Infinity Care of East Los Angeles

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and complete a daily skin assessments for one of two sampled residents (Resident 2) who was assessed to be at high risk for developing pressure injury (PI-a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, shear, and/or friction, or a combination of these factors) from 2/11/2026 to 2/16/2026 in accordance with the facility's policy and procedures. These deficient practices may result into Resident 2's worsening of current PI and or developing new PI.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of two (2) sample residents (Resident 1) received Tramadol Hydrochloride (a prescription drug that helps reduce pain by acting on the brain's pain receptors) as indicated on the physician's order. This deficient practice had the potential to result in over medicating Resident 1 and causing respiratory depression (breathing too slowly or shallow) and sedation (stated of calm, relaxation, or sleepiness caused by certain drugs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy requiring notification of the Administrator and the local police department when, on 6/15/2026 at 9 PM, the facility received a report from a neighbor in an apartment building across the street that a suspicious person had been seen on the facility's rooftop. On 6/15/2026 at 11:40 PM, a fire occurred on the facility's rooftop. This deficient practice placed a potential risk to the health, safety, and security of all residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received reasonable accommodation of needs for two (2) of 2 sampled residents (Residents 12 and 92) reviewed for environment/call devices by failing to ensure:Resident 12's call light (a visible and audible alarm activated by a call button) was within reach and was functioning. Resident 92's call light was within reach. This deficient practice had the potential to result in the delay or inability for Residents 12 and 92 to obtain necessary care and services, which could negatively affect the residents' overall wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, sanitary and homelike environment for three (3) of five (5) sampled residents (Residents 47, 48 and 92), in the environment task, by failing to ensure: 1. Resident 47's bathroom sink was not leaking, and the ceiling light above the bathroom sink was functioning.2. Resident 92's ceiling was clean and free of dirt.3. Resident 48's bed was maintained in a safe condition. These failures had the potential to negatively affect Resident 47, 48, and 92's quality of life and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive, resident-centered care plan (integrated health care services delivered in a setting and manner that is responsive to individuals and their goals, values, and preferences, in a system that supports good provider-resident communication and empowers individuals receiving care and providers to make effective care plans together) was developed for two (2) of 2 sampled residents (Residents 3 and 74) reviewed under care planning as indicated on the facility's policy:Resident 3 did not have a care plan for Restorative Nursing Assistant (RNA) services (provided by certified nursing assistants [CNAs] who specialize in rehabilitation and restorative care for residents with limited mobility). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive proper treatment and/or assistive devices to maintain vision and/or hearing abilities for two (2) of 2 sampled residents (Residents 6 and 51) reviewed for vision/hearing to ensure:Resident 6 receive a proper assistive device to maintain hearing and have a comprehensive person-centered care plan to address the resident's hearing loss. The medical doctor (MD) for Resident 51 was informed of the resident's missed ophthalmology (the specialized field of medicine that focuses on the health of the eye appointment) to ensure alternative ophthalmology care, services and/or appointments were provided to maintain the resident's vision health. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the intake and output for two (2) of three (3) sampled residents (Residents 3 and 34) reviewed for dialysis (a lifesaving treatment for residents with kidney failure) treatment in accordance with the resident's care plan and the facility's policy and procedure (P&P). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to take timely action on a Medication Regimen Review (MRR, also known as a Drug Regimen Review-is a structured, comprehensive evaluation of all medications a resident is taking, conducted typically by a pharmacist to ensure medications are appropriate, safe, effective, and used correctly) irregularity (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) for two (2) of five (5) sampled residents (Resident 36 and Resident 51) reviewed for unnecessary medications by failing to ensure:Resident 36's Depakote level (refers to the measured concentration of valproic acid (the active ingredient in Depakote) [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) for two (2) of 2 sampled residents (Residents 34 and 57) reviewed for insulin (a natural hormone that turns food into energy and manages your blood sugar level, can be produced by the body or given artificially via medication). This deficient practice had the potential for Residents 34 and 57 to experience episodes of hypoglycemia and hyperglycemia without proper monitoring while receiving insulin which could result in harm, hospitalization, and diabetic coma (a life-threatening state of unconsciousness caused by extremely high or low blood sugar levels).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored per facility policy and procedure (P&P) by failing to ensure:1. One eye drop bottle was stored in the refrigerator and not in Medication Cart A.This deficient practice had the potential for harm to residents due to the potential loss of strength of the drugs, and the potential for the residents to receive ineffective drug dosages. 2. One insulin pen had a pharmacy label to indicate the drug name, dose, and expiration date. This deficient practice had the potential for the residents to receive the wrong formulation of the medication and be administered to the wrong resident. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure (P&P) by:Failing to ensure staff put on gloves before taking cooked food's temperatureTo sanitize the food thermometer with an alcohol swab before using it to check the cooked food's temperature. Failing to ensure staff keep the kitchen floor dry and ensure water was not leaking from the kitchen floor. These deficient practices had the potential to result in food born illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) to 96 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy by failing to ensure:1. A trash bag containing soiled gauze with bodily fluids and wipes with the resident's bowel movement were not placed on top of Resident 5's bed, next to the resident's left leg during dressing change. This deficient practice had the potential to contaminate clean items and can place Resident 5 at risk for infection. 2. All facility linens and resident gowns were stored appropriately to maintain infection control. [...]

Inspectors wroteBased on interview and record review, the facility failed to educate and offer the pneumococcal vaccine (a medical injection that protects against the bacteria Streptococcus pneumoniae, [a bacterium that colonizes the respiratory tract causing serious infections, including Pneumonia {PNA, lung infection}) and/or influenza (flu, a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) vaccine (an annual vaccine that helps protect the body from the influenza virus) to four (4) of five (5) sampled residents (Residents 48, 14, 3, and 34), reviewed for infection prevention, control, and immunizations (process of protecting a person from a disease by giving a vaccine that helps the body build immunity) upon admission and when appropriate, as indicated in the facility's policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure Resident 96's foley bag (the external collection pouch attached to a thin, sterile tube inserted into the bladder to drain urine) was covered with a dignity bag for one (1) of two (2) sampled residents (Residents 96) reviewed for dignity. This deficient practice may compromise Resident 96 's psychological well-being, social interaction, personal privacy and dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure three (3) of 3 sampled residents (Residents 57, 72 and 103) who were discharged from Medicare Part A (a type of insurance that covers skilled nursing home stays) coverage in the last six (6) months received a Notice of Medicare Non-Coverage (NOMNC; form that notifies someone when their Medicare Part A benefits will expire and allows them to file an appeal) before their Medicare Part A coverage ended. This deficient practice had the potential to result in resident and/ or resident's responsible party not being able to exercise their right to file an appeal.

Inspectors wroteBased on interview and record review, the facility failed to ensure an ordered orthopedic (ortho- the branch of medicine focused on the diagnosis, treatment, prevention, and rehabilitation of the musculoskeletal system) appointment was scheduled for (1) of 31 sampled residents (Resident 48) per physician's order. This failure resulted in a delayed evaluation, services and care related to Resident 48's left hip pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) for one (1) of 1 sampled residents (Resident 5) reviewed for pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was at the correct settings in accordance with the facility's policy and procedure (P&P) and physician's order. On 6/8/2026, Resident 5, who weighed 159 pounds (lbs, unit of measurement for weight) LALM setting was set at 180 lbs. This deficient practice placed Resident 5 at risk for deterioration of the resident's current pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain weekly weights from 2/17/2026 through 3/17/2026 and record the fluid intake every shift from 6/1/2026 to 6/11/2026 for one (1) of 1 sampled resident (Resident 48), reviewed for nutrition care area, per the physician's order and care plan. These failures had the potential for Resident 48 to receive inadequate care and interventions to prevent weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order for one of five sampled residents (Resident 68) observed during medication administration by failing to ensure the resident rinsed his mouth after receiving Budesonide Inhalation Suspension (an inhaled corticosteroid [class of drugs that reduce inflammation and immune system activity] medication for the maintenance treatment of asthma [a chronic condition that affects the airways in the lungs and makes it harder to breathe]) as indicated on the facility's policy. This deficient practice had the potential for an increased risk of oral thrush (fungal infection in the mouth), throat irritation, and increased systemic absorption of the medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the food preferences for one (1) of 1 sampled resident (Resident 80), reviewed for food care area, were honored as requested. This failure resulted in a violation of Resident 80's right to have preferred food choices, with the potential for decreased food intake, inadequate nutrition, and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete medical records for one (1) of three (3) sampled Residents (Resident 2), when Resident 2's Notice of Proposed Transfer/Discharge (an official, written document that must be issued before moving a resident to another location or discharging them) did not indicate a reason for the resident's transfer/discharge. This failure resulted in an incomplete notice of transfer/discharge within Resident 2's medical record.

Inspectors wroteBased on interview and record review, the facility failed to educate and offer the Covid-19 (a highly contagious respiratory illness caused by the SARS-CoV-2 virus) vaccine to one (1) of five (5) sampled residents (Resident 48) reviewed for infection prevention, control, and immunizations (process of protecting a person from a disease by giving a vaccine that helps the body build immunity) as indicated in the facility's policy. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the facility's air conditioner was maintained in safe operating condition in accordance with the facility's policy and procedure (P&P) titled Maintenance Service. The air conditioner has water leaking on the floor in a high traffic area near the nursing station. This deficient practice had the potential to create a fall risk hazard for residents walking by the nursing station.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment by failing to: Ensure the ceiling and walls in the residents' hallways across from the second dining or televisions (TV) room on the facility's second floor did not have water leak marks, brownish discoloration and paint peeling off the walls. Ensure three (3) rooms' (Room C, D and E) ceiling and/or walls did not have water leak marks and brownish discoloration. Ensure that Room B did not have a framed painting on the wall with an unidentified greenish and blackish substance spreading from inside the frame to the surrounding wall. Ensure that Room A did not have multiple scratches on the wall, peeling paint on the wall, and a cracked baseboard protruding from the wall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one (1) of six (6) sampled residents (Resident 1) right to be free from sexual abuse (non-consensual [without the person's permission] sexual contact of any type with a resident who does not wish to engage in sexual activity or may not have the capacity to consent) when Resident 2 was observed playing with Resident 1's private part on 1/10/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to report to the state agency (California Department of Public Health- CDPH, where state law provides for jurisdiction in long-term care facilities) an allegation of sexual abuse (non-consensual [without the person's permission] sexual contact of any type with a resident who does not wish to engage in sexual activity or may not have the capacity to consent) within two (2) hours after the allegation was made and the results of the investigation within five (5) working days of the incident for one (1) of six (6) sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further abuse and/or under reporting from the facility. Cross referenced with F600Findings:1. [...]

Inspectors wroteBased on observation, interview and record review, the facility (Facility 1) failed to ensure one (1) of six (6) sampled residents (Resident 2) was admitted to the resident's previous bed (Bed AA) that was on bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) from 1/10/2026 to 1/14/2026. This failure resulted in discharge of Resident 2 from general acute care hospital (GACH) to another Skilled Nursing Facility (SNF) 2 on 1/14/2025 and violates the right of Resident 2 to return to his previous bed that was reserved for the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan for two of three sampled residents (Residents 1 and 3) for the use bed [pad] alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) as indicated in the facility policy. This deficient practice had the potential for Residents 1 and 3 not to receive care and services specific to their needs which could affect the residents' over all well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary treatment interventions for one of three sampled residents (Resident 1). Resident 1 was assessed to have stage II pressure ulcer (Stage 2 PU- a partial-thickness wound that damages the first two layers of skin-the epidermis [the thin, tough, outer layer of skin] and dermis[the thicker, middle layer located beneath]) on the resident's sacrum (a triangular bone in the lower back) on 11/7/2025 and the facility failed to provide wound treatment on 11/8/2025 to 11/10/2025. This failure may result in worsening of the PU and may lead to infection or Resident 1's hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to or failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST-a form that gives seriously ill patients more control over their end-of-life care) form for one (1) of three (3) sampled residents (Resident 1) was accurately complete. This deficient practice had the potential to cause conflict in carrying out the resident's wishes for medical treatment and regarding the resident 1's health care decision.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident specific care plans (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) was developed and implemented for one (1) of two (2) sampled residents (Resident 1) in accordance with the facility policy. This deficient practice had the potential for Resident 1 not to receive interventions specific to the resident's needs which could affect resident's overall health and wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure to ensure the personal fund for one (1) of two (2) sampled residents (Resident 1) was not overcharged. This deficient practice resulted in Resident 1 being overcharged in the share of cost for 11/2024.

Inspectors wroteBased on observation, interview and record review, the facility did not provide the necessary care and services for 1 of 2 sample residents (Resident 1) who had a fall by failing to:1. Ensure Resident 1's fall assessment was accurate and complete.2. Ensure Resident 1's fall was thoroughly investigated by interviewing the roommate.3. Ensure Resident 1's Care Plan was resident centered.4. Ensure Resident 1's Minimum Data Set (MDS) was accurate to reflect the resident needs for Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily).5. Ensure LVN 1 reported and monitored Resident 1 after a suspected fall.6. Ensure Resident 1's fall was monitored and documented on 8/31/2025 11pm to 7am shift, 9/1/2025 3pm to 11pm shift and 11pm to 7am shift, 9/2/2025 3pm to 11am shift and 11pm to 7am shift. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its Resident Rights policy for two (2) of 2 sampled residents (Residents 1 and 2) when they did not accommodate their request to be roomed together as a married couple. This failure had the potential to negatively affect Residents 1 and 2's psychosocial wellbeing. 1. During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of atherosclerosis (the buildup of fats, cholesterol and other substances in and on the artery [a blood vessel that carries oxygen-rich blood from the heart to the rest of the body] walls) of aorta (the largest artery in the body) and cardiomegaly (an enlarged heart). [...]

Inspectors wroteBased on record review and interview, the facility failed to submit the second quarter of 2025 Payroll Based Journal (PBJ- a system for healthcare facilities to submit staffing information. This system allows staffing information to be collected on a regular and more frequent basis than previously collected) for the month from 1/1/2025 to 3/31/ 2025 on the designated time. This deficient practice compromised the accuracy of the facility's staffing levels and potential for the facility to not be adequately staffed and/or have the necessary staff to provide care to meet the needs of all the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and home like environment for seven (7) of 7 sampled residents (Residents 7, 33, 55, 37, 57, 64, and 66) when facility failed to ensure: 1. Resident 33's closet handle was not tied using a plastic bag. 2. Resident 55's bed sheet was not worn out and discolored. 3. and 4. Residents 37 and 57's shared restroom had a rack to hang towels, and the ceiling paint was not peeled off. 5. Resident 64's room wall next to the resident's head of bed area was free of multiple scratches. 6. Resident 7 was provided with a rollator walker's (a mobility aid, essentially a wheeled walker, that provides support and stability for individuals with walking difficulties. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of three (3) sampled resident (Resident 81 and86) was free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body) when the facility failed to: 1. Conduct an assessment for Resident 81 and 86 for the use of geriatric chair (Geri chair- a large, padded, and mobile reclining chair that prevents a resident from rising). 2. Obtain a physician's order for Resident 81 and 86 for the use of Geri chair. These deficient practices had the potential to result in limiting Resident 81 and 86's mobility and cause injury. [...]

Inspectors wroteBased on interview and record review the facility failed to implement its abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish and includes verbal abuse [a range of words of behaviors used to manipulate, intimidate, and maintain power and control over someone]) policy for two (2) of 2 sampled residents (Residents 15 and 241) by failing to report an allegation of abuse to the state agency (CDPH, California Department of Public Health), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement (Police Department) within 2 hours. This deficient practice had the potential to compromise or impede the protection of Resident 15 from further abuse, which could affect the residents' emotional and mental wellbeing.

Inspectors wrote2. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 54's diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), pressure ulcer of right heel unstageable (a type of pressure injury where the true depth of the wound cannot be determined due to the presence of dead tissue obscuring the wound bed.), and type II type 2 diabetes mellitus (a medication condition characterized by the body's inability to regulate blood sugar level). During a review of Resident 54's MDS, dated [DATE], the MDS indicated Resident 54's cognitive skill for daily decision making was moderately impaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of five (5) sampled residents (Resident 55 and 84) as indicated on the facility policy and physician's order when during a Medication Pass observation, Licensed Vocational Nurse 4 (LVN 4) failed to administer Resident 55 and 84's medications within 60 minutes of scheduled time of 9 AM on 6/11/2025. This deficient practice had the potential to result in Resident's 55 and 84 not obtaining the therapeutic level (medicine levels in your blood are in a range that is medically helpful but not dangerous) of the medication, which could lead to complication and negatively affect the overall wellbeing of the residents. Cross reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Eight (8) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles out of 25 total opportunities (observed administered medications) for error, to yield an overall medication error rate of 32 % for one (2) of five (5) sampled residents (Resident 55 and Resident 84) observed for medication administration. Licensed Vocational Nurse 4 (LVN 4) failed to administer Resident 55 and 84's medications within 60 minutes of scheduled time of 9 AM on 6/11/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure by failing to label food that were stored in the kitchen refrigerator and freezer. This deficient practice had the potential to place residents at risk for developing food borne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, and diarrhea, which could lead to other serious medical complications and hospitalization

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its policy and procedure on infection control for four (2) of 23 sampled residents (Resident 24 and 29) and in the laundry when: 1. Staff did not use personal protective equipment (PPE, used to prevent or minimize exposure and to protect from potential transmission of biological agents that can be transferred from person to person by direct and indirect contact) while rendering care to Resident 24 who was on enhanced barrier precaution (EBP, use of PPE beyond anticipated blood and body fluid exposures) on 6/9/2025. 2. PPE cart and EBP signage was not available outside Resident 29's room who was on EBP precaution. 3. [...]

Inspectors wroteBased on interview and records review failed to ensure dementia management was included to the nurse aide in-services at least 12 hours in a year for (2) two out of (2) two sampled certified nursing assistant (CNA) employees. These deficient practices may result in a potential compromised resident safety and reduced quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote dignity and respect for one of two sampled residents (Resident 24) when Certified Nurse Assistant 5 (CNA 5) was observed standing above Resident 24's eye level while assisting the resident during mealtime on 6/10/2025. This deficient practice had the potential to affect Resident 24's self-esteem and self-worth and violate the resident's right to be treated with dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of six (6) sampled residents (Resident 85 and 86) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure (P&P) by failing to ensure Resident 85 and 86's Lorazepam (medication used to treat anxiety [persistent and excessive worry that interferes with daily activities) as needed (PRN) order was discontinued after 14 days from the order date. This deficient practice had the potential to place Resident 85 and 86 at risk for significant adverse consequences from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper care and treatment for gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) for one of two (2) sampled residents (Resident 28) by failing to: a. Check Resident 28's G-tube placement by checking the gastric residual volume (GRV, the amount of liquid drained from a stomach following administration of enteral feed [a method of providing nutrition directly into the gastrointestinal (GI) tract when a person cannot consume enough food or nutrients orally]) b. Disinfect the tip of the resident's G-tube before administering G-tube feeding (a liquid food mixture provided through the G-tube). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the head of bed for one (1) of 23 sampled residents (Resident 34) who was on oxygen therapy for shortness of breath was maintained at 30 to 45 degrees (unit of measurement) in accordance with facility's policy and procedure. This deficient practice had the potential to cause complications including for Resident 34 to have increase work of breathing and respiratory distress that can lead to hospitalization and death.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 29), who was receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment was provided dialysis care and services by failing to assess the resident's right femoral dialysis access site (the use of the femoral vein, located in the groin area, as a point of entry for dialysis catheter [a thin tube that is placed under the skin in a vein, allowing long-term access to the vein]) on 5/24/2025, 5/27/2025, 5/29/2025, 5/31/2025, and 6/3/2025 in accordance with the facility policy and physician's order. This deficient practice had the potential for complications such as bleeding or infection and potential for unnoticed or missed excessive bleeding and infection on Resident 29's right femoral central venous catheter dialysis access.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a Registered Nurse (RN) on duty for at least eight (8) consecutive hours on 6/1/2025 to ensure all the residents' clinical needs were met either directly by the RN or indirectly by the Licensed Vocational Nurses (LVNs) or Certified Nurse Assistants (CNAs) for whom the RN was responsible for overseeing resident care. This failure had the potential to result in the delay in care and services and harm to residents.

Inspectors wroteBased on interview and record review the facility failed to ensure the irregularities (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) on the Medication Regimen Review (MRR, consists of a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one (1) of five (5) sampled Residents (Resident 86) was reported to the resident's primary physician in accordance with the facility policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one (1) of 23 sampled residents (Resident 29) as indicated on the facility policy and physician's order by failing to administer Resident 29's calcium acetate (a medicine to treat high level of phosphate [necessary for the formation of bones and teeth] in the blood]) with food on 6/12/2025. This deficient practice had the potential to result in Residents 29 not obtaining the therapeutic level (medicine levels in your blood are in a range that is medically helpful but not dangerous) of the medication, which could lead to complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its Medication Storage policy by failing to: 1. Properly dispose expired and discontinued medications in the incineration (burn) bin in medication storage room [ROOM NUMBER] (MSR 1). This deficient practice increased the risk for residents to accidentally receive the medication that had become ineffective or toxic due to improper storage which could possibly lead to health complications, which may result to harm and hospitalization. 2. Ensure non-licensed nurse was left alone inside medication room [ROOM NUMBER] (MSR 2). This deficient practice increased the risk for medications to be mishandled and improperly dispensed and administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and properly store the food found in the resident's room for one (1) of 23 sampled residents (Resident 54) in accordance with the facility policy. This deficient practice had the potential to result in food-born illnesses (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever, other serious medical complications, and hospitalization.

Inspectors wroteBased on observation and interview, the facility failed to have a functioning call light system for one (1) out of 23 sampled residents (Resident 55) in accordance with the facility's call light policy. This failure had the potential to prevent Resident 55 from receiving assistance for needs in a prompt and timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 11 of 41 resident rooms (rooms 105, 108, 116, 201, 203, 205, 207, 212, 214, 218 and 222) met the square footage requirement of 80 square feet (sq. ft.) per resident in a multiple resident room. This failure had the potential to affect the residents' personal space, decrease freedom of mobility and could compromise the provision of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 1), who has a diagnosis of nontraumatic (not caused by trauma or injury to the body) intracerebral hemorrhage (ICH, also known as hemorrhagic stroke [medical emergency where bleeding occurs within the brain tissue]) in brain stem (the lower part of the brain that connects to the spinal cord [a tube of tissue that carries nerve signals from the brain to the rest of the body]), assessed with severe cognitive impairment (ability to think, remember and reason) for daily decision making, and at risk for elopement (a resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected) was supervised to prevent injury and did not elope on 5/30/2025 between 8:40 AM to 9:30 AM by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) for abuse (the willful infliction of physical or psychological harm or the knowing deprivation of goods or services that are necessary to meet essential needs or to avoid physical or psychological harm) prevention, reporting, and investigation for two of three sampled residents (Resident 1 and Resident 2) by failing to: 1. Report physical abuse (any intentional act causing injury or trauma to another person) by Resident 3 to Resident 2 within two hours from when the Activities Assistant (AA) witnessed Resident 3 punching (strike with a fist) Resident 2 on the chest while waiting inside the elevator on 4/15/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) right to be free from sexual abuse (non-consensual [without the person's permission] touching of one person for the sexual gratification of another) on 5/6/2025 by failing to ensure: 1. Resident 1 was protected from sexual abuse by Resident 3. On 5/6/2025, while Resident 1 was sitting on her wheelchair along the hallway in front of Room A, Resident 3 touched Resident 1 on her inner thigh and later Resident 3 was witnessed touching Resident 1's upper back by placing his hands inside Resident 1's shirt. 2. Resident 1 was protected from further abuse by Resident 3 when facility staff did not separate Resident 1 from Resident 3. On 5/6/2025, Resident 1 and Resident 3 attended the same recreational group activity in the Activities Room. 3. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure three of three sampled residents (Resident 1, 2 and 3) received treatment and care in accordance with professional standards of practice by failing to: 1. a. Assess and monitor Resident 1's physical, emotional, and mental status after a change in condition on 5/6/2025 when she was inappropriately touched on her inner thigh and upper back by Resident 3. b. Develop a resident-centered care plan for Resident 1 addressing an incident on 5/6/2025 after Resident 1 was inappropriately touched on her inner thigh and upper back by Resident 3 c. Inform the physician after Resident 1 was inappropriately touched on her inner thigh and upper back by Resident 3. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to maintain an accurately documented medical records for two of three sampled residents (Resident 1 and Resident 3) when: 1. Charge Nurse 1 (CN 1) initiated Resident 3's SBAR (Situation, Background, Assessment, Recommendation - a structured communication tool used to improve clean and efficient communication, especially in critical situations or when transferring information between health-care professionals) that indicated Resident 3 inappropriately touched a staff (unknown) instead of Resident 1. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) were free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when Resident 1 allegedly grabbed Resident 2 by the neck and shook Resident 2 on 2/23/2025. This deficient practice resulted in Resident 1 had a scratch to left side of the neck and had the potential to negatively affect Resident 1's comfort and psychosocial (having to do with the mental, emotional, social, and spiritual effects of a disease) well-being which can lead to hospitalization and/ or death.

Inspectors wroteBased on observation, interview and record review, facility failed to ensure wander guard (used to keep track of patients) was checked for functionality and expiration date according with the facility's policy and procedure (P&P) titled Wander Guard, for one of two sampled resident (Resident 1) who was cognitively (ability to think and reason) impaired and displayed behaviors of wandering (walking around aimlessly without a fixed plan) in the facility. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the building in good repair and free from hazards in accordance with the facility's policy and procedure (P&P) titled Maintenance Service. The facility did not repair dark brown, moldy (covered with a fungal growth that causes decay, due to damp conditions) looking water damage and an opening in the ceiling of the second-floor dining room (Dinning room [ROOM NUMBER]). Furthermore, the facility did not close off Dining room [ROOM NUMBER] to residents upon discovering water damage and hole in ceiling. These deficient practices had the potential to expose residents to mold and debris from the opening in the ceiling roof of Dining room [ROOM NUMBER] which may cause illness to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and comfortable environment to their 52 residents residing at the facility's second floor by failing to ensure that there was no leakage in the second floor's ceiling located above Shower room [ROOM NUMBER] (shower room used for the residents) and hallway across room [ROOM NUMBER]. This deficient practice had the potential to result in ceiling collapse (fall down) and had the potential for residents to be placed at risk for injury.

Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedure titled Advance Directive (a written statement of a resident's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the resident be unable to communicate them) by not providing a written information to three (3) of seven (7) sampled residents (Residents 47, 2, and 10) concerning the option to formulate an advance directive. This deficient practice violated Resident 47, 2, and 10 the right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for two (2) of three (3) sampled residents (Resident 92 and 22) in accordance with the facility's policy and care plan by failing to: 1. Administer oxygen at 2 liters per minute (lpm, unit of measurement) via nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) to Resident 92 as indicated on the physician's order. This deficient practice had the potential to result in respiratory distress and/or other complications to Resident 92. 2. Keep Residents 22's oxygen nasal cannula (NC, a device that delivers extra oxygen through a tube into your nose) tubing sprawled out on and touching the floor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two outside garbage dumpsters' lids were fully closed per facility policy and procedure (P&P). This failure had the potential to attract pests and insects to the facility and can place its resident's health at risk for potential infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures as indicated on the facility policy when facility failed to establish and maintain an effective water management program to prevent the development and transmission of Legionnaire's disease (LD, a serious and often deadly form of lung infection [pneumonia], acquired by breathing in water droplets caused by the bacteria, legionella [the bacteria that causes LD]). This deficient practice placed the residents in the facility at risk for developing severe respiratory infection (pneumonia).

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately equip and allow resident to call for staff assistance for five (5) of 24 sampled residents (Residents 74, 55, 79, 26 and 46) by: 1., 2, and 3. Failing to ensure the call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach of Residents 74, 26 and 46 as indicated in the facility's policy and procedure. 4. and 5. Failing to ensure the call light was working for Resident 79 and 55. This deficient practice had the potential not to meet Resident 74, 55, 79, 26 and 46's needs and preference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided a homelike environment for three of 13 sampled residents (Residents 79,76, and 55) for the environment care area by: 1. and 2. Failed to provide Resident's 79 and 76 with a clean and comfortable environment. The resident's room have unfinished patching, water marks and peeling paint on the ceilings and walls. 3. Failed to provide Resident's 55 a clean room by having white towels on the floor. 4. Failed to ensure ceiling in the resident's hallways in the first and second floor did not have water leak marks and brownish discoloration. These deficient practices had the potential for an unsafe and unclean resident's environment and had the potential to negatively affect the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an effective pest control program for gnats' (small, winged insect) infestation, which affected three (3) of 24 sampled residents (Residents 2, 70, and 89). This deficient practice had the potential to cause itchy, painful bites to Residents 2, 70, and 89, which could result to open sores (an ulcer) that are susceptible to bacterial infection. This also had the potential for transmission of infectious diseases to other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained the resident's dignity and respect in full recognition of their individuality for one of one sampled resident (Resident 30) by failing to ensure Resident 30's indwelling catheter (a tube inserted into the bladder to help drain urine) collection bag (designed to collect urine drained from the bladder via a catheter or sheath) as covered with a dignity bag (a bag used to cover and hold the catheter drainage/collection bag so it is not visible). This deficient practice violated Resident 30's right for privacy and had the potential to affect Resident 30's self-worth, self-esteem, and psychosocial well-being (the state of mental, emotional, and social health of an individual).

Inspectors wroteCross reference F610 Based on interview and record review, the facility failed to report an allegation of verbal abuse (a range of words of behaviors used to manipulate, intimidate and maintain power and control over someone) within two hours for two (2) of 24 sampled residents (Residents 28 and 77) to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement, in accordance with the facility's abuse policy. This deficient practice has the potential to result in unreported abuse in the facility and failure to protect Resident 28 and other residents from abuse.

Inspectors wroteCross reference: F609 Based on interview and record review, the facility failed to investigate an allegation of verbal abuse (a range of words of behaviors used to manipulate, intimidate and maintain power and control over someone) for two (2) of 24 sampled residents (Residents 28 & 77) as indicated in the facility's abuse policy when Resident 77 used inappropriate verbal language with Resident 28. This failure had the potential to result in failing to protect Resident 28 and other residents from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise and update the care plan as indicated on the facility policy and procedure to address Resident 2's preference for activities of daily living (ADL) while in the shower. This deficient practice placed Resident 2 at risk of not having appropriate care and interventions during showering and potential to violate resident's rights to choose preferred care.

Inspectors wroteBased on interview and record review, the facility failed to provide care services to prevent worsening and promote healing of pressure ulcer/injury (damaged skin caused by staying in one position for too long) for one of three sample residents (Resident 26) who was admitted in the facility with a UTD (unable to determine or unstageable pressure ulcer). The facility did not accurately monitor and set the correct settings of the low air loss mattress (LALM, is designed to prevent and to treat pressure sores, or pressure ulcers) according to Resident 26's weight. These deficient practices placed Resident 26 at risk of poor wound healing and deterioration of current pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate services to prevent complications for one of three sampled residents (Resident 46) who has G-tube (GT, is a tube inserted through the belly that brings nutrition directly to the stomach).observe infection control measures for Resident 46: 1. Failed to ensure Resident 46's [NAME] valve (a device allowing movement in one direction only to use for the administration of medication without having to disconnect a suction or feeding line and reduces exposure to potentially infectious bodily fluids or gastric secretions) was covered at GT site. 2. Failed to ensure Resident 46's enteral tube feeding (delivery of liquid nutrients through a tube directly into the gastrointestinal tract) equipment were cleaned and did not have an accumulation of dried brown stains. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a one (1) of 1 sampled resident (Resident 33) who was receiving dialysis (process of removing waste products and excess fluid from the body) received care and treatment in accordance with the resident's care plan by failing to ensure a dialysis emergency kit was placed at bedside. This deficient practice had the potential for Residents 33 to be at risk for complications such as bleeding and potential for delay in provision of dialysis care and treatment in case of emergencies.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy on Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for two of five sampled residents (Residents 15 and 40) by failing to: 1. Conduct an MRR for Resident 15 for May 2024 2. Act upon the pharmacy recommendations for Resident 40's MRR for May 2024 This deficient practice had the potential to result in adverse medication outcome for potential unnecessary medications to Residents 15 and 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to properly label the medications of one (1) of 24 sampled residents (Resident 19) as indicated on the facility policy. This deficient practice had the potential for adverse reaction if these improperly labeled medications were administered to Resident 19 in the wrong route.

Inspectors wroteBased on interview and record review, the facility failed to ensure a bladder retraining program (use of a timed schedule for bladder based on the resident's identified need and routine to maximize control of the resident ' s bladder function as much as possible) and scheduled toileting program (use of a timed schedule for bowel movement to match the resident's bowel habits) were implemented for one of three sampled residents (Resident 1) as indicated on the facility policy. This deficient practice had the potential to result in not restoring the resident ' s bowel and bladder function, development of urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder, or urethra), and fall.

Inspectors wroteBased on interview and record review, the facility failed to have a Cardiopulmonary Resuscitation (CPR, refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased) team per shift to ensure effective delivery of basic life support (level of medical care which is used for victims of life- threatening illnesses or injuries until they can be given full medical care at a hospital and may include recognition of sudden cardiac arrest [is when the heart stops beating suddenly]) for one (1) of seven (7) sampled residents (Resident 1) in accordance with the facility's policy and 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the facility has a complete progress notes provided in the resident's medical record for one (1) of six (6) sampled residents (Resident 1) per facility's policy and procedure. This deficient practice had the potential to result in miscommunication and improper delivery of care and inaccurate information of the care provided to the resident during the medical emergency.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the administration of Hydrocodone and acetaminophen (Norco, controlled medication given for moderate to severe pain [pain sale of four to seven out of ten [10 as the most painful]) 5-325 milligram (mg, unit of measurement) tablet on 1/16/24 as indicated in the physician order for one (1) of three sample residents (Resident 3). The facility also failed to ensure Norco 5- 325 mg 1 tablet was not missing on 1/6/24. This deficient practice had the potential for Resident 3's pain no to be relieved which can affect residents over all wellbeing and for potential abuse of controlled medications (are substances that have an accepted medical use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of two sampled residents (Resident 1) from physical harm during the dialysis (a process of purifying the blood of a person whose kidneys are not working normally) by not implementing the facility's Abuse Prevention Program Policy. This deficient practice placed the resident at risk for harm and injury.