, which could affect the residents' well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an effective pest control program for gnats' (small, winged insect) infestation, which affected two (2) of 94 residents residing in the facility (Resident 2 and 12). This deficient practice had the potential to cause itchy, painful bites to Residents 2 and 12, which could result to open sores (an ulcer) that are susceptible to bacterial infection. This also had the potential for transmission of infectious diseases to other residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy and procedures for safe medication storage and handling by failing to ensure: 1. Medications including opened and unopened insulin pens (a device used to give an insulin [a hormone that lowers the level of glucose {a type of sugar} in the blood] injection) were labeled with the resident's name, an opened date, and a prescription label (contains information on how much, how often, and how to take a medication) for three out of five residents (Resident 1, 2 and 6). 2. Expired Afluria Quadrivalent Influenzae Vaccine 2023-2024 Formula (Flu Vaccine, helps the body defend against the flu virus [small particles, germs, that can cause illness]) was discarded and not stored in the facility's refrigerator and available for resident use. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to permit one of two sampled residents (Resident 1) back to the facility after the patient was hospitalized at the General Acute Care Hospital (GACH), in accordance with the facility policy. This deficient practice resulted in a violation of Resident 1's rights to resume residency at the facility which could also cause psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to one of four sampled residents (Resident 4) by: 1. Facility failed to ensure refills of Hydrocodone - Acetaminophen (Norco, controlled substances [medications with a high potential for abuse] medication to treat pain) 5-325 milligrams (mg - a unit of measure for mass) were ordered in advanced to ensure sufficient supply was available between 12/12/2023 - 12/21/2023 for Resident 4. 2. Facility failed to maintain accountability on twelve (12) tablet of Norco 5- 325 mg for Resident 4. These deficient practices increase the risk of diversion (when medications are obtained or used illegally) and possibly caused Resident 4 to missed dose of Norco 5-325 mg (pain medication).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper care and treatment for gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) was provided for one of five sampled residents (Resident 3). Resident 3's head of bed (HOB) was not elevated to an angle of 30 to 45 degrees while the resident was receiving G-tube feeding (a liquid food mixture provided through the G-tube). This deficient practice had the potential for the resident to acquire aspiration (when something you swallow enters your lungs) pneumonia (infection that inflames air sacs in one or both lungs) and/or choke.