Imperial Care Center

Inspectors wroteBased on interview and record review, the facility failed to allow one of two sampled resident (Resident 1) to return to the facility following hospitalization at General Acute Care Hospital 1 (GACH 1) on 7/21/2026 according to the facility's policy and procedure (P&P) titled, Bed-holds and Returns. This failure had the potential to result in Resident 1 remaining in GACH 1 since 7/19/2026 and had the potential to cause psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to notify the Ombudsman and the resident's family member regarding the resident's discharge and appeal rights for one of two sampled residents (Resident 1). This failure violated Resident 1's right to appropriate discharge planning and due process by limiting access to advocacy services and the opportunity to appeal the discharge decision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of six sampled residents' (Resident 4, Resident 5, and Resident 6) meal trays were served at the same time. These deficient practices resulted in Resident 4 and Resident 6's agitation. This deficient practice furthermore had the potential to negatively affect Resident 4's, Resident 5's, and Resident 6's dignity and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to follow its policies and procedures regarding individualized care planning by failing to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) addressing one of three sampled residents` (Resident 1) prednisone (a powerful steroid used to decrease swelling, inflammation, and allergies) use. This deficient practice increases the risks for Resident 1 to not understand the purpose of the medication's use, the possibility of treatment failure, and the lack of interventions for staff to monitor Resident 1 for any harmful adverse side effects related to taking the medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received care in accordance with professional standards of practice to attain or maintain the highest practicable physical well-being, when Registered Nurse (RN 2) and RN 3 failed to complete the admission assessment timely when Resident 1 was re-admitted to the facility on [DATE]. This deficient practice had the potential to result in Resident 1 receiving inadequate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Fall Risk Evaluation (used to find out if you have a low, moderate, or high risk of falling) was accurately documented to reflect the fall risk of one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect Resident 1's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) within two hours to the State Survey Agency (SSA) on 7/17/2025, when the Director of Staff Development (DSD) received a text message from Certified Nurse Assistant (CNA) 4 that she (CNA 4) witnessed abuse while training with CNA 3. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management was provided to one of three sampled residents (Resident 2) when there was no documented evidence in Resident 2's medical record showing Licensed Vocational Nurse (LVN 3) had assessed Resident 2's reported pain on 6/29/2025. This failure had the potential to result in Resident 2's reported pain to be left unmanaged which can prevent Resident 2 from reaching her highest practicable wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from a significant medication error when Licensed Vocational Nurse (LVN 1) was about to administer Gabapentin (a medication that prevents/controls seizures and can also relieve nerve pain) without first checking Resident 1's respiration rate (the amount of breaths a person takes per minute) per the doctor's order. This failure had the potential to result in an adverse effect (undesired effect of a drug or other type of medical treatment) from taking Gabapentin, which can significantly decrease respirations (the process of breathing air in and out of the lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record of one of three sampled residents (Resident 2) was complete, accurately documented, and contained a record of Resident 2's pain assessments when Licensed Vocational Nurse (LVN 3) stated Resident 2's pain was assessed on 6/29/2025 after Resident 2 reported pain to both knees. This failure resulted in an incomplete medical record as there was no documented evidence that Resident 2's reported pain was addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control in one of four sampled residents (Resident 1) when Licensed Vocational Nurse (LVN 1) prepared to administer Gabapentin (a medication that prevents/controls seizures and can also relieve nerve pain) without first washing hands or using alcohol hand sanitizer per the facility's protocol. This failure had the potential to result in spreading infection to Resident 1 during the administration of Gabapentin.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one of three sampled residents (Resident 2) was treated with dignity and care in a manner that promotes maintenance or enhancement of their quality of life by failing to ensure Certified Nursing Assistant (CNA) 1 assisted Resident 2 with their meal was not standing over Resident 2. This deficient practice had the potential to negatively affect Resident 2 psychosocially (involving mental, emotional, social, and spiritual aspects of a person's life).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for three of three sampled residents (Residents 70, 81, and 102) reviewed for physical restraints by failing to ensure: 1. Resident 70's restraint bed placed against the wall had a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the resident and/or representative, and a physical restraint assessment for its safe use. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for three of eleven sampled residents (Residents 116, 81 and 70) by: a. Failing to implement Resident 116 ' s care plan on the use of wheelchair pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) on 6/17/2025 and 6/18/2025 as per physician order. b. Failing to ensure a care plan was developed for Resident 116 ' s behavior of removing the bed pad alarm. c. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide quality of care in accordance with professional standards of practice to meet the resident ' s physical, mental, psychosocial needs (encompass the emotional and social requirements that individuals have to feel safe, supported, and function effectively in their environment) for one of three sampled resident (Resident 116) by: 1. Failing to ensure nurses follow physician order to monitor Resident 116 for orthostatic hypotension (also known as postural hypotension, is a sudden drop in blood pressure that occurs when you stand up after sitting or lying down) every Tuesday. No blood pressure documentation on 6/3/2025 (Tuesday), 6/10/2025 (Tuesday), and 6/17/2025 (Tuesday) on a lying position. 2. [...]

Inspectors wrote3. During a record review of Resident 116 ' s admission Record, the admission Record indicated the facility admitted Resident 116 on 10/15/2024, with diagnoses that included unspecified (unconfirmed) cerebrovascular disease (a group of conditions that affect blood flow to the brain), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and vascular dementia (reduced blood flow to the brain, which damages brain tissue and impairs cognitive functions). During a review of Resident 116 ' s H&P Visit, dated 10/15/2024, the H&P indicated Resident 116 was alert and needed visual cues (non-verbal signals that provide information, guide actions, or enhance understanding through visual elements). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of five sampled residents (Resident 33) reviewed during the Medication Administration task, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 3 administered medication per facility policy and procedure (P&P) within one hour of the scheduled time. 2. Ensure LVN 3 documented the administration of medication per facility P&P at the time of administration in the resident ' s medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (% - one part in every hundred). Three medication errors out of 25 total opportunities contributed to an overall medication error rate of 12% affecting one of five sampled residents observed for medication administration (Resident 33). Resident 33 did not receive divalproex sodium (a medication to treat conditions related to mood regulation and the nervous system), apixaban (a medication to help prevent blood clots [clumps that occur when blood hardens from a liquid to a solid]), and olanzapine (a medication to treat mood disorders) on 6/18/2025 at the prescribed time. [...]

Inspectors wroteBased on interview and record review, the facility failed to rotate (a method to ensure repeated injections are not administered in the same area) insulin (a hormone that lowers the level of sugar in the blood) injection sites each time insulin was administered for one of three sampled residents (Resident 96). This failure resulted in a significant medication error when multiple nurses repeatedly failed to rotate insulin injection sites during the administration of insulin to Resident 96 in 4/2025 and 5/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen reviewed during the Kitchen task by failing to: 1. Ensure food items in Refrigerator 1, the Walk-in Refrigerator, and the Walk-in Freezer were labeled according to facility policy. 2. Ensure kitchen areas were cleaned and sanitized when the Walk-in Freezer floor had sticky, discolored ice buildup and the Dry Food Storage Area had spilled dry cereal. 3. Ensure five dented cans were not found with non-dented cans in the Dry Food Storage Area. [...]

Inspectors wroted. During a record review of Resident 116 ' s admission Record, the admission Record indicated the facility admitted Resident 116 on 10/15/2024, with diagnoses that included unspecified (unconfirmed) cerebrovascular disease (a group of conditions that affect blood flow to the brain), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and vascular dementia (reduced blood flow to the brain, which damages brain tissue and impairs cognitive functions). [...]

Inspectors wroted. During a concurrent observation and interview on 6/17/2025, at 8:27 a.m., with Laundry Staff 1 (LS 1), observed a liquid container with light green fluid and was placed inside the linen cart beside the folded clean linens. LS 1 stated the liquid container belongs to her (LS 1) and it contains water. During a concurrent observation, and interview on 6/17/2025, at 8:28 a.m., with the Account Manager (AC), inside the clean laundry room. The AC stated there should be no water or food inside the clean laundry room for infection control. The AC stated staff were informed not to put any food, water or belongings in the clean laundry room. The AC stated LS 1 failed to follow infection control policy. During an interview on 6/17/2025, at 8:36 a.m., with the IP, the IP stated staff are not allowed to keep food or water inside the laundry room. [...]

Inspectors wrote3. During a review of Resident 90 ' s admission Record, the admission Record indicated the facility admitted Resident 90 on 10/30/2024, with diagnoses that included metabolic encephalopathy (brain disorder resulting from chemical imbalances in the body, often caused by underlying medical conditions or organ dysfunction), sepsis (a life-threatening blood infection) due to MRSA and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 90 ' s H&P, dated 6/9/2025, the H&P indicated Resident 90 did not have the capacity to understand and make decisions. During a review of Resident 90 ' s MDS, dated [DATE], the MDS indicated Resident 90 ' s cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 90 needed maximum assistance from staff for toileting and showering. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the electrical patient care equipment was in safe operating condition for three of five sampled residents (Residents 102, 51, and 23) reviewed under environmental task by failing to ensure: 1. Resident 102 ' s pad/tab alarm (a device that helps caregivers monitor someone, usually in bed or a chair, who might need help getting up or moving) did not have a broken sensor cord. 2. Residents 51 and 23 ' s bed remote control did not have frayed/exposed wires. These deficient practices had the potential for Residents102, 51, and 23 to sustain accidents such as electrical shock and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within reach of the resident for one of one sampled resident (Resident 5) reviewed under accommodation. This deficient practice had the potential for residents unable to summon health care worker for help as needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Residents 116) was free from chemical restraints (use of medication to manage a resident's behavior or restrict their freedom of movement, primarily to control agitation [a feeling of irritability, mental distress or severe restlessness] or aggression [any behavior, word, or action that is intended to harm another person, animal, or object]) by failing to ensure quarterly (every three months) behavior management interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together) meeting for Resident 116 use of psychotropic (medications that affect the mind, emotions, and behavior) medication was done. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident to resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) immediately, but no later than two hours after the allegation was made to the State Survey Agency (CDPH, California Department of Public Health), the Ombudsman (a resident advocate), and local law enforcement (LLE) in accordance with federal and state law for one of seven sampled residents (Resident 37) reviewed under the Hospitalization care area. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from harm from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice as indicated in the resident ' s care plans by failing to check a resident ' s gastrostomy tube (g-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems) placement before administering medications for one of seven sampled residents (Resident 61) reviewed under Medication Administration facility task. This deficient practice had the potential for Resident 61 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcer/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of one sampled resident (Resident 36) by failing to: 1. Ensure a thorough skin check of Resident 36 was done upon readmission to the facility on 5/22/2025. 2. Ensure a reassessment of Resident 36 ' s pressure injury was done within 24 hours after readmission. These deficient practices had the potential for a delay of necessary care and services and worsening of Resident 36 ' s pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its residents with or without limited range of motion (ROM - movement of the joints) receive appropriate treatment and services to increase, prevent, or maintain the ROM mobility for one of three sampled residents (Resident 18) who had a physician's orders for Restorative Nursing Assistant (RNA) exercises and use of left knee splint (a device used to immobilize and support a body part, typically an arm or leg, that has been injured) five times a week. This failure resulted to Resident 18 not receiving RNA exercises and placed him (Resident 18) at risk for decline in physical function and at risk for contractures (a condition where muscles, tendons, or other tissues shorten and tighten, limiting the movement of a joint).

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer a therapeutic diet when there was a nutritional problem, and the healthcare provider ordered a therapeutic diet for one of two sampled residents (Resident 70) reviewed under nutrition. The Interdisciplinary Team ' s (IDT, is a group of people from different fields or areas of expertise who work together towards a common goal) recommendation in Resident 70 ' s Weight Management Care Plan, dated 6/16/2025, was not followed by failing to obtain a physician ' s order for Glucerna (a brand of meal replacement shakes and bars) 1 can daily (qd). This deficient practice placed Resident 70 at risk for continued weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 96) was free from unnecessary medication when Resident 96 was being treated with an anticoagulant (a medication that prevents blood clots from forming or existing clots from getting larger) without being adequately monitored for adverse effects (an undesired effect of a drug or other type of treatment). This failure had the potential to result in Resident 96 developing an adverse effect, such as bleeding, from the use of an anticoagulant without the facility being aware.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the results of the most recent survey was posted in a place readily accessible where individuals including the residents wishing to examine the survey results do not have to ask the assistance of the staff to see them for one of eight sampled residents (Resident 74) reviewed during Resident Council facility task. This deficient practice had the potential for the residents and their legal representatives to not be fully informed of the facility's deficient practices and how they were corrected.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit the Minimum Data Set (MDS - a resident assessment tool) timely for six of six sampled residents (Resident 107, 110, 113, 85, 75, and 74) reviewed under the Resident Assessment task. This deficient practice had the potential to result in care that does not address the residents' specific care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirement for no more than four residents per room for two of 45 resident rooms (rooms [ROOM NUMBERS]) for ten of ten sampled residents (Residents 44, 27, 45, 58, 10, 26, 82, 11, 52, and 24). This deficient practice had the potential to result in inadequate space to provide sufficient nursing care and privacy for the affected residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of 44 resident rooms (rooms [ROOM NUMBERS]) for ten of ten sampled residents (Residents 44, 27, 45, 58, 10, 26, 82, 11, 52, and 24) met the square footage (sq ft-a unit of measurement) per resident in multiple resident rooms. The room size for these rooms had the potential to have inadequate space for resident care and mobility.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, by failing to report an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) to the State Survey Agency (SSA) no later than two hours for one of four sampled residents (Resident 2) when on 5/31/2025 at 5 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of a resident) to one of three sampled residents (Resident 1), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities) and was admitted to a secured facility (specialized healthcare setting that restricts patient movement and access to promote safety with measures such as locked doors and surveillance). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for one of four sampled residents (Resident 1) by failing to measure Resident 1 ' s blood sugar when Resident 1 returned to the facility on 4/25/2025. This failure had the potential to delay Resident 1 ' s care and negatively affect Resident 1 ' s well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a licensed Administrator (ADM) held a current and active license from the State to serve in the capacity of a nursing home administrator (NHA). This deficient practice resulted in the facility operating without a licensed ADM that had the potential to negatively affect the facility's functions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of two of four sampled residents (Resident 2 and 3) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to: 1. Ensure Resident 2 ' s Informed Consent (IC, voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was signed by a physician. 2. Ensure Resident 3 ' s Attending Physician (MD) reviewed and signed the resident's Order Summary every month. These deficient practices had the potential for inaccurate documentation and inaccurate medical interventions for Resident 2 and Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by not following the physician's orders. This deficient practice had the potential to result in Resident 1 not receiving medication order by the physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of three sampled resident (Resident 1) was allowed to keep medications at beside without a physician's order. Resident 2 kept a cold (a mild infection of your upper respiratory tract which includes your nose and throat) and flu (highly contagious [able to be passed on by contact between individuals] viral infection of the respiratory tract that can cause severe illness and life-threatening complications) medication at Resident 1's bedside drawer. This deficient practice had the potential to result in unsafe medication administration.

Inspectors wroteBased on interview and record review, the facility failed to report allegation of family-to-resident abuse within two hours to the State Survey Agency (SSA), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement (police) as per its policy on abuse for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to create a comprehensive care plan for one of three sampled residents (Resident 1) by failing to ensure care plan was created on Resident 1's refusal of facility food and Resident 1 receiving outside food delivery. This deficient practices had the potential for delayed provision of necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure Attending Physician (AP) sign the consent for Merry [NAME] (a walking device that combines a walker and a wheelchair designed to help people with balance or walking difficulties walk independently and safely) for one of three sampled residents (Resident 2). This deficient practice had the potential for delay of necessary services, poor continuity of care and follow-up on the resident's status.

Inspectors wroteBased on interview and record review, the facility failed to provide one out of three sampled residents (Residents 1) with meals that accommodated their food preferences. This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition (lack of proper nutrition, caused by not having enough to eat or not eating enough of the right things).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by failing to ensure that one of two sampled kitchen staff (Cook 1) was wearing a hair net (hair cover) while inside the kitchen. This deficient practice had the potential to compromise the integrity of food and placed the residents at risk for foodborne illnesses (illness caused by the ingestion of contaminated food or beverage).

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1). This deficient practices had the potential to cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding influenza (a contagious respiratory illness caused by influenza viruses) for two of seven sampled residents (Resident 3 and Resident 5) by failing to: 1. Ensure Licensed Vocational Nurse 1's (LVN 1) personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was worn properly before touching Resident 3. LVN 1's disposable gloves were worn under the disposable isolation gown. LVN 1's N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) top elastic strap was on the neck and created a break in the seal of the N95 mask. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) for one of three sampled residents (Resident 1) when on 12/4/2024 the facility failed to notify the local law enforcement officials (a law enforcement agency that is responsible for enforcing laws in a city, town, county, or region) when Resident 1 alleged being a victim of misappropriation of funds (an illegal use of another person's money or property for one's own gain or other unauthorized purpose). This deficient practice resulted to Resident 1's allegation not investigated by the local law enforcement.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1). On 10/11/2024 Certified Nurse Assistant hit Resident 1 on the face causing him to fall on the floor. This deficient practice resulted in Resident 1 being subjected to physical abuse by Certified Nurse Assistant (CNA 1) while under the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to offer one of four sampled residents (Resident 91) or their resident representative assistance with formulating an Advance Directive (AD - a legal document telling the doctor one ' s wishes about their healthcare in the event they cannot make the decision for themselves) upon admission. Additionally, the facility failed to ensure resident's medical records were updated to show documented evidence that advance directives were discussed with three of five sampled residents (Residents 6, 118, and 114). This deficient practice violated the resident and/or their representative the right to fully be informed of the option to formulate an AD and had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident ' s body that he or she cannot easily remove that restricts freedom of movement or normal access to one ' s body) for one of four sampled residents (Resident 4 by failing to: 1. Complete a Physical Restraint Assessment Form prior to the application of both upper side rails (adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) as a restraint. 2. Obtain an informed consent from the resident or resident representative prior to the application of both upper side rails as a restraint. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (CP, a written course of action that helps a patient achieve outcomes that improve their quality of life) for residents by failing to: 1. Develop and implement a person-centered care plan regarding Post Traumatic Stress Disorder (PTSD, a mental health condition caused by very stressful, frightening, or distressing events) for one of five residents (Resident 39) reviewed under the Behavioral-Emotional care area. 2. Develop and implement a comprehensive person-centered care plan for the use of insulin glargine-yfgn (a form of hormone insulin made in the laboratory used to control the amount of sugar in the blood of patients with diabetes) for one (1) out of five (5) sampled residents (Resident 74). 3. [...]

Inspectors wroteBased on interview and record review, the facility ' s licensed nursing staff failed to provide care in accordance with professional standards for two of two sampled residents (Residents 20 and 74) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. This deficient practice had the potential to result in adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wrote2. A review of Resident 93 ' s admission Record indicated the facility admitted the resident on 4/1/2024, with diagnoses that included lack of coordination, muscle weakness, and a Stage 4 pressure ulcer of the sacral region. A review of Resident 93 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/12/2024, indicated Resident 93 sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had impaired upper and lower extremities and was dependent on mobility and activities of daily living (ADLs). The MDS indicated the resident was at risk for further developing pressure ulcer/injuries and had an unhealed Stage 4. The MDS did not indicate that Resident 93 was on a turning/repositioning program. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards, ensure residents received adequate supervision, and implement interventions to prevent accidents for five (5) of 5 sampled residents (Resident 54, 58, 27, 77, and 60) investigated under the Accidents care area by failing to: 1. Ensure Resident 58 ' s left side floor mat was not overlapping with Resident 54 ' s right side floor mat during a random observation. This deficient practice placed Resident 54 and 58 at risk for fall incidents which may lead to injuries. 2. Ensure Resident 27 ' s sensor pad alarm (a device consisting of a pressure-sensing pad that sends a signal to a nearby receiver to sound when the resident rises and their weight shifts) was functioning properly when the resident tried to get out of bed unassisted during a random observation. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the safe and appropriate use of side rails (adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) to one of four sampled residents (Resident 4) investigated during review of physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident ' s body that he or she cannot easily remove that restricts freedom of movement or normal access to one ' s body) by failing to: 1. Complete a Physical Restraint Assessment Form prior to the application of both upper side rails as a restraint. 2. Obtain an informed consent from the resident or resident representative prior to the application of both upper side rails as a restraint. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 2 (LVN 2) completed documentation indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications that have been received, dispensed, administered, and wasted) for Resident 83 ' s clonazepam (a controlled substance [medications that are considered to have a strong potential for abuse and may also lead to physical or psychological dependence] to treat anxiety [feeling of worry, nervousness, or restlessness) on the Antibiotic or Controlled Drug Record form (a document used to track the administration of controlled substances) in one of two observed medication carts (Medication Cart 3) observed during the Medication Storage and Labeling task. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber ' s order, manufacturer ' s specifications, and accepted professional standards) for one out of two sampled residents (Resident 20) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and one out of five sampled residents (Resident 74) reviewed under unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication and biologicals were stored with currently accepted professional standards for one of two medication carts (Medication Cart 3) reviewed during the Medication Storage and Labeling task and for one of eight sample residents (Resident 48) reviewed during the Medication Administration task by failing to: 1. Ensure residents ' insulin pens were labeled with the open date in Medication Cart 3 for four randomly sampled residents (Residents 49, 101, 21, and 33). 2. Ensure the licensed nurse labeled the Artificial Tears (an eye drop medication administered in the eye to provide moisture) in Medication Cart 1 with the resident ' s name for one of eight sample residents (Resident 48). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure open bags of flour tortilla, frozen chocolate chip cookies, and a box of lentils were labelled with open date. 2. Indicate the received or delivery date on a bag of fresh cilantro and a bag of fresh parsley. 3. Ensure a bottle of chocolate syrup with an open date of 5/15/2024 had a cap on it and covered tightly with plastic wrap. 4. Ensure a can of applesauce with dent was placed in the shelf for dented cans. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) were implemented for one of eight sampled residents (Resident 67) observed during the Medication Administration task. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the requirement for no more than four residents per room for two of 45 resident rooms (rooms [ROOM NUMBERS]). This deficient practice had the potential to result in inadequate space to provide sufficient nursing care and privacy for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 2 of 45 resident rooms (rooms [ROOM NUMBERS]) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. The room size for these rooms had the potential to have inadequate space for resident care and mobility.

Inspectors wroteBased on interview and record review, the facility failed to facilitate the inclusion of the resident in all aspects of person-centered care planning for one of one sampled resident (Resident 30) reviewed under the Choices care area by failing to encourage and include the resident during the interdisciplinary team (IDT - professional disciplines that work together to provide the greatest benefit to the resident) meetings. This deficient practice had the potential to violate Resident 30's right to be an active participant in her care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified of a change of condition/status for one of one sample residents (Resident 30) reviewed under the Choices care area by failing to notify the primary physician regarding the facility ' s assessment of a decline in the resident ' s capacity to understand and make decisions that significantly affected the resident ' s right to leave the facility against medical advice. This deficient practice had the potential to result in a delay of care and confusion in Resident 30 ' s plan for discharge, potentially resulting in psychosocial harm to the resident.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion (ROM, how far and in what direction the joint or muscle can move) and/or prevent further decrease in range of motion for one of two sampled residents (Resident 4) by failing to conduct a consistent restorative nursing weekly summary for the month of April 2024. This deficient practice had the potential to place the resident at increased risk of ROM decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident receiving enteral feeding (any method of feeding that uses the gastrointestinal tract to deliver nutrition and calories) received appropriate care and services to prevent complications of enteral feeding for one out of one sampled resident (Resident 93) being investigated under enteral nutrition by failing to label the irrigation syringe (a specialized medical instrument designed for the irrigation or cleansing of wounds, cavities, or body orifices) pouch with the name of the resident and the date it was last changed. The deficient practice had the potential for complications associated with enteral feeding such as peritonitis (a redness and swelling [inflammation] of the lining on the abdomen).

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents entire medication regimen was managed and monitored to promote the resident ' s highest practicable mental, physical, and psychosocial well-being for two of five sampled residents (Resident 74) selected for the unnecessary medications review by failing to ensure the monthly Psychotropic Monthly Summary Sheet was completed and readily available from 2/2024 to 6/2024. This deficient practice placed the resident at risk for not being accurately evaluated by the physician and experiencing side effects for the use of psychotropic medications (a type of medications that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) which may lead to unnecessary use of psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to follow up on the recommendation by the dentist for one (1) out of one sampled resident (Resident 9) during an interview by failing to schedule a full mouth x-ray (FMX - a safe and painless test that uses a small amount of radiation to make an image of bones, organs, and other parts of the body) for a new full upper denture (FUD). This deficient practice had the potential to result in the inability to effectively chew foods, weight loss, lack of energy and loss of muscle mass of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition for one (1) of 1 sampled resident (Resident 91) investigated during a random observation when Resident 91 ' s bed controller (device used to change the height and angle of the bed) cable was observed with frayed and exposed wires. This deficient practice had the potential to place Resident 91 at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of ten sampled facility staff (Registered Nurse 2 [RN 2], Licensed Vocational Nurse 2 [LVN 2], and Certified Nursing Assistant 2 [CNA 2]) were competent to provide nursing services to the residents by failing to ensure competency skill assessments were completed upon hire and annually. This deficient practice had the potential to negatively impact the residents ' safety and prevent the residents from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received services with reasonable accommodation of the resident needs for one of three sampled residents (Residents 2). Resident 2, who was at risk for falls, did not have the call light (an alerting device for residents to call for assistance) within the resident ' s reach. This deficient practice had the potential for not meeting the residents needs for assistance.

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policies and procedures (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, and Abuse & Mistreatment of Residents, to protect one of three sampled residents (Resident 1) from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) received abuse training. 2. Ensure CNA 1 did not hit (slap and punch) Resident 1. As a result, on 5/1/2024 at 5:30 p.m., Student Nurse 1 (SN 1) walked in Resident 1 ' s room and witnessed CNA 1 slapping and punching Resident 1 in Resident 1 ' s arms and back. Resident 1 was subjected to physical abuse inflicted by CNA 1 while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1), who was at risk for urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that conducts urine from the bladder to the outside of the body] and infect the urinary tract), received care and services to prevent UTI. For Resident 1 who had an indwelling urinary catheter (also known as Foley catheter, a hollow flexible tube inserted in the bladder through the urethra to drain urine), the facility failed to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents ' rights to be free from neglect (a form of abuse where the perpetrator, who is responsible for caring for persons unable to care for themselves, fails to do so) and physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) inflicted by another resident for six of 11 sampled residents (Residents 8, 1, 2, 9, 11, and 10). The facility failed to: 1. Ensure Residents 8, 1, 2, 9, 11, and 10, who were confused, were assessed as a high fall risk, had wandering behavior (moving around without any clear purpose or direction) and history of falls, were provided with supervision, redirection, and monitoring of their whereabouts. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent falls and injury for six of 11 sampled residents (Residents 8, 1, 2, 9, 11, and 10), who were confused and were identified as high risk for falls and risk for elopement (a confused person leaving the facility unnoticed by staff and does not return, it is the most dangerous type of unsupervised wandering [moving about aimlessly or without a specific purpose]). The facility failed to: 1. Ensure Residents 8, 1, 2, 9, 11, and 10, were assessed as a high fall risk, had wandering behavior (moving around without any clear purpose or direction) and history of falls, were provided with supervision, redirection, and monitoring of their whereabouts. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy by not conducting a thorough investigation for a resident-to-resident abuse for five of eight sampled residents (Residents 9, 10, 11, 12 ,and 15). This deficient practice had the potential to result in unidentified abuse and placed the residents at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for three of eight sample residents (Resident 8, 12, and 15) by: 1. Failing to develop and implement an individualized person-centered fall care plan with interventions that meet Resident 8 ' s needs. 2. Failing to develop a comprehensive person-centered care plan regarding the physical abuse allegation that Resident 15 did to Resident 12. These deficient practices had a potential to negatively affect the delivery of necessary care and services and increased the risk for further fall and abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the resident-to-resident altercation to the State Survey Agency within 2 hours after the allegation occurred for two of three sample residents (Resident 12 and Resident 15). This deficient practice had the potential to place Resident 12 at risk for elder abuse.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) and neglect for two of five sampled residents (Resident 1 and Resident 3). The facility failed to: 1a. Ensure Certified Nursing Assistant 3 (CNA 3) did not leave Resident 1 on the floor after CNA 3 witnessed the resident fall. 1b. Ensure CNA 3 provided supervision and appropriate care to Resident 1 to prevent the resident ' s fall. This deficient practice resulted in Resident 1 being neglected by CNA 3 while under the care of the facility and was placed at a high risk of increased feelings of anxiety (feeling of worry, nervousness, or uneasiness) because of the resident ' s diagnoses of anxiety disorder (persistent and excessive worry that interferes with daily activities). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent a fall and injury for two of five sampled residents (Resident 1 and Resident 4), who was identified as a high fall riskwith poor safety awareness. The facility failed to: 1a. Ensure Resident 1 was assisted safely to the dining table while the resident held on a wheelchair. Certified Nursing Assistant 3 (CNA 3) swung her arm backwards releasing Resident 1 ' s grip on her. 1b. Ensure Resident 1 was not left unattended after CNA 3 witnessed the resident fall in the dining room. As a result, Resident 1 lost the balance and fell on the floor. These deficient practices had the potential for Resident 1 to sustain a fracture which could lead to death. 2a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for four of six sampled residents (Residents 1, 2, 5, and 6), by failing to: a. Ensure Registered Nurse 1 (RN 1) perform hand hygiene (hand washing with soap and water or use of alcohol-based hand sanitizer) after exiting Resident 2's room and before touching the utility room door. RN 1 also failed to wear gloves when rendering care to Resident 2. Resident 2 was on enhanced standard precaution (ESP - an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities). b. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for two of six sampled residents (Resident 5 and Resident 6) by failing to develop and implement individualized care plans and interventions addressing Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) exposure. This deficient practice had placed Resident 5 and Resident 6 at risk for not receiving the necessary services and assistance that can result in exposure and contracting COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) when on 11/8/2023, at 6:45 p.m., Resident 2 hit Resident 1 on the face. Resident 1 was lying in bed and Resident 2, while standing at Resident 1 ' s bedside punched Resident 1 several times on the face and body, causing pain and redness to the right eye area which needed ice pack application and pain medication. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility and caused Resident 1 to report pain and feelings of anxiety (feeling of worry, nervousness, or uneasiness) because of the altercation with Resident 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three Certified Nursing Assistants (CNA 9, CNA 10, and CNA 3) were not standing while assisting residents with feeding for three out of four sampled residents (Residents 46, 86, and 1) investigated for dignity. This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for three out of three sampled residents (Resident 11, 350, and 351) investigated addressing accommodation of needs. This deficient practice placed the residents at risk for inability to summon health care workers as needed to receive assistance that may include urgent care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards were met for two of two sampled residents (Resident 30 and 58) investigated under the Medication Storage facility task by: 1. Failing to ensure Resident 30 was not administered expired doses of tramadol (used to treat moderately severe pain). 2. Failing to ensure Resident 58's Combivent (inhaler used to manage shortness of breath) was administered according to physician's orders. These deficient practices increased the risk that Resident 30 could have received a medication that had become ineffective or toxic due to improper storage or labeling; and placed Resident 58 at risk for health complications resulting from not receiving the medication as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe proper storage and labeling of drugs and biologicals for one of two medication storage refrigerators (Yellow Zone Nursing Station - facility area where persons with unknown COVID-19 [a highly contagious viral infection that can trigger respiratory tract illness] status are placed) and for two of three medication carts (Medication Cart 1 and Medication Cart Station 2) by: 1. Failing to ensure Resident 30's tramadol (used to treat moderately severe pain) with expiration date of [DATE] was discarded immediately in Med Cart 1. Resident 30 received 22 expired doses from observation date of [DATE]. 2. Failing to ensure Florastor (dietary supplement) with expiration date of 01/2021 was discarded immediately in Medication Cart Station 2. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling practices by: 1. Failing to ensure that a staff's Coca Cola bottle with a brown substance was not stored in the walk-in refrigerator intended for residents' foods. 2. Failing to ensure that the freezer in the kitchen was at or below zero degrees Fahrenheit (° F - a scale of temperature measurement). 3. Failing to ensure that cream puffs stored in the walk-in freezer were discarded on or before the best by date (indicates when a product will be of best flavor or quality). 4. Failing to ensure that Dietary Aide 3 (DA 3) wash hands in between tasks and before donning (putting on) new gloves. 5. Failing to ensure that a half-eaten banana was not left on a plastic storage bin in the dry storage room. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the inventory of resident's personal valuables and property was conducted on the day the resident was admitted to the facility for one (Resident 146) out of one sampled resident reviewed under the care area of personal property. This deficient practice had the potential for inaccurate inventory of the resident's personal valuables and property and the potential for possible inability to readily identify loss of property and/or theft. 2. Ensure the administrations of a resident's medications were accurately documented in the Medication Administration Record (MAR) for one (Resident 146) out of one sampled resident reviewed addressing accuracy of documentation. The medications were: a. Depakote sprinkles (medication for the treatment of mood disorder) b. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Implement infection control practices for Coronavirus disease (COVID-19, a highly contagious viral infection that can trigger respiratory tract illness) prevention by failing to monitor and document vital signs and signs and symptoms of COVID-19 for one (Resident 146) of two sampled residents investigated addressing transmission-based precautions (additional measures observed for patients who may be infected with certain infectious agents to prevent infection transmission). This deficient practice had the potential to result in increasing the risk of spreading COVID-19 to resident and staff members. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's representative when a resident sustained scratches after Certified Nursing Assistant 1 shaved the resident's face, for one (Resident 146) out of one sampled resident investigated addressing the right to be informed/make treatment decisions. This deficient practice violated Resident 146's representative's right to be informed of change in the resident's health status and the right to make decisions about the resident's treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Social Services Designee (SSD) provided written information regarding Advance Directives (a legal document that explains how you want medical decisions about you to be made if you cannot make the decisions yourself) to two out of two sampled residents (Resident 8 and 23) investigated for Advance Directives. This deficient practice had the potential to violate the residents' and/or their representatives' right to be fully informed of the option to formulate an Advance Directive and had the potential to cause conflict due to lack of communication regarding residents' wishes about their medical treatment.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive plan of care (written guide that organizes information about the resident's care) with measurable objectives and specific interventions for the use of Remeron (an antidepressant medication that can treat depression [a mood disorder that causes persistent feeling of sadness and loss of interest in activities causing significant impairment in life] for one (Resident 72) out of seven sampled residents reviewed for unnecessary medications. This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure an interdisciplinary team (IDT - involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting was done and the care plan (contains all of the relevant information about a patient's diagnoses, the goals of treatment, the specific nursing orders [including what observations are needed and what actions must be performed], and a plan for evaluation) was updated with new interventions after a resident had a fall for one out of three sampled residents (Resident 62) investigated for accidents. This deficient practice had the potential to place the resident at risk for recurrent falls.

Inspectors wroteBased on interview and record review the facility failed to address the resident representative's interest in transferring a resident to another facility for one (Resident 146) of two sampled residents investigated under the care area of discharge. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 18) investigated under the care area of activities was engaged in preferred activities as identified in the care plan. This deficient practice had the potential to affect the resident's sense of self-worth and psychosocial well-being through feelings of usefulness, self-respect, and self-satisfaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adaptive eating equipment (tools to assist individuals with their feeding independence) as ordered by the physician for one out of one sampled resident (Resident 52) investigated for assistive devices. This deficient practice had the potential to result in the resident not being able to feed herself.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident bedrooms accommodated no more than four residents in one (room [ROOM NUMBER]) of 45 resident rooms. This deficient practice had the potential for residents not to be able to move freely in their own room or for nursing staff to not be able to provide resident care.