Huntington Valley Healthcare Center

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate an allegation of staff-to-resident abuse for one of four sampled residents (Resident 1). * The facility did not attempt to interview other residents under the care of the alleged CNA and/or other staff members who had contact with Resident 1 during time of the alleged incident. This failure had the potential to place the resident at risk for abuse and jeopardize their safety.

Inspectors wroteBased on interview, medical record review, document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of three sampled residents (Resident 1). * Resident 1 was assessed as a high fall risk, exhibited ongoing confusion and had multiple unwitnessed falls in the facility. There was no enhanced supervision such as 1:1 (one resident: one staff) monitoring implemented, despite the resident sustaining repeated unwitnessed falls and staff recognition regarding the resident not being able to follow instructions. This failure resulted in Resident 1 experiencing multiple unwitnessed falls, sustaining injuries including skin tears, and ultimately requiring a transfer to the acute care hospital. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) was readmitted back to the facility. * The facility failed to readmit Resident 1 back to the facility when the resident was transferred to an acute care facility. This failure had the potential for Resident 1 to have an inappropriate discharge.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for six of 27 final sampled residents (Residents 2, 5, 29, 74, 92, and 137) reviewed for oxygen therapy. * The facility failed to ensure Resident 2's oxygen tubing was labeled and dated. * The facility failed to ensure Resident 5's oxygen tubing was labeled and dated and inside a bag when not in use. * The facility failed to ensure a physician's order was obtained for Resident 29's use of the continuous oxygen therapy via the nasal cannula. * The facility failed to follow the physician's order for the administration of continuous oxygen for Resident 74. Resident 74 had a physician's order to receive continuous oxygen at a rate of two LPM; however, Resident 74 received continuous oxygen at a rate of three LPM. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate hemodialysis care was provided for two of four final sampled residents (Residents 29 and 60) reviewed for dialysis services. * The facility failed to ensure Resident 29's hemodialysis communication records were complete and accurate; and failed to ensure the accurate documentation of bruit (a turbulent whooshing sound heard with a stethoscope over a blood vessel) and thrill (the palpable vibration felt with your fingers in the same location). * The facility failed to ensure Resident 60's fluid intake was monitored per physician's order, and the dialysis access site was consistently and accurately assessed as ordered by the physician. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility's P&P review, the facility failed to ensure the Consultant Pharmacist's recommendation were acted upon for four of five residents (Residents 3, 4, 7, and 60) reviewed for unnecessary medications. * The facility failed to ensure the Consultant Pharmacist's recommendations for March 2026 were followed up for Resident 3's use of the metoclopramide (anti-nausea), pantoprazole, and sucralfate (medication to treat and prevent gastrointestinal ulcers) medications. * The facility failed to ensure the Consultant Pharmacist's recommendations for March 2026 were followed up for Resident 4's use of Lovenox (anticoagulant) and Prednisone (medication used to rapidly reduce inflammation and suppress an overactive immune system) medications. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to maintain the hood over the stove in a clean and sanitary condition. * The facility failed to ensure the kitchen utensils had smooth, cleanable surfaces and were maintained in good repair. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were maintained in sanitary condition and had smooth, cleanable surfaces. * The facility failed to ensure the heavy-duty blender, and the clear plastic rectangular food-storage containers were air dried prior to storage. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for five of 27 final sampled residents (Resident 4, 7, 29, 60, and 73) were complete and accurately documented. * Resident 4's POLST showed she had no advance directive; however, Resident 4's medical record showed she had an advance directive and a copy of the advance directive was in her medical record. * The facility failed to ensure Resident 7's blood pressure access site was accurately documented in the resident's medical record with right upper arm AV site. * The facility failed to ensure accurate documentation in the medical record for Resident 29. Resident 29 had the hemodialysis access on the left arm; however the documentation showed Resident 29's blood pressures were obtained in the left arm. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for May 2025 through March 2026. The facility conducted surveillance of resident infections based on whether residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and/or symptoms of infections, and were not prescribed antimicrobial medications, met the facility's criteria for infection (McGeer's Criteria) and thus, failed to include these residents in the facility's infection control surveillance program. [...]

Inspectors wroteBased on interview, document review, and medical record review, the facility failed to ensure the residents or their representatives were informed in advance of the proposed treatment regarding the use of psychotropic medications (medications affecting brain activity) for one of five residents reviewed for unnecessary medications (Resident 3). * The facility failed to ensure the informed consent for the valproic acid (anticonvulsant) medication included the manifested behaviors for Resident 3. This failure had the potential to compromise the resident's right, or the right of the designated representative, to be fully informed regarding the psychotropic medication in order to make an informed decision.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one nonsampled resident (Resident 54) was assessed for safe self-administration of medications. * Resident 54 was observed with an Equate nasal spray (medication to relieve allergies) medication at the bedside. This failure had the potential for Resident 54 to administer the medication inaccurately and may negatively impact the health and safety of the resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to inquire about the existence of an advance directives and failed to inform, provide, and document the written information regarding the rights to formulate the advance directives to one of three final sampled residents (Resident 23) reviewed for Advance Directives. * The facility failed to show evidence that an Advance Directive Acknowledgement was available in Resident 23's medical record. This failure had the potential for the facility to provide treatment and services against the resident's wishes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 3) reviewed for unnecessary medications was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 3's orthostatic blood pressure was accurately monitored, as ordered by the physician, for the use of the quetiapine (antipsychotic) medication. This failure had the potential for adverse effects from the psychotropic medication for Resident 3.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to follow their protocol for written notification of transfer or discharge for two of three residents (Residents 29 and 138) reviewed for hospitalizations. * The facility failed to provide written information to Resident 29 about the facility's bed-hold information and failed to ensure a copy of the transfer discharge notification was sent to the Ombudsman when Resident 29 was transferred to the acute care hospital on 4/19/26. * The facility failed to ensure a copy of the transfer discharge notification was sent to the Ombudsman when Resident 138 was transferred to the acute care hospital. These failures had the potential for Residents 29 and 138 to not receive additional protection when the residents were being inappropriately transferred or discharged from the facility.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS assessment was accurate for two of 27 final sampled residents (Residents 15 and 50) reviewed for MDS. * Resident 15's MDS assessment dated [DATE], showed Resident 15 had a diagnosis of schizophrenia (a chronic and severe brain disorder that affects how a person interprets reality); however, Resident 15 did not have schizophrenia. * Resident 50 was administered lamotrigine (anticonvulsant/mood stabilizer) medication for bipolar (a mental health condition that causes extreme mood swings) disorder. The facility failed to code the diagnosis of bipolar disorder in Resident 50's quarterly MDS assessment dated [DATE]. These failures posed the residents at risk of not receiving an individualized plan of care based on their specific needs.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the PASRR (Preadmission Screening and Resident Review) Level 1 screening (identifies if a resident has a suspected mental illness or intellectual/developmental disability or related condition) contained accurate information specific to mental illness, for one of one resident (Resident 11) reviewed for PASRR. * Resident 11 had a diagnosis of Bipolar (a mental health condition that causes extreme mood swings) disorder and was prescribed divalproex sodium (mood stabilizing medication); however, the level 1 PASRR showed Resident 11 had no diagnosed mental illness and was not prescribed a psychotropic medication. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was implemented for one of 27 final sampled residents (Resident 74). * The facility failed to implement Resident 74's care plan specific to oxygen administration. This failure placed the resident at risk for not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care were revised to reflect the residents' current care needs and interventions for four of 27 final sampled residents (Residents 31, 50, 63, and 84) reviewed for care plans. * The facility failed to revise Resident 31's care plan for impaired skin integrity and coccyx (tailbone) pressure injury (localized areas of skin and tissue damage from prolonged pressure) to include the Wound Consultant's recommendations to avoid sitting for longer than two-hour periods at a time. * The facility failed to revise Resident 50's care plan for anticoagulant (blood thinners) therapy to reflect the resident's current Eliquis (anticoagulant) medication use. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the quality of care and services were provided for one of 27 final sampled residents (Resident 3) reviewed for quality of care. * The facility failed to ensure the injection sites for the insulin (medication to control blood glucose levels) administration were rotated for Resident 3. This failure had the risk for lipodystrophy (buildup of fatty lumps) and decreased with insulin absorption.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure to provide the necessary care and services to maintain skin integrity for one of three sampled residents (Resident 17) reviewed for pressure injuries. * The facility failed to ensure Resident 17's LAL (low air loss mattress) setting was consistent with the resident's weight. This failure had the potential for the resident not to benefit from the therapy provided by the LAL mattress.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the nutritional recommendations from the RD were followed for one of three final sampled residents (Resident 29) reviewed for nutrition. * The facility failed to ensure the physician was notified of the RD/IDT team's recommendations for the liquid protein supplement and therapeutic diet change to address Resident 29's weight loss. Resident 29 did not receive the supplement as recommended by the RD. This failure had the risk of not providing the nutritional needs and poor health outcome for Resident 29.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous access for one sampled resident (Resident 23) and two nonsampled residents (Residents 9 and 123) reviewed for intravenous fluids. * The facility failed to ensure Resident 9's IV medication was correctly labeled. * The facility failed to ensure Resident 23's PICC line external catheter and arm circumference measurements were completed and documented upon admission in the resident's medical record. * The facility failed to ensure Resident 123's IV tubing was labeled. These failures had the potential to delay the identification of catheter related complications for the residents.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8%. Two of five licensed nurses (LVNs 2 and 4) who were observed during medication administration were found to have errors. * LVN 2 failed to administer Resident 85's metformin (medication to lower the blood sugar) as ordered by the physician. * LVN 4 failed to administer Resident 92's diltiazem (medication used to treat high blood pressure) as ordered by the physician. These failures created the risk for the residents to have potential side effects or complications related to the medications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the drugs and biologicals were stored, labeled, and/or disposed properly. * The facility failed to ensure discontinued or expired medications and supplies were removed from Medication room [ROOM NUMBER] and Medication Cart A. * The facility failed to ensure the orally administered medications were stored separately from the externally used medications in Medication Cart A. These failures posed the risk for the administration of potentially contaminated or deteriorated medications, and posed the risk for the medications to be used or improperly administered to the residents.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed for one of one nonsampled resident (Resident 120) reviewed for therapeutic diet. * The facility failed to ensure Resident 120 was served with the boiled potatoes as per the therapeutic spreadsheet for the lunch meal on 5/18/26. This failure had the potential to not meet Resident 120's nutritional needs and negatively impact the resident's nutritional health.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure one of 27 final sampled residents (Resident 31) received food that accommodated the resident's preferences. * Resident 31 was not served with the fresh fruit cup as per the lunch meal ticket on 5/18/26. This failure posed the risk of Resident 31 not enjoying her meal and for her food preferences not being honored.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in two of four garbage dumpsters. * Two garbage dumpsters were observed with the lids partially propped open by the garbage bags, preventing the lids from fully closing. This failure had the potential to attract pest/rodents that carried diseases.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of two final sampled residents (Resident 63) reviewed for hospice services. * The facility failed to ensure the hospice staff were included in Resident 63's interdisciplinary team meetings to discuss Resident 63's plan of care; and failed to ensure the hospice plan of care was integrated into the facility's care plan to include the frequency of visits of each hospice staff and the provisions of care. These failures posed the risk for delay in communication and/or uncoordinated medical care between the facility and hospice provider which may affect Resident 63's care.

Inspectors wroteBased on observation, interview, facility document review, and manufacturer's guidelines review, the facility failed to ensure the facility equipment was maintained in a safe operating condition for one of two medication carts (Medication Cart A) inspected. * The facility failed to ensure Medication Cart A's glucometer's (a device that measures the amount of sugar in the blood) serial number was documented on the quality control record and failed to ensure the lot number for the glucometer test strips in Medication Cart A matched the lot number on the quality control record for the cart. Additionally, the documented control test results were not observed on the glucometer result history. These failures had the potential risk of inaccuracy for the blood glucose test resultsFindings: [...]

Inspectors wroteBased on interview, medical record review and facility P&P review, the facility failed to provide the necessary skilled nursing care and services for four of eight sampled residents (Residents 1, 3, 4, and 7). * The facility failed to provide continued life-saving measures to Resident 7 when the resident remained unconscious, barely breathing and did not have any blood pressure reading and until the paramedics arrived. This failure resulted to interrupted chest compressions and rescue breathing in an arrest resuscitation and potentially contributed to the resident's death in the acute hospital. * The facility failed to timely and accurately complete a hip/femur x-ray as recommended by the physical therapist due to Resident 1's consistent right hip pain. [...]

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the facility staff provided the necessary emergency care and services to Resident 7. * LVNs 4 and 5 and RN 3 failed to provide continued CPR to Resident 7 when the resident remained unconscious, barely breathing and did not have any blood pressure reading. These failures had the potential to put the resident at risk for care not provided in a safe and competent manner.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the Office of the State LTC Ombudsman was provided with a copy of the notice of transfer/discharge for one of 11 sampled residents (Resident 1). * The facility failed to send a copy of the notice of transfer/discharge to the representative of the Office of the State LTC Ombudsman when Resident 1 was discharged from the facility. This failure posed the risk of the LTC Ombudsman not being aware of the circumstances of the resident's transfer/discharge should an appeal be filed or requested by the resident or their representatives regarding the transfer.

Inspectors wroteBased on interview and medical record review, the facility failed to implement the plan of care to reflect the individual care needs for one of five sampled residents (Resident 2). * The facility failed to ensure Resident 2's care plan was followed when the resident went out to an outpatient medical appointment without someone or was not accompanied by the resident's responsible party. This failure had the potential to negatively affect the resident's well-being and safety.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary treatment and services for the provision of parenteral fluids (liquids administered to the body, most commonly via a vein (intravenous, to provide hydration, correct the electrolyte imbalances, deliver nutrients, or administer the medications when normal oral intake is not possible) for one of six sampled residents (Resident 1). * The facility failed to ensure Resident 1's intravenous fluids (IVF) was administered and documented as per the facility's P&P. This failure had the potential to negatively affect Resident 1's health and well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage of the medications for one of six sampled residents (Resident 2). * The facility failed to ensure Resident 2 had no medication stored at the bedside. This failure had the potential for Resident 2 to administer the medication inaccurately.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the laboratory tests for one of six sampled residents (Resident 1) was performed as ordered. * The facility failed to ensure Resident 1's physician's order for stat CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) were completed as ordered. This failure posed the risk for Resident 1 not receiving the appropriate treatment, which could significantly impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of six sampled residents (Resident 1) was complete. * The facility failed to ensure Resident 1's TAR for August 2025 was complete regarding the monitoring of the resident's urine characteristics. This failure had the potential to result in inadequate care due to an incomplete medical record for Resident 1.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical records for three of eight sampled residents (Residents 1, 2, and 3) were accurate and complete. * Resident 1's POLST did not show the physician's phone number, license number, signature, or the resident's responsible party's signature, address, and telephone number. In addition, the responsible party's signature was written in by the nurse filling out the form and did not indicate it was a verbal consent. Additionally, the NP's name was written in the section where the NP's supervising physician's name should have been. * Resident 2's POLST did not show the NP's phone number, license number, date signed, or the name of the NP's supervising physician. In addition, the POLST did not indicate if the NP had discussed the information with Resident 2. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the heavy-duty blender used for puree preparation, scoops used for food portioning, and clear plastic bins were air dried and clean prior to storing and stacking. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the facility's monthly Infection Prevention and Control Surveillance Log was accurate. * The facility failed to implement the EBP as per the facility's P&P for Residents 916 with a central line (thin, flexible tube inserted into a large vein near the heart). * OT 1 failed to perform hand hygiene in between resident care for Residents 33 and 52 during the dining observation. * LVN 6 failed to don the gown before entering Resident 3's EBP room to change and administer the resident's enteral feeding. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the safe self-administration of medication for one nonsampled resident (Resident 41). * Two bottles of Systane eye drops (medication to temporarily relieve dry, irritated eyes) were kept at Resident 41's bedside table. Resident 41 had self-administered the Systane eye drop medication after being assessed to not self-administer her medications. This failure had the potential for the resident to administer the medications inaccurately and negatively affect the resident's physiological well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain and/or maintain the copies of the advanced directives (written statement of a person's wishes regarding medical treatment) and provide the written information regarding how to formulate the advanced directives for four of 28 final sampled residents (Residents 44, 88, 97, and 106). * The facility failed to ensure a copy of the advance directive was available in Residents 44 and 106's medical record. * The facility failed to provide the written information and assistance regarding how to formulate an advance directive for Resident 88. * The facility failed to provide the written information regarding how to formulate the advance directive for Resident 97 was provided to the resident or responsible party. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to meet the professional standards of care for one nonsampled resident (Resident 370) observed for medication administration. * LVN 1 failed to follow the proper procedure for the administration of insulin. This failure posed the risk for the resident to develop complications related to the inappropriate technique with the administration of insulin (used to treat high blood sugar).

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of 28 final sampled residents (Resident 21) and two nonsampled residents (Residents 57 and 101) as evidenced by: * The facility failed to ensure the follow-up assessment and documentation were completed for Resident 21's foot scab and bilateral feet dryness. * The facility failed to ensure Resident 57's post fall neurological assessment and monitoring were accurately completed after the resident had a fall on 3/16/25. * The facility failed to ensure the attending physician was made aware regarding the recommendations from the acute care hospital for Resident 101 to be assisted in drinking the thickened liquid with a spoon. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided to prevent the decline in the ROM functions for one of three final sampled residents (Resident 63) reviewed for prevention of ROM functions. * The physician's order to apply an extension splint to Resident 63's left knee was not followed. In addition, Resident 63's skin was not assessed when the splint was applied. This failure had the potential for Resident 63 to sustain a decline in ROM functions, leading to muscle atrophy (loss of muscle mass and strength) and decrease in functioning.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 28 final sampled residents (Resident 73) received the appropriate care and services for an indwelling urinary catheter. This failure had the potential for the resident to develop complications associated with the use of indwelling urinary catheter.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for two of two final sampled residents (Residents 3 and 30) reviewed for enteral feeding. * The facility failed to ensure the intake and output were monitored for Resident 30 who was receiving an enteral feeding. * The facility failed to ensure Resident 3's enteral feeding formula was changed within 24 hours and label the resident's enteral feeding water bag with the date and time the bag was prepared. These failures posed the risk for developing complications related to enteral feeding and GT.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to to provide the necessary care and services to maintain the IV site accesses for two of 28 final sampled residents (Residents 67 and 667) and two nonsampled residents (Residents 366 and 916) as evidenced by: * The facility failed to ensure the PICC line baseline external catheter length and arm circumference measurements were obtained and documented for Residents 667 and 916. * The facility failed to ensure the arm circumference and external catheter length were measured on admission and during the midline dressing change for Resident 366's midline line use. * Residents 67's PIV site was not labeled with the date, time, and licensed nurse's initials. In addition, the facility failed to ensure a physician's order was obtained for the use of the PIV. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of two final sampled residents (Residents 21 and 30) and two nonsampled residents (Residents 7 and 101) reviewed for respiratory care were provided with the appropriate respiratory care and services when: * The facility failed to ensure Residents 7 and 30 were receiving the oxygen as per the physician's order and the nasal cannula tubing was stored in a sanitary manner. * The facility failed to ensure Resident 101's CPAP machine was cleaned as per the manufacturer's user guidelines. * The facility failed to ensure Resident 21's oxygen tubing was not on the floor. These failures had the potential to affect the respiratory health and well-being of these residents in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for one of two final sampled residents (Resident 111) reviewed for pain management. * The facility failed to accurately document the monitoring of pain for Resident 111 and administer the pain medication according to the physician's order. In addition, the facility failed to ensure the non-pharmacological interventions were provided to Resident 111 prior to the administration of the pain medication. These failures had the potential to put Resident 111 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate dialysis care was provided for two of 28 final sampled residents (Residents 70 and 88) reviewed for dialysis services. * The facility failed to ensure the dialysis communication records were accurately completed for Resident 70. * The facility failed to ensure the emergency dialysis kit was kept at Resident 88's bedside. In addition, the facility failed to ensure the licensed nurses assessed and documented Resident 88's dialysis access, and covered Resident 88's dialysis access site with a transparent dressing. These failures had the potential for the residents to experience medical complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure dementia care interventions were being implemented for one of five sampled residents (Resident 105) reviewed for dementia care. This failure had the potential for Resident 105 to not receive the appropriate treatment and services needed for her dementia.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services as per the facility's P&P for one of 28 final sampled Resident (Resident 65) and one nonsampled resident (Resident 55). * The facility failed to ensure the administration of the controlled medication for Residents 55 and 65 was documented on the EMAR. This failure had the potential for the medications to be administered in error and opportunities for drug diversion or drug misuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 42) reviewed for unnecessary medication was free from unnecessary medications. The facility failed to adhere to Resident 42's blood pressure parameters prescribed by the physician for three medications: amlodipine (blood pressure medication), spironolactone (diuretic medication), and ethacrynic acid (diuretic medication). This failure had the potential for Resident 42 to receive unnecessary medications and to experience adverse effects.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents (two final sampled residents, Residents 95 and 105) reviewed for unnecessary medication were free from the unnecessary psychotropic medication. * The facility failed to obtain Resident 95's informed consent prior to administering the Depakote (mood stabilizer) medication. * The facility failed to evaluate the behavioral symptoms for the use of psychotropic medication for Resident 105. These failures had the potential for the residents to experience adverse effects from the psychotropic medication.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and labeling of the medications. * The facility failed to ensure the orally administered medications were stored separate from the externally used medications in Medication Carts D and E. * The facility failed to ensure Resident 111's gentamicin (used to treat skin infections) medication was labeled with the opened date. * The facility failed to ensure Resident 44's Preparation H (medication is used to temporarily relieve swelling, burning, pain, and itching caused by hemorrhoids) external cream and Lidocaine (pain reliever) cream were not stored at the bedside. These failures had the potential to negatively impact the residents' well-being, and the potential for the medications to lose the stability and effectiveness.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food items were served in the appetizing temperatures as evidenced by: * The food temperatures were below the recommended temperature for hot meats, vegetables, and potatoes. This failure posed the risk for not providing palatable and appetizing food for the residents receiving a meal tray from the kitchen.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. Resources necessary to care for residents including weekends; 3. A plan to maximize recruitment and retention of direct care staff; and 4. A contingency plan for staffing needs. This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled residents (Resident 100) reviewed for hospice services. * The facility failed to ensure Resident 100's HA visits schedule for two times a week was followed per the hospice provider's calendar. This failure posed the risk for delays in the communication between the hospice provider and facility, which may affect the resident care.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean homelike environment in three of 50 resident rooms (Rooms A, B, and C). This failure posed the risk of the residents not having a sanitary, comfortable living space and potential to negatively impact the residents' quality of life.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident and/or their representative were provided with the written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital for one of two final sampled residents (Resident 3) reviewed for hospitalization. This failure had the potential for Resident 3 and/or their representative to be unaware of their rights to request a bed hold and return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for four of 28 final sampled residents (Residents 20, 29, 65, and 70) were accurate and complete. * The facility failed to ensure the Inventory of Personal Effects for Resident 20 was reviewed with and signed by the resident's representative upon the resident's admission to the facility. * The facility failed to ensure the Inventory of Personal Effects for Resident 29 was reviewed with and signed by the resident's representative upon the resident's admission to the facility. * Resident 65's POLST was incomplete and did not show the physician's phone number, the resident's signature, address and phone number, and the date when the POLST was completed by the resident. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B when the facility failed to report an allegation of resident-to-resident abuse to the CDPH, L&C Program and to the local ombudsman for one of the nine sampled residents (Resident 5). This failure had the abuse allegation going unreported and uninvestigated.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement their abuse P&P related to investigation of the resident-to-resident abuse for one of nine sampled residents (Resident 5). * The facility failed to conduct a thorough investigation when Resident 5 was reported to be verbally abusive to the roommate. This failure posed a risk for the resident to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of nine sampled residents (Resident 1) was free from the unnecessary psychotropic medications. * The facility failed to obtain the informed consent from Resident 1 or surrogate decision maker for the use of lorazepam (a drug used to relieve anxiety) and when there was an increase in the dosage of the citalopram (a drug used to treat depression) medication. * The facility failed to ensure Resident 1 was provided with the non-pharmacologic interventions for the use of the citalopram, quetiapine fumarate (a drug that can treat schizophrenia, bipolar disorder and depression), and buspirone (a drug used to treat anxiety) medications. These failures have the potential to negatively affect Resident 1's well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the resident's food preferences and allergies were considered and adhered to for one of nine sampled residents (Resident 4). * The facility failed to ensure Resident 4 was not served food containing fish as Resident 4 was allergic to fish. This failure caused an adverse reaction on Resident 4's well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the facility's environmental conditions were kept sanitary as evidenced by: * The toilet/bathroom shared by Rooms A and B was observed with several used washcloths and a yellow and pink pitcher by the sink with no label. * The Dirty laundry collection rolling bin was observed to be with brown colored residue located on the top corner of the bin and was observed to be touched with bare hands several times by the facility staff member while pushing the bin. These failures posed the risk of unsanitary and unsafe conditions for the residents, staff, and visitors.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for two of eight sampled residents (Residents 1 and 2). * The facility failed to ensure the necessary care and services were provided timely for Resident 2 who had a fall. Additionally, Resident 1's physician ordered the CBC, CMP, and UA with culture laboratory tests; however, the facility failed to perform these laboratory tests. * The facility failed to complete the neurological assessments following Resident 1's unwitnessed fall on 11/23/24. These failures had the potential for the delay of care provided and poor health outcomes for the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of eight sampled residents (Residents 1 and 8) were free from unnecessary psychotropic drugs. * Resident 1, who had diagnoses including dementia, was prescribed lorazepam (antianxiety medication) PRN for anxiety manifested by restlessness. There was no documented diagnosis, or diagnosis of anxiety prior to starting the PRN lorazepam medication. Additionally, Resident 1's physician's orders for the lorazepam medication were continuously renewed PRN for 14 days and eventually extended to be given PRN for 30 days. There was no documented evidence of the evaluation for the renewal of the PRN lorazepam medication order nor rationale from the prescribing practitioner to indicate why it was appropriate for the PRN lorazepam medication order to be extended beyond 14 days. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 2) to help attain and maintain their highest practicable physical well-being. * The facility failed to ensure Resident 2's Senna (stool softener), enoxaparin (anticoagulant medication), acetaminophen (analgesic), gabapentin (anticonvulsant and nerve pain medication) and nystatin suspension (antifungal medication) were administered as per the physician's order. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of 12 sampled residents (Resident 8) attained and maintained the highest practicable physical well-being. This failure posed the risk for delayed care and intervention to Resident 8.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure injury (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure ulcer for two of three sampled residents (Residents 8 and 11) reviewed for pressure injury. * The facility failed to ensure Resident 8 was turned and repositioned at least every two hours as per the plan of care. * The facility failed to ensure Resident 11's pressure ulcer was assessed weekly. These failures posed Residents 8 and 11 at risk for developing new pressure ulcers and worsening of the existing pressure ulcer.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to ensure the EBPs (Enhanced Barrier Precautions) were followed for Resident 9 when the staff did not wear a disposable gown before providing care to the resident. * The facility failed to ensure the hand hygiene was performed after using the gloves in between the dressing change. These failures had the potential for spread of infections in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure the accommodation of needs was met for one of 12 sampled resident (Resident 12). * The call light was not answered promptly for Residents 12. This failure had the potential for the resident not getting the needs met timely.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record was complete and accurate related to oxygen saturation level, oxygen administration, and POLST for one of 12 sampled residents (Resident 8). This failure had the potential to negatively impact the delivery of services as the medical information was inaccurate.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report an allegation of staff-to-resident abuse to the law enforcement agency, CDPH L&C Program, and Ombudsman office (an advocate for long term residents) for one of three sampled residents (Resident 1). This failure had the potential to put residents at risk for further abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement their abuse P&P related to investigation of the physical abuse for one of three sampled residents (Resident 1). * The facility failed to complete a thorough investigation including to conduct the interview of the person(s) reporting the incident, any witnesses to the incident, the resident, the staff members from different shifts and disciplines, resident's roommate if appropriate, family members, other residents to whom the accused employee provides care or services and report the result of the investigation to the CDPH L&C Program, Orange District Office within five working days. This failure posed the risk for the potential abuse to remain unidentified and for the residents to go unprotected.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services related to foot care for one of three sampled residents (Resident 2). * The facility failed to ensure the skin check, accurate assessment, and monitoring of Resident 2's bilateral feet after the podiatry care for fungal infection, including debridement and nail trimming. This failure had the potential to negatively impact the resident's health and well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was provided non-pharmacologic intervention for the use of psychotropic medication (medication that affects the mind, emotions, and behavior). This failure had the potential for Resident 1 to have adverse complications from the medication.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure injuries for three of six sampled residents (Residents 2, 4, and 5).

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement and maintain their infection control program for two of six sampled residents (Residents 2 and 6) as evidenced by: * LVN 1 failed to wear a disposable gown as required for EBP prior to performing the wound care to Resident 2. * LVN 1 failed to establish a clean field to place the clean and sterile wound supplies for Resident 2. * LVN 3 failed to wear a disposable gown as indicated for EBP while performing wound care and to establish a clean field to place the wound supplies while performing wound care for Resident 2. * CNA 1 failed to wear a disposable gown as indicated for EBP during transfer and repositioning of a resident. These failures have the potential risk of transmission of disease-causing microorganisms and infections to the residents.

Inspectors wroteBased on observation, interview and facility P&P review, the facility failed to ensure the infection control practices were maintained. * LVN 1 failed to perform hand hygiene after administering an eyedrop medication to Resident 2. This failure had the potential to result in the spread of infection to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the adequate supervision and necessary services for one of two sampled residents (Resident 1) to prevent the elopement. * The facility failed to monitor Resident 1's whereabouts, resulting in Resident 1 leaving the facility undetected and sustaining a fall. * The facility failed to notify Resident 1's responsible party of Resident 1's episodes of elopement and fall. These failures had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record for one of two sampled residents (Resident 1) was accurate and complete. * The facility failed to ensure Resident 1's MDS was accurate. This failure had the potential for the resident's care needs not being met as their medical information was inaccurate and incomplete.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure Resident 1 was free from the physical abuse when Resident 2 hit Resident 1 across the face, causing Resident 1 to have a bloody nose and a skin tear to the left forearm. This failure had the potential for not protecting the resident and negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure one of three sampled residents' (Resident 3) medication was administered as ordered by the physician. This failure had the potential to affect Resident 3's physical well-being. Findings Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in accordance with theprescriber's orders including any required time frame. The policy also showed medication times are determined by resident need and benefit including enhancing the optimal therapeutic effect of the medication, preventing potential food interactions, and honoring resident preferences. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medications brought by the family was accurately and safely accounted for one of three sampled resident (Resident 3). This failure had resulted in a missing dose of Resident 3's medication.

Inspectors wroteBased on interview and medical record review, the facility failed to maintain the accurate medical record for one of three sampled residents (Resident 3) when LVN 7 inaccurately documented the administration of Resident 3's Promacta medication. This failure had the potential to cause a delay on Resident 3 receiving his medication.

Inspectors wroteBased on observation, interview, facility document review, and P&P review, the facility failed to ensure the professional standards for food safety and sanitation guidelines were followed when: 1. Pasteurized eggs were not used to serve under cooked eggs. 2. Time Temperature Control for Safety Foods (TCS) (food that require time and temperature controls to limit the growth of illness causing bacteria) were not handled safely. 3. Expired food was not discarded. 4. Food was not stored properly. 5. Food was not dated. 6. Hair restraints were not worn appropriately. 7. Food contact surfaces were worn and no longer cleanable. 8. Kitchen equipment was not clean. These failures had the potential to cause food borne illnesses in a medically vulnerable population of 131 who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal medications. * The facility failed to ensure two expired oral inhaler medications were removed from Medication Cart A. * The facility failed to ensure properly label an eye drop medication in Medication Carts A and B. * The facility failed to ensure three opened insulin pens in Medication Carts A and B had an open date. * The facility failed to ensure personal medications in Medication Cart A were removed and not used. * The facility failed to ensure eight expired boxes of influenza vaccine were removed from the refrigerator in Medication Room A. * The facility failed to ensure one opened insulin pen in the refrigerator in Medication Room A had an open date. [...]

Inspectors wroteBased on observation and interview, the facility failed to show their Quality Assessment and Assurance (QA&A) plan of correction. There was no evidence of documentation to show the facility had developed a plan of correction for the repeated deficient practices cited at F558, F689, F694, F758, F759, F761, F806, F812, and F880 from the last recertification survey completed on 4/21/21. This had the potential to negatively affect the quality of care for all the residents in the facility.

Inspectors wrote3. Review of the facility's P&P titled Isolation - Categories of Transmission-Based Precautions revised 9/2022 showed when a resident is placed on transmission-based precaution, appropriate notification is posted on the entrance door of the room and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of CDC precautions, instructions for the use of PPE, and/or instructions to see a nurse before entering the room. The signage and notifications must comply with the resident's right to confidentiality or privacy. Review of the CDC Type and Duration of Precautions Recommended for Selected Infections and Conditions updated 9/2018 showed the following: [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen and patient care equipment was maintained. * The ice machine manufacturer's guidelines for cleaning and sanitizing were not followed and the ice machine did not have an air gap. * The walk-in freezer floor located in the kitchen was not leveled. * The facility failed to ensure the glucometers (a device which measures the amount of sugar in the blood) currently used and stored in the medication carts were properly calibrated. The facility failed to ensure the glucometer monitoring log was completed and the quality control showed the serial numbers of the glucometer calibrated. In addition, the facility failed to ensure the control solutions used to calibrate the glucometer machine for Station 1 were not expired. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the regular inspection of all the bed frames, mattresses, and side rails was conducted as part of the regular maintenance program to identify areas of possible entrapment rails. This failure had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the call light for one of 27 final sampled residents (Residents 81) was answered promptly. In addition, the facility failed to ensure Resident 81's call light was within the resident's reach. These failures had the potential for the residents to not get their needs met timely.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify Responsible Party 1 of a change in condition for one nonsampled resident (Resident 24). * The facility failed to notify Responsible Party 1 when Resident 24 had new medication orders, lab orders, and new appointment. This failure had the potential to negatively impact the resident's psychosocial and physical wellbeing and prevent the resident's responsible party from being fully aware of the resident's treatments, understand the course of actions, and not make appropriate decisions in the care and treatment of Resident 24.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the restraint free periods and least restrictive measures for one of 27 final sampled residents (Resident 72) when Resident 72's bed was placed against the wall without medical necessity. This failure posed the risk of compromising Resident 72's independence and had the potential for increased risk of physical harm to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for four of 27 final sampled residents (Residents 72, 88, 96, and 727) and one of 21 nonsampled residents (Resident 114). * The facility failed to develop an individualized a care plan problem to address Resident 114's use of ipratropium- albuterol medication (a breathing treatment that works by relaxing and opening air passage to the lungs to make breathing easier) and implementation of enhanced standard precaution related to infection in the urine. [...]

Inspectors wroteBased on medical record review, interview, and facility P&P review, the facility failed to ensure the comprehensive care plans for four of 27 final sampled residents (Residents 6, 18, 92, and 86) were revised. * The facility failed to ensure Residents 6 and 86's care plans were revised to reflect the residents' severe weight losses. This failure posed the risk for Residents 6 and 86 to not receive the necessary care needed to maintain acceptable parameters of nutritional status. * The facility failed to ensure Residents 18 and 92's care plans were person-centered and comprehensive to address the use of oxygen therapy and its related medical complications from COPD. This failure posed the risk for Residents 18 and 92 to not receive the necessary care needed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide a safe environment free from potentially serious accident hazards for two of 27 final sampled residents (Residents 81 and 96) as evidenced by: * The facility failed to ensure the smoking materials were securely stored. In addition, Resident 96 had been assessed with a need for a smoking apron and was not provided with a smoking apron during the smoking period. This posed the risk for serious injury to Resident 96. * The facility failed to provide a floor mat as per the IDT and PT recommendations for Resident 81 following a fall on 3/18/23. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the acceptable parameters of nutritional status were maintained for two of 26 final sampled residents (Residents 6 and 86) who were administered enteral (a form of liquid nutrition that is delivered into the digestive system via tube) feeding as evidenced by: * The physician and responsible party were not notified of the severe weight losses for Residents 6 and 86. * The interventions to mitigate the severe weight loss for Residents 6 and 86 were not implemented in a timely manner. * The resident-centered plans of care for Residents 6 and 86 were not revised to address Resident 6 and 86's severe weight losses. As a result of these failures, Resident 6 and 86's compromised nutritional status was not addressed timely, which could lead to further medical complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary treatments to six of 27 final sampled residents (Residents 18, 31, 88, 92, and 114) receiving the oxygen therapy. * The facility failed to follow the physician's order for Resident 18's oxygen therapy. * The facility failed to ensure Residents 18, 31, 88, and 92's nasal cannula tubing was dated as per the facility's P&P. In addition, the facility failed to ensure the nasal cannula tubing was stored in a set-up bag when not in use for Resident 31. * The facility failed to ensure Residents 83, 88, and 114's nebulizer tubing and mask were dated as per the facility's P&P. * The facility failed to ensure Resident 31's nebulizer mask was dated. In addition, the facility failed to ensure the nebulizer mask was stored in a set-up bag when not in use. [...]

Inspectors wroteBased on observation, interview, medical record review, facility P&P review, the facility failed to provide the necessary care and services to attain and maintain the highest physical well-being for two of 27 final sampled residents (Residents 16 and 75) who required dialysis. * The facility failed to ensure Resident 16's dialysis checklists were accurate and complete which included Resident 16's pre dialysis check list (for blood sugars, vital signs, access site, skin integrity, medications sent with resident, an special instructions) and post dialysis checklist (for vital signs, access site, skin integrity, and special instructions). * The facility failed to ensure Resident's 75 dialysis access site was assessed for bruit and thrill as per the physician's order. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the least restrictive alternative measures were implemented prior to the use of side rails for six of 27 final sampled residents (Residents 21, 25, 65, 72, 115, and 727). These failures had the potential to put the residents at risk for serious injury.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the licensed nurses had specific competencies and standard of practice skill sets needed to provide the safe and efficient nursing care to the residents as evidenced by: * LVN 9 was unable to demonstrate competency in the administration of insulin injection subcutaneously to one of 21 nonsampled residents ( Resident 23). In addition, there was no documented evidence the annual competency skills checklist for LVN 9 was completed. * The facility failed to ensure RN 2 had the appropriate competency and skill set to assess for one of 27 final sampled residents (Resident 16)'s dialysis access site. This had the potential risk of an adverse outcome in Resident 16's care or services. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide pharmaceutical services to ensure accurate reconciliation, administration and disposal as evidenced by: * The facility failed to ensure administration of the controlled medications for one of 27 final sampled residents (Resident 112), and two nonsampled residents (Residents 9 and 73) were accurately documented to ensure accurate reconciliation and to prevent the medication administration errors. These failures posed the risk for diversion of controlled medications and medication administration errors. * The facility failed to ensure the discontinued controlled medications for Residents 72, 99, 107, 112, 377, and 378 were removed from the current medication supply and disposed of. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure three of 27 final sampled residents (Residents 2, 72, and 118) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure Resident 72 was not prescribed quetiapine fumarate (antipsychotic medication) unless the medication was necessary to treat a specific condition or diagnosis. In addition, the facility failed to monitor Resident 72's target behavior for the use of quetiapine fumarate and failed to evaluate whether a GDR should be attempted as per the Pharmacy Consultant's recommendation. * The facility failed to ensure Resident 2's target behavior for the use of Seroquel (quetiapine fumarate) was monitored accurately. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12.5%. Three of three licensed nurses (LVNs 1, 3, and 9) who were observed during the medication administration were found to have made errors. * LVN 3 administered the metoprolol (blood pressure medication) oral tablet without food when the pharmacy placed an alert to administer the medication with food on the medication packaging and without checking the heart rate as per the physician's order. * LVN 3 administered the budesonide nebulizer (medication to decrease inflammation in the lungs) and did not have Resident 83 rinse mouth after nebulizer was administered as per the medication label instruction. [...]

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to complete a laboratory test for one of 27 final sampled residents (Resident 2) as per the physician's order. This had the potential to result in the delay in evaluating the effectiveness of the medication and adjusting the dosage of the medication to meet Resident 2's needs.

Inspectors wroteBased on observation, interview, facility document review, and P&P review, the facility failed to ensure the nutritional needs were met for two of 21 nonsampled residents (Residents 107 and 877) with a vegetarian diet preference. This failure posed the threat of the nutritional needs of Residents 107 and 877 to not be met which could lead to medical complications. In addition, the facility failed to ensure the food preference was honored for one of 21 nonsampled residents (Resident 427). Resident 427 stated she disliked scrambled eggs; however, she was served scrambled eggs on her breakfast tray. This had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to accurately determine whether one of 21 nonsampled residents (Resident 13) who was prescribed the antibiotics had met the McGeer's criteria. As a result, the facility failed to inform the resident's physicians that the residents did not meet McGeer's criteria for true infection and potentially inhibited the resident's physicians from discontinuing the unnecessary antibiotics. This had the potential to result in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the waste was properly contained and transported when: 1. Three of three dumpsters were overflowing preventing closure of the dumpster lid. 2. Kitchen trash was not covered during transportation. These failures had the potential for harborage and feeding of pests.

Inspectors wroteBased on observation and interview, the facility failed to ensure the results of the most recent recertification and abbreviated surveys were in a place readily accessible to the residents and public. This failure posed the risk of the residents, their families, and visitors not being able to examine the most recent survey results and the facility's plan of corrections.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure an accurate coding of the MDS was completed for one of 27 final sampled residents (Resident 118). * Resident 118 was inaccurately code for the PASRR (Pre-admission Screening and Resident Review). This failure posed the risk of the resident not receiving an individualized plan of care based on the resident's specific needs.