Inland Valley Care and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure related injury prevention practices for four of five sampled residents (Residents 2, 3, 5 and 6) by failing to ensure nursing staff set residents' low air loss mattress ([LALM], a mattress that provides airflow to help keep skin dry, as well as to relieve pressure, treat pressure sores and prevents pressure sores) according to Residents 2, 3, 5 and 6's weight. These deficient practices placed Residents 2, 3, 5 and 6 at risk for developing pressure injuries (localized area of tissue damage that develops when prolonged pressure or shear forces are applied to the skin and underlying tissues) and put these residents at risk for further skin damage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer enteral feeding (delivering liquid food and nutrients directly into the stomach or small intestine) per physician's order for two of four sampled residents (Residents 7 and 8) by failing to ensure Resident 7 and Resident 8 received the correct enteral feeding formula per the physician's order. This deficient practice caused enteral feeding error for Resident 7 and Resident 8, and potentially placed Resident 7 and Resident 8 at risk for adverse effects of the wrong feeding formula (liquid medical food delivered directly into the stomach through an abdominal opening).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide safe oxygen administration practices ([oxygen therapy], is the medical practice of delivering oxygen at a concentration greater than ambient air) for three of four sampled residents (Residents 4, 5, 6) by failing to: 1. Ensure Residents 5, and 6's nasal cannulas (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) were dated with an open/change dates and did not ensure nasal cannula was not touching the floor. 2. Ensure Resident 4 had an order for oxygen administration before administering oxygen to Resident 4. 3. Ensure Resident 4's nasal cannula was dated and placed in a bag when not in use and did not ensure humidifier bottle (a medical device that adds water vapor to dry supplemental oxygen before it reaches a patient) was changed. [...]

Inspectors wroteBased on interview and record review the facility failed to implement its abuse reporting and investigating policy by failing to report an alleged abuse for one of two sampled residents (Resident 9) by failing to: 1. Report an allegation of abuse to the Department of Public Health (DPH) after Resident 9 notified facility's staff of an alleged abuse. 2. Ensure to notify DPH within two hours of an alleged abuse allegation. These deficient practices violated Resident 9's right and resulted in unidentified alleged abuse in the facility and failed to protect Resident 9 from further abuse.

Inspectors wroteBased on observation and interview, the facility staff failed to assist a dependent resident who was unable to carry out activities of daily living (ADLs) for one of three sampled residents (Resident 2) when: 1. Facility's staff did not ensure Resident 2's nails were clean and trimmed. This deficient practice caused Resident 2's fingernails to dig into Resident 2's palm and had the potential to result in a negative impact on Residents 2's quality of life and Resident 2's quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of gnats in one of six nurse stations (station 3). This failure had the potential to place the residents in station 3 at risk of severe eye infections like pinkeye (inflammation or infection of the eyelid and eyeball), ingestion of contaminated food leading to gastrointestinal illness (any condition affecting the digestive tract, which includes the esophagus, stomach, intestines, liver, pancreas, and gallbladder), and psychological distress due to gnats being present in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly notify one of three sampled residents (Resident 4's) Responsible Party Guardian (RPG 1) and FM 1 regarding Resident 4's self-inflicting injury to Resident 4's left wrist. This failure resulted in Resident 4's representatives not being informed of Resident 4's change in condition and not being aware Resident 4 was transferred to General Acute Care Hospital (GACH 1) on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled alleged staff (Licensed Vocational Nurse 1 [LVN 1]), who was involved in an allegation of staff to resident abuse involving one of three sampled residents (Resident 1), received a performance evaluation (PE - a review based upon an individual's job performance and assigned duties) at least once every twelve (12) months. This deficient practice resulted in the facility's failure to assess and evaluate the skills and competencies of LVN 1 and placed Resident 1 and other residents assigned to LVN 1, at risk for inadequate and unsafe care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of nine sampled residents (Resident 2) and Family Member 1 (FM 1) was informed and involved in the resident's ongoing treatment plan. This failure violated Resident 2's rights and resulted in Resident 1 and FM 1 being unaware of Resident 2's current treatment plan. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted by the facility on 5/19/2026, with diagnoses that included fracture of the neck of the right femur (a break near the ball of the right hip joint) and dislocation of the right shoulder (when the ball of right upper arm bone popped out of the shoulder socket). [...]

Inspectors wroteBased on observation, interview, and records review the facility failed to provide sufficient staffing to accommodate residents' needs when the facility failed to appropriately redistribute resident assignments after Licensed Vocational Nurse 1 (LVN 1) left the facility prior to the completion of LVN 1's shift, resulting in LVN 3 being responsible for approximately 14 residents for one of three shift (Shift 1/Day Shift, 7 am to 3:30 pm). This deficient practice had the potential to result in residents not receiving needed services timely and efficiently during the day shift on 6/14/2026.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT, a tube surgically placed through the abdomen and into the stomach, and used to administer nutrition, liquids, or medications) flush water bag (used to administer water through the GT) and tubing was changed before exceeding the expiration date (within 24 hours) for one of three sampled residents (Resident 2). This deficiency practice resulted in Resident 2 not receiving the appropriate care and services on feeding tube and placing Resident 2 at risk for health complications. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor one of three sampled residents' (Resident 1's) response to pain medication when Resident 1's heart rate (HR, the number of times the heart beats in a minute, also known as the pulse rate) was not assessed one hour after pain medication was given to Resident 1. This deficiency practice resulted in Resident 1 not receiving the appropriate care and services on pain management and placed Resident 1 at risk for ineffective pain control. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the allegation of abuse for one of two sampled residents (Resident 1) was reported to the California Department of Public Health (CDPH), Ombudsman (agency that helps residents and families with complaints about healthcare services), and the local police within two hours in accordance with the facility's Policy and Procedure (P&P) titled Abuse Reporting and Investigation, when: On 6/3/2026, Certified Nursing Assistant 2 (CNA 2) reported to Licensed Vocational Nurse 2 (LVN 2) that CNA 2 witnessed Resident 2 threw a pitcher filled with water at Resident 1 and hit Resident 1. On 6/4/2026, Resident 1 reported to Registered Nurse 1 (RN 1) that Resident 2 threw a pitcher filled with water at Resident 1 on 6/3/2026, which hit Resident 1's head. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control for one of two sampled residents when two urinals (a handheld plastic container designed for residents to urinate into) were observed on top of Resident 3's bedside tray table next to a food tray containing Resident 3's breakfast meal. This deficient practice had the potential to spread infection in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the residents' dignity for three of four sampled residents (Residents 1, 3 and Resident 4) by failing to:1. Provide peri care (washing/cleaning the genitals/anal area) to Resident 1.2. Answer Residents 1 and 3's call light promptly.3. To assist Resident 3 with activities of daily living (ADLs).4. To assist Resident 4 with ADLs upon returning from dialysis (procedure to remove wastes or toxins from the blood and adjust fluid and electrolyte imbalances). These deficient practices did not maintain the residents' dignity and the residents' highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light system was functioning for one of one sampled resident (Resident 2). This deficient practice placed Resident 2 at risk for delays in care and services affecting the resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide and document sufficient preparation and orientation to ensure a safe and orderly discharge for one (1) of 20 sampled residents (Resident 8) when:The facility failed to conduct a Discharge Planning Review prior to discharge. The facility failed to complete a Discharge Summary/Comprehensive Assessment (DSCA) and to provide Resident 8's caregiver upon discharge from the facility. The facility failed to provide caregiver training to Resident 8's caregiver. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform one (1) of 20 sampled residents (Resident 1), in writing, why Resident 1's bedside dialysis (hemodialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) services will not be covered by Resident 1's insurance. This deficient practice had the potential to result in Resident 1 not receiving the appropriate care and services and impairing Resident 1's physical and psychosocial well-being. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/15/2026 with diagnoses which included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD- irreversible kidney failure), and dependence on renal dialysis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable, homelike environment by not fixing the window curtain from falling off the curtain rail for one (1) of 20 sampled residents (Resident 3). This deficient practice violated Resident 1's right to have a comfortable, homelike environment and had the potential to violate Resident 1's privacy and affect Resident 1's physical and psychosocial well-being. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurate for one (1) of 20 sampled residents (Resident 8) when Resident 8's MDS, dated [DATE], incorrectly indicated Resident 8 did not have any pressure ulcer/injuries (localized injury to the skin and/or underlying tissue) upon discharge from the facility on 2/23/2026. [...]

Inspectors wroteBased on interview and record review, the Wound Care Specialist (WCS) inaccurately diagnosed on e (1) of 20 sampled resident's (Resident 8) pressure injury (localized injury to the skin and/or underlying tissue) as a diabetic foot ulcer (ulcers [an open sore] caused by the neuropathic [a condition, disease, or pain caused by damage or malfunction in the nervous system] and small blood vessel complications of diabetes [a chronic condition that affects the way the body processes blood sugar]). [...]

Inspectors wroteBased on interview and record review, the facility failed to create a care plan to ensure one (1) of 20 sampled residents (Resident 8), who was at high risk to develop pressure injury/ulcer (localized injury to the skin and/or underlying tissue), received interventions to prevent Resident 8 from developing a pressure injury/ulcer. This failure resulted in Resident 8 developing pressure injury to Resident 8's left heel while at the facility.(Cross reference F627, F641, and F658)During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on [DATE] with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), chronic pain, and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). [...]

Inspectors wroteBased on interview and record review, the facility failed to arrange transportation to ensure one (1) of 20 sampled residents (Resident 3) received dialysis (hemodialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) on 4/13/2026 and on 4/20/2026 as scheduled. This deficient practice resulted in Resident 3 missing two (2) dialysis treatments, placing Resident 3 at risk for serious health complications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice by failing to perform reassessment, repeat blood pressure measurement or physician notification by the licensed nurse following the elevated blood pressure reading of Resident 1 on 2/27/2026. This deficient practice placed Resident 1 at risk of harm.

Inspectors wroteBased on observation, interview and record review the facility failed to accommodate the needs for two (2) of 22 sampled residents (Resident 1 and Resident 2) when: 1. The facility did not ensure the call light (a device used by a resident to signal his or her need for assistance from staff) system was audible (able to be heard) for staff (in general) to hear. 2. The facility did not ensure the call light was answered in a timely manner for Resident 1 and Resident 2. These deficient practices resulted in Resident 1's and Resident 2's calls for assistance to be unanswered and for the residents to feel ignored. These deficient practices also placed Resident 1 and Resident 2 at risk for a delayed emergency response, accidents, or prolonged incontinence (lack of voluntary control over urination or defecation/bowel movement).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure fluids were provided to two (2) of 22 sampled residents (Resident 1 and 2) to maintain hydration (having enough water or fluids in the body) when Resident 1 and Resident 2 did not have a water pitcher in their room. This deficient practice had the potential to cause dehydration (absence of enough water or fluids in the body) which could lead to severe health complications for Resident 1 and Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the light fixture above the resident's bed was operable (functional) for one (1) of 22 sampled residents (Resident 13). This deficient practice violated Resident 13's right to a safe, comfortable and homelike environment.

Inspectors wroteBased on interview and record review the facility failed to provide medically related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) to one (1) of 22 sampled residents (Resident 15) when the Case Manager (CM- healthcare professional who supports, guides, and coordinates care for residents, families and caregivers) did not meet with Resident 15 upon Resident 15's request. This deficient practice resulted in Resident 15 not being seen by the CM from 2/10/2026 to 2/23/2026 which caused Resident 15 to be unaware of Resident 15's discharge plan and caused Resident 15's mental stress.

Inspectors wroteBased on interview and record review, the facility failed to promote and protect the rights of two of three sampled residents (Residents 6 and 17) and/or their representatives to voice grievances (any formal or informal complaint about care or living conditions) and to have those grievances addressed promptly and thoroughly when:Facility staff failed to guide complainants (in general) on how to file written grievances and/or were unaware of grievance form locations or the identity of the facility's Grievance Officer. For Resident 6, the facility failed to investigate thoroughly and document the investigation regarding the grievances Resident 6's family member (RR 1) submitted to the facility on [DATE]. The facility also failed to inform (verbally and in writing) RR 1 of the findings of the investigation and the actions that will be taken to correct any identified problems. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Residents 6), was provided with a clean, comfortable, and homelike environment when the sliding screen door in Resident 6's room would not latch and lock closed. This failure had the potential for Resident 6 not to feel safe and comfortable while in the care of the facility. During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 6/18/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse Reporting and Investigation, for one of two sampled residents (Resident 2) by failing to ensure Social Services Assistant (SSA) 1 reported Resident 1's episode of yelling at Resident 2 and at Resident 2's family member (RR 2) and Resident 1's verbalization of harming Resident 2 on 1/28/2026. This deficient practice resulted in Resident 1's verbalization of harming Resident 2 to not be investigated and reported and placed Resident 2 at risk for abuse or harm by Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide foot care and treatment and failed to assist the resident in making appointments with a podiatrist (medical doctor focused on the treatment of disorders of the foot, ankle, and the lower leg) for one of three sampled residents (Resident 6). This failure had the potential in Resident 6 to experience compromised foot health and overall quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the attending physician or designee wrote, signed, and dated original progress notes at each required visit for one of three sampled residents (Resident 6) when Resident 6's Nurse Practitioner (NP- a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) photocopied the previous month's progress notes for visits on 8/4/2025, 9/5/2025, 10/6/2025, 11/7/2025, 12/7/2025, and 1/26/2026. This failure had the potential to result in overlooked changes in Resident 6's health status and had the potential for compromised physician oversight of Resident 6's total program of care.(Cross Reference F585, F790, and F804)

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist one of three sampled residents (Resident 6) in obtaining routine dental services to meet the resident's oral health needs, when the facility did not ensure timely follow-up or coordination after the dentist visit on 12/8/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hot foods were served at a palatable, safe, and appetizing temperature for one of three sampled residents (Residents 6), when Resident 6's food was served cold. This failure had the potential for Resident 6 to experience weight loss and/or dehydration.(Cross Reference F585, F711, and F790)During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 6/18/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). [...]

Inspectors wroteBased on interview, and record review, the facility staff members failed to provide peri-care (the cleaning and maintenance of the perineum, the area between the anus and the genitals) for two of three sampled residents (Residents 2 and 3) who required physical assistance with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after urinating or having a bowel movement). This deficient practice had the potential to place Residents 2 and 3 at risk for increased risk for infection, skin breakdown and further potential health complications.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing, resulting in toileting and/or incontinent care not being provided for two of three sampled residents (Residents 2 and 3) in a timely manner. This failure had the potential to result in Residents 2 and 3 experiencing skin breakdown and/or placing the residents at risk for urinary tract infection (UTI, an infection in any part of the urinary system).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to one of three sampled residents (Resident 3) by failing to ensure: 1. RNA 1 correctly applied Resident 3's right palm protector as indicated by rehabilitation staff. 2. RNA 1 and RNA 2 informed nursing staff when Resident 3's right palm and hand was known to get sweaty and develop moisture accumulation between the right thumb and index finger. These failures resulted in Resident 3 developing multiple open skin wounds on Resident 3's right thumb and index finger, and Resident 3 developed redness and an indentation on Resident 3's index finger knuckle. 3. [...]

Inspectors wroteBased on observation, interview , and record review, the facility failed to provide a safe environment that allow residents who wish to smoke, the opportunity to do so with optimal safety of themselves and others for two of eight sampled residents (Residents 4 and 5) according to the facility's policy and procedure (P&P) titled, Smoking by Residents, by failing to: Ensure Activities Assistant (AA) 1 provided adequate supervision (oversight, encouragement, or cueing) while Residents 4 and 5 were smoking on 11/13/2025 at 1 pm. As a result of this failure, AA 1 did not visualize Residents 4 and 5 smoking at the smoking patio. This failure placed Residents 4 and 5's safety at risk and had the potential for the residents to sustain cigarette burns (an injury to the skin's tissues caused by heat) and being harmful to themselves, each other, and being susceptible to abuse.

Inspectors wroteBased on interview and record review, the facility failed to protect a residents' right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one of three sampled residents (Resident 8) when Resident 9 pushed Resident 8 during an altercation on [DATE]. This failure resulted in Resident 8 falling to the floor, sustaining a laceration (a pattern of injury in which skin and underlying tissues are cut or torn) to the back of Resident 8's head and a fracture (broken bone) to Resident 8's right elbow.

Inspectors wroteBased on interview and record review, the facility failed to arrange for a safe and orderly discharge for one of two sampled residents (Resident 7) when the facility failed to communicate Resident 7's medical conditions and needs to Intermediate Care Facility (ICF, provides long-term care for individuals who need more assistance than residential care but less than a skilled nursing facility) 1 prior to Resident 7's transfer to ICF 1. This failure had the potential for Resident 7 to experience an unsafe discharge due to receiving inappropriate and or inadequate care.

Inspectors wroteBased on interview and record review, the facility failed to provide one of three sampled residents (Resident 14) or the Resident's Representative a copy of the Resident 14's medical record upon request and within two working days from notice per the facility's Policy and Procedure (P&P) titled, Residents Access to Records. This failure resulted in violation of Resident 14's rights and in Resident 14's Representatives not receiving the medical records in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled resident (Resident 8) from medication administration error in accordance with prescriber orders as indicated in the facility's policy and procedure (P&P) titled, Administering Medications. This failure resulted in Resident 8 administered melatonin (a hormone supplement that signals the body that it's time to sleep) pills without a physician order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the privacy and dignity of seven of seven sampled residents (Resident 11, Resident 27, Resident 33, Resident 45, Resident 116, Resident 136, and Resident 239), by failing to: A. Ensure the privacy curtain was closed while providing care and treatment to Resident 33. B. Ensure Resident 116 did not experience an extended waiting time for care for approximately one hour. C. Ensure Resident 45 and Resident 239 did not experience an extended wait time to receive care for approximately 30 minutes to 2.5 hours. D. Ensure Resident 136 did not experience an extended wait time for peri-care of more than four hours after requesting assistance. E. Ensure Resident 27's personal choices for showers instead of bed bath were respected. F. Ensure Resident 11 did not wait 20 minutes to be changed after soiling her diaper.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the residents' needs and preferences in accordance with the facility's policy and procedures (P&P) for five of five sampled residents (Residents 8, 41, 163,165, and 218) by failing to:a. Provide Resident 8 with an appropriate call light consistent with Resident 8's functional capability.b. Ensure Resident 41's call light was within reach.c. Ensure Resident 163's call light was within reach.d. Ensure Resident 165's bed was not too short causing Resident 165's feet to rest against the footboard. e. Ensure to accommodate Resident 218's request for room change due to noise from the roommate (Resident 209). These failures had the potential for Residents 8, 41, 163, 165, and 218 not to receive necessary care or receive delayed services and could affect the residents' quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure its policies and procedures (P&P) for Advance Directive (AD, a written preference regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) was implemented for three of three sampled residents (Resident 7, 16 and 119) by failing to: a. Ensure Resident 7's AD was discussed and written information was provided to the residents and/or responsible parties.b. Ensure Resident 16's AD was discussed and written information was provided to the residents and/or responsible parties.c. Ensure Resident 119's Advance Directive Acknowledgement (ADA) Form was completed upon admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents' (Resident 9's and Resident 13's), Minimum Data Set (MDS - a resident assessment tool) assessments were accurately documented to reflect:a. Resident 9's use of oxygen.b. Resident 13 was receiving hospice care. These failures had the potential to negatively affect Resident 9's and Resident 13's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to develop an individualized and person-centered care plan for two of five sampled residents (Resident 13 and Resident 33) in accordance with the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, by failing to ensure:a. Resident 13, who had a diagnosis of dementia (a progressive stated of decline in mental abilities), had a plan of care for dementia.b. Resident 33's peripherally inserted central catheter (PICC - a long, thin catheter inserted into a vein in the arm, usually in the upper arm, and threaded to a large vein near the heart, used to administer fluids and or medications) was included in Resident 33's plan of care. These deficient practices had the potential for Resident 13 and Resident 33 to not receive appropriate care, treatment, and or services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of three sampled residents (Residents 8, 11, and 58) received treatment and care in accordance with physician's orders/professional standards of practice when:a. The facility failed to provide a bolstered mattress to Resident 8, as ordered. b. The facility failed to provide treatment for Resident 11's complaint of burning pain when urinating. c. The facility failed to manage the pain & burning sensation upon urination for Resident 58. These failures resulted in Residents 11 and 58 continuing to experience burning pain when urinating and had the potential for Residents 8, 11, and 58 to experience a decline in health and wellbeing.(Cross Reference F580 and F697)

Inspectors wroteBased on observation, interview and record review, for five of five sampled residents, the facility failed to ensure:a. Resident 218's blisters under the ostomy bag were assessed.b. Resident 212's LAL mattress (tiny laser made air holes in the mattress top surface continually blowing out air causing the resident to float) was set up accurately according to manufacturer's instruction and not on static mode.c. Resident 213's LAL mattress was not set to static while the resident was in bed.d. The LAL mattress was set according to Residents 41 and 136's weight. These deficient practices placed the residents at risk for altered skin integrity and had the potential to result in the development/worsening of pressure ulcers (PU - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for residents on oxygen therapy (treatment that provides supplemental, or extra oxygen) in accordance with the facility's Policy and Procedure (P&P) on Oxygen Administration for three of four sampled residents (Residents 9, 25, and 122). These failures had the potential for Residents 9, 25, and 122 to result in respiratory complications and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) an emergency kit (E-kit, contains the main items needed in an emergency) at the bedside for two of six sampled residents (Residents 111 and 219) in accordance with the residents' comprehensive care plan. These failures had the potential for Residents 111 and 219 not to receive or receive delayed care and emergency treatment from complications caused by unexpected bleeding from the hemodialysis access site.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing, resulting in toileting and/or incontinent care not being provided for two of three sampled residents (Residents 11 and 136) in a timely manner. This failure had the potential to result in Residents 11and 136 experiencing skin breakdown and/or placing the residents at risk of experiencing a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra). (Cross Reference F550)

Inspectors wroteBased on observation, interview and record review the facility failed to:a. Administer medications in a timely manner for three of four sampled residents (Residents 218, 209 and 89). This failure had the potential to result in the effectiveness of the medication affecting the residents' wellbeing.b. Ensure during a medication pass observation on 8/21/2025 at 8:33 am, Licensed Vocational Nurse 8 (LVN 8) did not attempt to administer 2 tablets of Tylenol Oral Tablet 325 mg to Resident 34.c. Ensure an accurate account of the use of a controlled medication (medications that the use and possession of are controlled by the federal government), Pregabalin (a controlled medication used for pain and seizures) for Resident 47 when the licensed nurse did not document its usage on the controlled drug record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe storage of medications by failing to:a. Ensure Resident 15's eye drop bottle was labeled with the resident's name.b. Ensure Resident 71's eye drop bottle and box were labeled with the resident's name. c. Ensure the medication cart was not left open and unattended and outside of view of staff in nursing station 1. These deficient practices had the potential to result in unintentional medication administration to the wrong resident and could have also resulted in missing medications from the medication cart.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 70 and 244) received food that was palatable, attractive, and according to food preference according to the facility's Policy and Procedure (P&P) titled, Food and Nutrition Services, revised October 2017. These failures had the potential for Residents 70 and 244 to be at risk of unplanned weight loss, a consequence of poor food intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each kitchen sanitization bucket (used to sanitize surfaces in the facility kitchen) and the sink sanitization compartment used to sanitize tray line preparation area, was maintained at the required concentration for effective sanitization by failing to:Ensure two red buckets and the sink sanitization compartment (third compartment of the sink) used in the kitchen for sanitation of kitchen surfaces and in food preparation areas, were maintained at the correct concentration to maintain effectiveness to prevent cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its infection control policy for five of seven sampled residents (Residents 168, 175, 218, 1 and 105) by failing to ensure:a. The urine drainage bag was not touching the floor for Resident 168b. Resident 175 oxygen tubing was not touching the floor.c. Staff performed hand hygiene before and after taking care of Residents 218 and 1d. Resident 105's IV tubing was not looped at the end of the same administration set and the IV ports were not left uncovered. These deficient practices had the potential to result in infection for Residents 168, 175, 218, 1 and 105. a. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain written informed consent for one of five sampled residents (Resident 7) for the use of Buspirone (an antianxiety medication use to treat anxiety [emotion characterized by feelings of tension, worried thoughts and physical changes]. This deficient practice had the potential to result in Resident 7 not receiving adequate or sufficient information regarding Buspirone to make an informed health care decision.

Inspectors wroteBased on interview and record review, the facility failed to notify one of one sampled residents' (Resident 11) doctor of Resident 11's complaint of burning when urinating on 8/19/2025. This failure resulted in Resident 1 continuing to feel burning pain when urinating on 8/20/2025. (Cross Reference F550 and F684)

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean and stain-free floors of Resident 86's room and in Station 4 shower rooms. This failure resulted in an unsanitary appearance and did not maintain a homelike environment for the residents.

Inspectors wroteBased on interview and record review, the facility failed to revise a plan of care for one of one sampled resident (Resident 7), who sustained a fall on 8/15/2025, as indicated in the facility's policy Care Plans, Comprehensive Person Centered. This deficient practice had the potential to place Resident 7 at risk for recurrent falls.

Inspectors wroteBased on observation, interview, and record review, the facility staff members failed to provide peri-care (the cleaning and maintenance of the perineum, the area between the anus and the genitals) for two of two sampled residents, (Resident 136 and Resident 27), who required physical assistance with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). This deficient practice had the potential to place Resident 136 and Resident 27 at risk for increased risk for infection, skin breakdown and further potential health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bilateral (both sides) hand rolls (a cylindrical device used to support and position the hand) were maintained in correct position for one of one sampled resident (Resident 125). This failure had the potential for a decline in range of motion (ROM, measure of joint flexibility and functionality), stiffness, and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) for Resident 125.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Foley catheter (FC, a thin, flexible, rubber or plastic tube used to drain urine from the bladder) was secured on the resident's thigh in accordance with the facility's Policy and Procedure (P&P) Catheter Care, Urinary) for one of four sampled residents (Resident 131). This failure had the potential for Resident 131 to result in catheter-related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for a resident with gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) for one of two sampled residents (Resident 75) by failing to:a. Ensure Resident 75's GT site dressing was changed consistently with the physician's order.b. Ensure an individualized and comprehensive GT site plan of care was developed for Resident 75. These failures had the potential for complications related to tube feedings for Resident 75.

Inspectors wroteBased on interview and record review, the facility failed to manage urinary tract infection (UTI- bacteria enter the urinary tract) symptoms and urinary pain for one of four sampled residents (Resident 58). This deficient practice resulted in Resident 58 experiencing unrelieved pain which caused physical and emotional distress and did not maintain the resident's highest practical physical and mental well-being. (Cross Reference F684)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an informed consent (voluntary agreement to accept treatment and/or procedure after receiving education regarding the risks, benefits and alternatives offered) was obtained before the installation of bilateral (both sides) upper half siderails (adjustable metal or rigid plastic bars attached to the bed) for one of one sampled resident (Resident 8). This failure placed Resident 8 at risk for entrapment (an event in which a resident was caught, trapped, or entangled in the tight spaced around the bed) and injury from the use of siderails.

Inspectors wroteBased on observation, interview and record review, the facility failed ensure one of five sampled resident (Resident 34) was free from unnecessary drugs as indicated in the facility's policy and procedure titled, Administering Medication. This deficient practice had the potential to result in unnecessary use of Tylenol (Acetaminophen, medicine that relieves mild to moderate pain and reduces fever).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 118), received and was provided food that accommodated Resident 118's food preferences. This deficient practice had the potential for Resident 118 to develop further weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean and stain-free privacy curtain and window curtain for two of seven sampled residents (Resident 2 and Resident 3). This failure resulted in an unsanitary and non-homelike environment for the residents.a). During a review of Resident 2's admission Record (AR), the AR indicated the facility readmitted Resident 2 to the facility on [DATE] with diagnoses that included amyotrophic lateral sclerosis (nervous system disease), respiratory failure (lungs cannot properly exchange gases), and adult failure to thrive (syndrome characterized by weight loss, decreased appetite, poor nutrition). During a review of Resident 2's History & Physical (H&P), dated 2/23/25, the H&P indicated Resident 2 had the capacity to make medical decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) received care and services to prevent maggot (immature, worm-like stage in the life cycle of flies) infestation (when fly larvae (maggots) develop in a living organism's tissues or decaying organic matter) inside Resident 1's right ear, right nostril (openings in the nose) and mouth, by failing to: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Residents 2, 3, and 8) were treated with dignity and respect by CNA 1 who slapped Resident 2 on the hand, spoke rudely to Resident 2, refused to change the television channel for Resident 3, and did not provide perineal care (washing the genital and anal area) for Resident 8. This failure resulted in Residents 2, 3, and 8 feeling upset and frustrated at not having their needs met and had the potential for Residents 2, 3, and 8 to experience feelings of decreased self-worth.

Inspectors wroteBased on interview and record review, the facility failed to provide occupational (a treatment focused on improving the performance of activities required in daily life) and physical therapy (a treatment focused on improving or restoring physical movement and function) to one of one sampled residents (Resident 9) who was discharged from physical therapy after receiving four days of physical therapy and occupational therapy after receiving five days of occupational therapy. This failure resulted in Resident 9 not receiving rehabilitative services and had the potential to result in further decline of physical, functional, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility's doors were closed and facility's screen doors and windows (an exterior door/window with a mesh screen, typically made of wire or plastic, that allows air to pass through while blocking insects and other small debris from entering a building) were intact to prevent flies and other insects from going inside the facility, in accordance with the facility's policy and procedure (P&P) titled, Pest Control. This failure resulted in flies and other insects entering the facility and had the potential for flies and other insects to spread diseases to all 220 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (the voluntary agreement of a resident or a resident ' s representative to accept a treatment or procedure after receiving information regarding risks and benefits of the treatment) from one of one sampled resident (Resident 9) prior to administering the covid vaccine (a substance that helps the body ' s immune system learn to recognize and fight off the coronavirus [an infectious disease caused by the SARS-Cov-2 virus]) when Infection Prevention Nurse (IPN) 2 requested consent for the covid vaccine from Resident 9 ' s Family Member (FM) 1 instead of Resident 9. This failure resulted in Resident 9 receiving the covid vaccine without giving consent.

Inspectors wroteBased on interview and record review, the facility failed to provide three (3) of three sampled residents (Residents 4, 5, and 6) or the Residents' Representative a copy of the residents' medical records upon request and within two working days from notice per the facility's policy and procedure titled, Release of Information. This failure resulted violated Residents 4, 5, 6's rights and resulted in Resident 5 and Resident 4's and Resident 6's Representatives not receiving the medical records in timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 7) was provided with the necessary treatment and services to prevent formation of and promote healing of an existing pressure injury (PI, injury to skin and underlying tissue resulting from prolonged pressure on the skin) by: 1. failing to ensure Resident 7 received physician-ordered wound care treatment for a stage 3 PI on Resident 7's right knee. 2. failing to follow the physician's order that indicated cleansing with normal saline (NS-sterile salt solution) and application of zinc oxide (barrier ointment) for Resident 7's sacrococcyx (sacral [a triangular shaped bone at the bottom of the spine] coccyx [tailbone]) stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) PI. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) had a clutter-free room environment and did not have multiple plugs in the electrical outlet. These deficient practices placed Resident 2 at risk for accident hazards from a possible overloaded electrical circuit and heightened risk of fire with a cluttered area of flammable materials (ability to ignite easily and burn rapidly) surrounding Resident 2's bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and functional shower for one (1) out of four (4) shower rooms in the facility with two holes in the wall located where the wall meets the base of the tile floor. This deficient practice had the potential for residents to be placed at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to promptly (quickly/timely) notify the physician for, one of 16 sampled residents (Resident 1), who experienced a change of condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions) in accordance with the facilities policies and procedures (P&P) titled, Change in a Resident's Condition or Status, Resident Assessment and Examination, and Resident 1's Care Plan (CP) titled, Constipation ( difficulty in emptying the bowels), by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to examine and assess one of 16 sampled residents (Resident 1) according to the facility's policy and procedure (P&P) titled, and Resident Assessment and Examination, by failing to: 1. Ensure when Resident 1 experienced a change of condition (COC- a change in the resident's health or functioning that requires further assessment and intervention) on [DATE] at 8 am, Registered Nurse 2 (RN 2) and RN 3 assessed Resident 1's abdominal distension (bloating or swelling ), abdominal firmness (abdomen feeling hard or tight to the touch) rebound or guarding (physical signs that can indicate inflammation of the abdominal lining or other acute abdominal issues), bowel sounds (sound produced by the movement of fluid and air in the intestines) for hyperactivity (increased bowel sounds), hypoactivity (reduced bowel sounds) and pain. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate and complete documentation for one of one sampled resident (Resident 1), in accordance with the facility's policies and procedures (P&P) titled, Charting and Documentation and Change in a Resident's Condition or Status. This deficient practice resulted in no documentation of Resident 1's full assessments during a Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions) on 5/6/2025 and had the potential to result in complications leading to a physical decline to Resident 1. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of her individuality for four of 67 sampled residents (Residents 2, 5, 11 and 14) as indicated in the facility's policies and procedures (P&P) by failing to: a. Ensure Resident 2 was not awakened inappropriately early in the morning by a loud noise from the licensed nurse and the light was turned on in Resident 2's room. b. Ensure Resident 5's urinal receptacle (a container used to hold bodily waste) was kept clean and labeled with Resident 5's name. c1. Ensure staff (general) were not rude whenever they answered Resident 11's call light and disrespectful whenever they spoke to Resident 11. c2. Ensure staff (general) did not joked around loudly outside Resident 11's room while Resident 11 was taking a nap. d. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that 59 of 67 sampled residents (Resident 2, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34, Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, Resident 42, Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, Resident 52, Resident 53, Resident 54, Resident 55, Resident 56, Resident 57, Resident 58, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 66, and Resident 67) who required assistance with [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nurse staffing for 16 of 45 shifts staffing reviewed in the subacute unit (specific unit in the facility where residents with a tracheostomy tube [a tube inserted in a surgically created hole in the windpipe to provide an alternative airway for breathing] and residents on a ventilator [a medical device to help support or replace breathing] stayed) to provide care and assistance to 59 of 67 sampled residents in accordance with the facility's policy and procedure (P&P) titled, Staffing, and Facility Assessment, and the facility's Facility Assessment, (FA- a guide used by the facility to evaluate what resources are necessary to care for the facility's residents) and staffing goal for the subacute unit when: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication administration for six of six sampled residents (Resident 5, Resident 6, Resident 26, Resident 55, Resident 56, and Resident 68) by failing to: 1. Ensure the facility followed best practices for medication preparation and administration for Resident 6 when multiple medications were crushed and mixed in one medication cup and administered via gastrostomy tube (G-tube, a feeding tube inserted directly into the stomach through the abdominal wall). 2. Ensure medications were administered at their respective scheduled times as prescribed by the ordering physicians for Resident 6, 26, 55, 56, and 68 on 4/21/2025. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the facility clean for four of four rooms (Rooms 421, 416, 222 and 223). 1. There were dried reddish-brown stains on the privacy curtain next to the bed by the window in room [ROOM NUMBER]. The privacy curtain separated the two beds in room [ROOM NUMBER]. 2. The baseboards in room [ROOM NUMBER] were dirty. 3. There were unpainted white patches on the walls in room [ROOM NUMBER]. 4. There was a brownish gray stain on the ceiling and on the top of the wall by the air vent in room [ROOM NUMBER]. 5. There were holes in the wall with chipped paint behind the headboard of the bed by the window in room [ROOM NUMBER]. 6. The baseboards in room [ROOM NUMBER] were dirty. 7. The linoleum flooring in the restroom in room [ROOM NUMBER] was cracked and peeling off the wall. 8. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Maintenance Service, by failing to ensure floor tiles in two of six stations (Station 4 and Station 6) of the facility were free of holes and cracks. This deficient practice had the potential to place the safety of residents, staff, and visitors at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Smoking by Residents, for one of three sampled residents (Resident 1) by failing to: 1. Ensure Resident 1 was supervised while smoking in the smoking patio. 2. Ensure Resident 1 ' s smoking materials were stored in a locked box or drawer. These deficient practices had the potential to place Resident 1 and other residents ' safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ordered tab alarm (device used to notify staff when residents attempted to transfer unassisted by staff) was attached to one of three sampled residents (Resident 8) who was at risk of falls. This failure resulted in Resident 8 falling to the floor on 3/12/2025 while in the care of the facility. The failure had the potential for Resident 8 to be injured due to the fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when eight of eight facility dumpsters' lids were open, leaving the top of the dumpsters uncovered. This failure had the potential to negatively impact the health of residents by attracting rodents and pests to the facility, which could carry infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility ' s Policy and Procedure (P&P) titled, Answering the Call Light, and Maintenance Service, for 12 of 29 resident rooms (Rooms 112, 114a, 202, 208, 209, 211, 212, 216, 221, 222, 223 and 225) by failing to: a. Ensure the call lights in the resident rooms were functioning. b. Ensure the call light was accessible for one resident in room [ROOM NUMBER]a. These deficient practices had the potential to result in the delay of care for the residents affecting their safety and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to remain free from verbal (the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents) and physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) for one of two sampled residents (Resident 2), when Resident 3 physically and verbally abused Resident 2 on 2/10/2025. This failure had the potential to result in bodily injury to Resident 2 and/or Resident 2 to feel afraid and not safe while under the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 4) received Physical Therapy (PT, specialized rehabilitative service that helps you improve how your body performs physical movements) and Occupational Therapy (OT, specialized rehabilitative service that helps you improve your ability to perform daily tasks) as indicated in Resident 4's untitled care plan, dated 2/25/2025. This failure had the potential for Resident 4 to not attain, maintain or restore his highest practicable level of physical, mental, functional and psycho-social well-being. (Cross Reference F693 and F825)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper care and treatment for gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) was provided for two of three sampled residents (Resident 4 and Resident 8) when: a. Resident 4's head of bed (HOB) was not elevated to an angle of 30-45 degrees while on G-tube feeding. b. Licensed Vocational Nurse (LVN) 2, who was administering five medications to Resident 8 via Resident 8's G-tube, failed to flush the G-tube with water between administering the second, third, and fourth medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 4) received Physical Therapy (PT, specialized rehabilitative service that helps you improve how your body performs physical movements) and Occupational Therapy (OT, specialized rehabilitative service that helps you improve your ability to perform daily tasks) as indicated in the Resident 4's plan of care. This failure resulted in Resident 4 did not receive PT and OT services as indicated in Resident 4's care plan and had the potential for Resident 4 to not attain, maintain or restore Resident 4's highest practicable level of physical, mental, functional and psycho-social well-being. (Cross Reference F656 and F693)

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one of thirteen sampled residents (Resident 12) by failing to: 1. Ensure Housekeeper (HK) 1 timely reported an abuse allegation involving Certified Nursing Assistant (CNA) 3 and Resident 12 to the Housekeeping Supervisor (HS) and/or to the Administrator (ADM). 2. Ensure the facility reported an abuse allegation to the California Department of Public Health (CDPH) immediately but no later than two hours of knowing about the abuse allegation. These deficient practices had the potential to compromise the safety of Resident 12 and exposed Resident 12 to further potential abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for three of thirteen sampled residents (Residents 1, 2, and 13) as indicated in the facility's policies and procedures (P&P) titled, Neurological Assessment, Charting and Documentation, and Change in a Resident's Condition or Status by failing to: a. Ensure assigned licensed nurses completed neurological (relating to the functioning of the brain, spine, and nerves) assessments for the 72-hour monitoring period after Resident 1 was involved in a resident-to-resident altercation. b. Ensure assigned licensed nurses completed neurological assessments for the 72-hour monitoring period after Resident 2 was involved in a resident-to-resident altercation. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility to failed ensure two of three sampled residents (Residents 2 and 3) were provided with a safe, clean, comfortable and homelike environment, according to the facility's policy and procedure (P&P) titled, Homelike Environment, by failing to ensure Residents 2 and 3 did not smell the odor of cigarette smoke from facility staff smoking outside Residents 2 and 3's room window. As a result of this failure, Residents 2 and 3 were unable to keep their room window open throughout the day and were exposed to secondhand smoke (SHS- involuntary inhalation of tobacco [a plant with leaves that have levels of nicotine [addictive, poisonous chemical] that is generally smoked or ingested] smoke, that is a mixture of smoke exhaled by smokers and smoke from burning tobacco products). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call bell (device that is used to summon a staff member when needed) for one of three sampled residents (Resident 2) was within reach according to the facility's policies and procedures (P&P) titled, Accommodation of Needs, and Answering the Call Light. As a result of this failure, Resident 2 was unable to reach the call bell when assistance was needed from facility staff. This failure had the potential for Resident 2 to experience pain, distress, a medical emergency, and could lead to psychosocial (mental, emotional, social, and spiritual effects) harm from not being able to call for help when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary (clean) environment to prevent the spread of infection for nine of 13 sampled residents (Residents 1, 2, 5, 6, 7, 9, 10, 12, and 13) during a Coronavirus Disease 2019 (COVID-19, an illness caused by a virus that can spread from person to person) outbreak (OB-two or more linked cases of the same illness or the situation where the observed number of cases exceeds the expected number, or a single case of a disease caused by a microorganism), by failing to: 1. Perform hand hygiene appropriately. 2. Implement Enhanced Barrier Precaution (EBP-an infection control intervention designed to reduce the transmission of multidrug-resistant organisms [MDROs] in the nursing home). 3. Post Enhanced Barrier Precaution sign outside the room of residents who required EBP. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the toenails of one of 13 sampled residents (Resident 1) were kept trimmed according to the facility's Policy and Procedure (P&P) on Care of Fingernails/Toenails. This failure placed Resident 1 at risk for injury, infection, or complications from long toenails.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy to provide a two-person assist when using a mechanical lift during the transfer of one of four sampled residents (Resident 14). This failure placed Resident 14 at risk for a preventable accident and/or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medication to one of 13 sampled residents (Resident 2) according to the physician's order when Licensed Vocational Nurse 1 (LVN 1) administered Temazepam (a medication to aid sleeping) 7.5 milligrams (mg-a unit of measure) to Resident 2, five (5) hours and 51 minutes before bedtime (9 pm). This failure resulted in unsafe medication administration and had the potential to negatively impact Resident 2's health, safety, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and timely medical records for one of fourteen sampled residents (Resident 11), based on the facility's policy and procedure (P&P) titled, Charting and Documentation, and Change in a Residents Condition or Status, by failing to: 1. Ensure when Resident 11 had a change in condition (CIC- a change in the resident's health or functioning that requires further assessment and intervention) on 11/6/2024 4:26 pm, Licensed Vocational Nurse (LVN) 7, filled out the eINTERACT/situation-background-assessment-recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations) form that day and not on 11/10/2024 at 4:54 pm. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the care and services for one of 14 sampled residents (Resident 11), according to the facility's policy and procedure (P&P) titled Referrals, Social Services, by failing to: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Answering the Call Light, for two of two sampled residents (Resident 1 and Resident 3) by failing to: 1. Ensure Resident 1 ' s call pad/light was within reach. 2. Ensure Resident 3 ' s call light was answered promptly. These deficient practices had the potential to result in the delay of care for Resident 1 and Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Air purifiers were in working condition or set to on. 2. Ventilation system was set to on and not on auto or off. 3. A Licensed Vocational Nurse (LVN 1) was wearing proper personal protective equipment (PPE- protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) while in a Covid-19 (an infectious disease caused by the SARS-CoV-2 virus) room. 4. LVN 1 wore a N95 (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) mask properly while in the Red Zone (unit with Covid-19 confirmed positive residents). 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain comfort and skin integrity for one of two sampled residents (Resident 1) by: 1. Keeping a mechanical lift sling (a harness that supports and wraps around a patient on a device that is used to transfer a patient from one place to another) under Resident 1 for more than six hours while on a low air loss mattress (LALM - a mattress designed to prevent and treat pressure ulcers [bed sores]). 2. Using incorrect bedding for Resident 1's LALM. This deficient practice had the potential to worsen Resident 1's pressure ulcer.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of five sampled residents (Residents 4, 5, 6, and 7), who were incontinent (lacking voluntary control over urination or defecation) of bowel and/or bladder, where promptly changed by facility staff after episodes of incontinence, in accordance with the facility's Policy and Procedure (P&P) on Call System and Urinary Continence and Incontinence -Assessment and Management . This failure had the potential to result in skin breakdown and/or negatively affect the residents' dignity and quality of life for Residents 4, 5, 6, and 7.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) as indicated in the facility's policies and procedures (P&P) titled, Abuse Prevention/Prohibition and Resident Rights for one of four sampled residents (Resident 1). This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 and sustaining an acute fracture of the left nasal bone.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for two of two sampled residents (Residents 107 and 181) by failing to ensure the residents' call light were within reach and appropriate to the resident's physical ability. These deficient practices had the potential for residents not to receive necessary care or received delayed services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) and Request for admission and Authorization for Treatment and Medication (RAATM, permission given before a resident receive any type of medical treatment, test or examination) were discussed and written information were provided to the residents and/or responsible parties for four of five sampled residents (Residents 18, 66, 182 and 193). These failures had the potential for facility staff to provide medical treatment and services against the residents' will.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) were accurate for two of five sampled residents (Residents 184 and 216) by: a. Failing to assess and submit Resident 184's discharge assessment to the Centers of Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency timely. Resident 184 was discharge to General Acute Care Hospital (GACH) on 4/5/2024. b. Failing to ensure Resident 216 who was discharged home was coded in the MDS assessment accurately. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an effective communication method to two of two non-English speaking sampled residents (Resident 522 and 136). This failure had the potential to result in resident not receiving necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote healing and provide necessary treatments to prevent the development of pressure ulcer (lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) for five of six sampled residents (Residents 64, 91, 141, 162 and 182) by failing to: a. Ensure the low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure injuries) for Resident 64 was set to alternating pressure. b. Ensure the LAL mattress for Resident 162 was set to alternating pressure. c. Ensure the LAL mattress for Resident 141 was set to therapeutic mode and in accordance with the resident's weight. d. Ensure Resident 91 was not lying on the site of the pressure ulcer and was repositioned every two hours while in bed. e. Ensure Resident 182 was wearing heel protectors as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Residents 36, 109 and 135) with limited range of motion (ROM- full movement potential of a joint [where two bones meet]) and mobility (ability to move) received treatment and services to prevent further decline in ROM by failing to: 1. Provide Resident 36 with ROM exercises on both wrists, hands, and ankles in accordance with the physician's orders. 2. Identify and report Resident 36's right elbow splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) was not aligned with Resident 36's right elbow to the Occupational Therapist ([OT] professional aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]). 3. [...]

Inspectors wroteBased on observation, interview, and record review, for two of two sampled residents (Residents 199 and 521), the facility failed to: a. Label and date the peripheral intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products) for Resident 199 in accordance with facility's Policy and Procedure (P&P) on Administration Set/Tubing Changes and Resident 199's care plan. b. Ensure Resident 521's PICC line (a type of long catheter that is inserted through a peripheral vein into larger vein in the body, used to deliver medications and other treatments directly to the large central veins) dressing was kept clean, not soiled, and changed in accordance with the facility's P&P on Central Venous Catheter Dressing Changes. These failures had the potential to result in infection to Residents 199 and 521.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for residents on oxygen therapy (treatment that provides supplemental, or extra oxygen) consistent with professional standards of practice for four of four sampled residents (Residents 23, 92, 130 and 208) by failing to: a. Follow the physician's order to provide two liters of oxygen inhalation through nasal cannula to Resident 23. b. Label tracheostomy drainage bottle with date for Resident 92. c. Label oxygen tubing with date for Resident 130. d. Ensure Resident 208 had a physician's order for the use of oxygen at two liters per minute through nasal cannula. These deficient practices placed Residents 23, 92, 130 and 208 at risk for severe difficulty of breathing and serious respiratory complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to attempt the use of appropriate alternatives to bed rails before its installation for two of two sampled residents (Residents 26 and 191). These deficient practices placed Residents 26 and 191 at risk for entrapment and injury from the use of bed rails.

Inspectors wroteBased on interview and record review, the facility staff failed to respond to the call light and address residents' needs and requests for assistance with toileting and activities of daily living (ADL) in a timely manner for three of six sampled residents. This deficient practice had the potential to negatively affect the residents' quality of life and their feelings of self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered safely, in a timely manner, and as prescribed to meet the therapeutic needs for 16 of 18 sampled residents (Residents 26, 29, 50, 57, 59, 114, 138, 148, 171, 177, 187, 319, 320, 321, 56, and 569) by failing to ensure: 1. Resident 187, with a diagnosis of dialysis was administered sevelamer (Brands: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate was less than five percent (%). Six medication errors out of 28 total opportunities contributed to an overall medication error rate of 21.43 % for two of four residents (Residents 26 and 187) observed during medication administration (MedPass). a. For Resident 26, the facility failed to ensure Resident 26 received medications within an hour of the administration time to meet the resident's therapeutic needs. b. For Resident 187, the facility failed to ensure Resident 187's order for sevelamer (Brands: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were kept secure with limited access by failing to: 1. Lock the medication cart (MedCart) that contained residents' medications at Station 4 when the MedCart was not attended by a licensed nurse. 2. Ensure medications prepared for Resident 187 was secured and not left on top of the MedCart at Station 4 when the medications were outside of a licensed nurse's view. These deficient practices had the potential for Resident 187's medications to be accessible to other unauthorized staff and residents, and increased the risk for loss of control, safety, and security of all medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 8/27/2024 by failing to: a. Ensure staff followed food production recipes for the mechanical soft diet (diet for residents who experienced chewing or swallowing limitations, diet is modified to a soft, chopped or ground consistency) during lunch preparation and tray line observation for 33 residents on a mechanical soft diet, and received chopped roast beef with gravy instead of ground roast beef with gravy per menu and spreadsheet (food portion and serving guide.) b. Ensure 26 residents on a pureed diet received pureed green beans instead of pureed spinach au gratin per menu. c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Ensure one resident (Resident 8) on a puree diet (foods that is blended, do not require chewing, and are easily swallowed. Food should be smooth .consistency of pudding) received cottage cheese texture in form that meet their needs when they received regular cottage cheese that was lumpy and had small to medium size cheese curds. b. Ensure one resident (Resident 219) who was on a Mechanical soft texture chopped diet received a grilled cheese sandwich texture in form that meet their needs when the grilled cheese sandwich was dry with hard crust and was not chopped. These deficiencies had the potential to result in decreased intake related to inconsistent texture, meal dissatisfaction and increase choking and aspiration risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen by failing to: a. Ensure one Dietary Aide (DA1) working in the dish machine area washed his hands and changed gloves when removing the clean and sanitized dishes from the dish machine. b. Ensure two large packages of previously cooked, frozen, and thawed roasted turkey breast, was not stored in the refrigerator with dates of 8/22/24, which exceeded the storage period for thawed poultry. c. Ensure food brought to residents from outside of the facility, including leftovers stored in the resident food refrigerator and kitchen freezer were dated. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for seven of 10 sampled residents (Residents 69, 111, 133, 122, 66, 135, and 422) by failing to: a. Ensure staff wore eye protection, including a face shield or eye goggles, upon entering rooms for Resident 69, 111, 133, and 122 who were under observation for exposure to Coronavirus Disease 2019 (COVID-19, a highly contagious viral disease that can cause respiratory illness) in accordance with the facility's Policy and Procedure (P&P) on Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures. b. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the window screen in a resident's room was intact for one of one sampled resident (Resident 121). This deficient practice had the potential to affect the residents' right to a safe, clean, comfortable, and homelike environment and put the resident at risk for physical discomfort.

Inspectors wroteBased on interview and record review the facility failed to develop an individualized/person- centered care plan for one of one sampled resident (Resident 66) on bilateral hand mittens in accordance with the facility's Policy and Procedure (P&P) titled Care Plans - Comprehensive. This deficient practice had the potential for Resident 66 to not receive appropriate care treatment and/or services specific to the resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 124) had padded siderails as a seizure precaution, as ordered. This deficient practice had the potential to cause injury to Resident 124 during a seizure (abnormal movements or behavior due to unusual electrical activity in the brain) episode.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate care to prevent Urinary tract Infection ([UTI] an infection in any part of the urinary system [kidneys, bladders, ureters and urethral]) for one of two sampled residents (Resident 192) who was on Foley catheter (a thin, sterile tube inserted into the bladder to drain urine) by failing to ensure: Licensed staff monitor Residents 192's urine output and notify the physician promptly for signs and symptoms of UTI. This deficient practice placed Resident 192 at risk for delayed treatment and worsening of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 205) who was fed by enteral means received appropriate treatment and services by failing to elevate the head of the bed while the resident was receiving formula through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) and failing to ensure the GT flush was connected to Resident 205 in accordance with the resident's care plan and the facility's Policy and Procedure (P&P) titled Enteral Feedings - Safety Precaution. This deficient practice had the potential to cause aspiration (inhalation of foreign materials) and lead to other adverse consequences for the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily and was not posted in a prominent location readily accessible to residents and visitors for viewing in accordance with the facility's Policy and Procedure (P&P) titled Posting Direct Care Daily Staffing Numbers for three of three days ( 8/26/2024, 8/28/2024 and 8/29/2024). This deficient practice of posting inaccurate nurse staffing information would mislead the residents and visitors of the actual staffing in the facility that may affect the quality of nursing care provided to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain an informed consent when the physician ordered psychotropic medication (any drug that affects behavior, mood, thoughts, or perception), buspirone (an antipsychotic medicine, it works by changing the actions of chemicals in the brain) for one of five sampled residents (Resident 210). This failure had the potential risk to place the resident at risk for unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to offer preferences regarding food choices for one of one sampled resident (Resident 8). This deficient practice had the potential to result in insufficient meal intake and potentially result to weight loss for Resident 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 10 Restorative Nursing Aides (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) did not perform job duties out of the State certification, including managing feeding through a gastrostomy tube (G-tube, tube placed directly into the stomach for long-term feeding) for one of four sampled residents (Resident 109) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move). This failure had the potential for Resident 109 to have complications related to the G-tube.

Inspectors wroteBased on interview and record review, the facility failed to explain the Agreement To Arbitrate Disputes Related To Medical Malpractice Binding Arbitration Agreement (AA, Binding Arbitration Agreement), signed 8/12/2024, for one of three sampled residents (Resident 522), in a language Resident 522 understood when agreement was entered for binding arbitration (involves the submission of a dispute to a neutral party who hears the case and makes a decision). This failure had the potential to result in Resident 522 to not be able to make an informed decision and/or his rights to be denied.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of three sampled residents (Resident 1) who was assessed as high risk for fall by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1), the CNA 1 who was assigned to take care of Resident 1, had the knowledge that Resident 1 needed supervision or touching assistance [helper provides verbal cues and/or tactile (touch) cues or contact guard assistance (place one or two hands on the resident's body to help with balance) while the resident completes activity] and provided supervision (the act of overseeing, monitoring or watching over someone) to Resident 1 while Resident 1 was walking in the room and was using the bathroom (toilet use, the act of using a toilet). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure infection prevention and control practices were implemented for one of two sampled residents (Resident 6) and a census of 205 residents as indicated in the facility's policy and procedure (P&P) titled Policies and Practices- Infection Control, and the Los Angeles County Department of Public Health guidelines titled, Scabies Prevention and Control Guidelines for Healthcare Settings, by failing to: 1. Ensure Resident 6 did not experience a delay in treatment when Resident 6 tested positive for Scabies (a highly contagious skin condition caused by tiny insects called mites that infest and causes intense itching) on 7/31/2024. 2. Ensure the Infection Preventionist (IP; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive person-centered care plan for ADL (Activities of Daily Living, daily tasks that people perform to care for themselves and maintain independence) and Fall Risk for one of one sampled resident (Resident 1), who was assessed as high risk for falls ( to move downward, typically rapidly and freely without control, from a higher to a lower level). This deficient practiced placed Resident 1 at risk for falls. As a result, on 8/3/2024, Resident 1 fell in the bathroom. Resident 1 experienced pain (unrated) on the left shoulder and was transferred to General Acute Care Hospital 1 (GACH 1) via 911 (an emergency telephone number) for further evaluation. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide copies of medical records upon request within two working days for two of three sampled residents (Resident 7 and Resident 8). This deficient practice had the potential to violate Resident 7's, Resident 8's, and/or their representative's right to obtain copies of their medical records in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to develop a scabies (skin infestation caused by the human itch mite; a parasite that lives on the exterior of its host) line list (a table that contains key information about each case in an outbreak) of all residents, staff, visitors, and family members who may have had direct and physical contact with Resident 1 after General Acute Care Hospital (GACH) 1 reported to the facility on 7/8/24, that Resident 1 had a positive scabies result. This failure had the potential outcome to spread scabies to 51 residents in the Subacute Unit of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs) provided care and services to residents in accordance with the facility's policy and procedure (P&P) and the Facility Assessment Tool (used by the facility to evaluate what resources are necessary to care for the facility's residents) for four of four sampled residents ( Residents 8, 9, 10 and 11). As a result, Residents 8, 9, 10 did not receive showers. For Resident 8 for not getting up the resident out of bed and into the wheelchair, for Resident 8 and Resident 9 for allowing to sit on soiled adult brief for an extended period of time, and for Resident 11 to wait for assistance from staff for an extended period of time. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedure on Charting and Documentation by failing to document accurately and completely on the Certified Nursing Assistant (CNA) flowsheet the bowel and bladder function and communicate between the interdisciplinary team regarding the resident's condition for 3 of 42 residents in Station 4 (Residents 7, 8 and 9). This deficient practice had the potential to affect the provision of care and services to the residents and result in adverse consequences for Residents 7, 8 and 9.

Inspectors wroteBased on interview and record review, the facility failed to report suspected physical abuse within two hours on 5/1/2024 to the California Department of Public Health (CDPH), local enforcement, and Ombudsman for one of three sampled residents (Resident 1). Resident 1 reported to staff on 5/1/24 that Certified Nursing Assistant 1 (CNA 1) hurt Resident 1 when changing Resident 1 ' s adult brief. This failure had the potential to result in a delay in investigating potential abuse and expose Resident 1 to further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hazardous chemicals were kept in a secure area for one of three sampled units, (Unit 3), when one bottle of Melt Down Emulsifier stripper (removing multiple coats of finish from floors), one bottle of Pro-look wet shine floor finish (protects interior floors from stains, scuffs and provides a gloss finish to floors), and two bottles of undercoat sealer (used to seal absorbent surfaces and prevent the topcoat from being absorbed into the surface) were left in an open cart in the hallway, unattended. This failure had the potential to result in residents in Unit 3 to have access to toxic chemicals and possibly, ingest toxic chemicals and sustain a serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for one of five sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Homelike Environment, by failing to ensure Resident 1's room walls and ceilings were free of water damage, peeling paint, and discoloration from leaking water when the facility's roof sustained a leak due to rain on 4/17/2024. This failure had the potential for Resident 1 to be uncomfortable, not have a homelike environment, and be exposed to mold (fungus organism that grows in damp, dim areas) due to water damage that could lead to a decline of health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call lights were answered in a timely manner and/or within reach for four of four sampled residents (Residents 3, 4, 2, and 5) in accordance with the facility's policy and procedures (P&P) titled, Answering the Call Light and Call System, Resident. These deficient practices had the potential for Residents 3, 4, 2, and 5 to not receive assistance when needed which could result in harm, physical injury, and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care to maintain foot health for one of four sampled residents (Resident 2) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 and/or Licensed Vocational Nurse (LVN) 1 provided nail care to Resident 2 as indicated in the facility ' s policy and procedure (P&P) titled, Fingernails/Toenails, Care of. 2. Ensure Social Service Designee (SSD) 2 arranged podiatry services (services provided by a podiatrist [a health professional trained to diagnose and treat diseases and other disorders of the feet]) for Resident 2 as indicated in Resident 2's care plan titled Baseline Care Plan. 3. Develop a comprehensive resident-centered care plan for foot care for Resident 2 as indicated in the facility's policy and procedure (P&P) titled, Care Plans - Comprehensive. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to properly maintain the bed frame for two out of three sampled residents (Resident 1 and Resident 3) by failing to: Inspect and ensure Resident 1 and Resident 3's bed frame did not have any chipped wood and was in good condition. This deficient practice had the potential for Resident 1 and Resident 3 to sustain injuries and feel their environment was not homelike.

Inspectors wroteBased on interview and record review, the facility failed to secure and protect the personal belongings of one of three sampled residents (Resident 1) from loss or theft. This deficient practice had the potential to result in loss or theft of other residents ' personal belongings in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to ensure safety and prevent elopement (to leave or run away) of one of three sampled residents (Resident 2). This deficient practice had the potential to affect Residents 2's safety and increase the risk for injury and/or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure social services was provided for one of three sampled residents (Resident 1) to resolve Resident 1 ' s grievance (a complaint) relating to missing personal items. This deficient practice had the potential to cause Resident 1 emotional and psychological (related to the mental and emotional state of a person) distress (a feeling of extreme worry, sadness, or pain).

Inspectors wroteBased on interview and record, the facility failed to promptly (quickly/timely) notify the physician for one of three sampled residents (Resident 1) who experienced a change of condition (COC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains) as indicated in Resident 1's Care Plan titled, Atrial Fibrillation (A-fib- irregular and often very rapid heart rhythm) and the facility's policies and procedures titled, Resident Examination and Assessment, and Change in a Resident's Condition or Status, by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plans for two of three sampled residents (Residents 1 and 3), as indicated in the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, by failing to: 1. Ensure Resident 1 and Resident 3 had daily body checks to monitor for skin injury (bruising, redness, cuts, scratches), or skin tear (a wound that happens when the layers of skin separate or peel back) while giving care and keep Resident 3's bed dry and wrinkle-free, as indicated on Resident 1's and Resident 3's Care Plan (CP) titled, Risk for Skin Breakdown. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for two of three sampled residents (Residents 1 and 3), who were assessed as being high risk for developing pressure ulcers (PU- localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear [mechanical force that cause the skin to break off] and/or friction [movement of one surface of the skin against the others]), to prevent the development of new PU) by failing to: 1. Ensure facility staff accurately assessed and monitored Resident 1's and Resident 3's skin condition. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the mouth clean for one of three sampled residents (Resident 3) by failing to: Ensure Resident 3 was provided oral care (also known as oral hygiene- the practice of keeping the mouth clean and free of disease and other problems by regular cleaning of teeth, gums, and/or dentures). This failure had the potential for Resident 3 to develop an infection and put Resident 3 at risk for a decline in health.

Inspectors wroteBased on interview and record review, the facility to failed to follow their policy and procedure (PP) titled, Emergency Procedure- Cardiopulmonary Resuscitation, by failing to: 1. Ensure three (3) Certified Nursing Assistants (CNAs) 5, 8, 12, eight (8) Licensed Vocational Nurses (LVNs) 1, 2, 3, 6, 10, 21, 23, and 24, and two (2) Respiratory Therapists (RTs) 2 and 4, had updated (not expired) Basic Life Support (BLS- set of essential emergency procedures designed to sustain life in victims experiencing cardiac arrest) certification cards while working at the facility. 2. Ensure Certified Nursing Assistant (CNA) 15 received BLS certification from either the American Red Cross (ARC) or the American Heart Association (AHA). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a plan of care to address the Stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present) on the left clavicle (collar bone) of one of seven sampled residents (Resident 3) in accordance with the facility ' s policy and procedure (PP) titled, Care Plans, Comprehensive Person-Centered. As a result of this failure, Resident 3 went five days without care and treatment for Resident 3 ' s pressure ulcer on the left clavicle which had the potential to worsen Resident 3's pressure ulcer and/or cause infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure (P&P) titled, Care of Fingernails/Toenails, for two of three sampled residents (Resident 9 and Resident 10) who were on dialysis (a procedure where a machine cleans the blood because the kidneys can no longer clean the blood) by failing to: 1. Ensure Resident 9 ' s and Resident 10 ' s fingernails were cleaned daily and kept trimmed. 2. Provide Resident 9 and Resident 10 assistance with personal hygiene (includes combing hair, brushing teeth, shaving, applying make-up, nail care, washing/drying face, and hands) as indicated by Resident 9 ' s and Resident 10 ' s activities of daily living (ADLs) care plan. 3. Ensure provision of nail care was documented in Resident 9 ' s and Resident 10 ' s medical record according to the facility ' s P&P. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide wound care services to promote healing and prevent infection for one of seven sampled residents (Resident 3) by failing to: 1. Assess and monitor Resident 3 ' s Stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present) on the left clavicle (collar bone) when Resident 3 was readmitted to the facility on [DATE]. 2. Provide care and treatment to Resident 3 ' s Stage 3 pressure ulcer on the left clavicle from 1/17/2024 to 1/21/2024 (total of 5 days). As a result of these failures, Resident 3 went five days without care and treatment for Resident 3 ' s pressure ulcer on the left clavicle which had the potential to worsen Resident 3's pressure ulcer and/or cause infection. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain consistent communication and collaboration with the dialysis facility regarding care and services for 1 of 3 sampled residents (Resident 8) who was on dialysis (a procedure where a machine cleans the blood because the kidneys can no longer clean the blood) by failing to ensure: 1. Licensed Vocational Nurse 20 (LVN 20) reviewed Resident 8 ' s Dialysis Communication Record after Resident 8 came back from the dialysis center on 1/9/2024 and documented on the Communication Record any follow-up done to address the dialysis nurse report. 2. LVN 22 reviewed Resident 8 ' s Dialysis Communication Record after Resident 8 came back from the dialysis center on 1/16/2024 and documented on the Communication Record any follow-up done to address the dialysis nurse report. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper nail hygiene to two of three sampled residents (Resident 9 and Resident 10) who were on dialysis (a procedure where a machine cleans the blood because the kidneys can no longer clean the blood) by failing to: 1. Ensure Resident 9 ' s and Resident 10 ' s fingernails were cleaned daily and kept trimmed. 2. Provide Resident 9 and Resident 10 assistance with personal hygiene (includes combing hair, brushing teeth, shaving, applying make-up, nail care, washing/drying face, and hands) as indicated by Resident 9 ' s and Resident 10 ' s activities of daily living (ADLs) care plan. 3. Ensure provision of nail care was documented in the resident ' s medical record according to the facility ' s Care of Fingernails/Toenails policy and procedure (P&P). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment for one (Resident 7) of one resident, reviewed for elopement, was free of accident hazards and Resident 7 was provided adequate supervision. As a result of this deficient practice, Resident 7 eloped from the facility possibly through a double glass exit door by her room that led to the outside of the facility which put Resident 7 at risk for injury from being on her own and unsupervised outside of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies and procedures (P&P) titled, Departmental (Respiratory Therapy) - Prevention of Infection and CPAP (continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while you sleep) / BiPAP (bilevel positive airway pressure - a machine that helps you breathe) Support, by: 1. Failing to ensure a nasal cannula (NC - a device that delivers extra oxygen through a tube and into your nose) tubing was changed every seven days for one of two sampled residents (Resident 1). 2. Failing to ensure a No Smoking sign was posted for two of six rooms (R2 and R3) with oxygen concentrators (a medical device that gives you extra oxygen) being used. [...]

Inspectors wroteBased on interview and record review, the facility failed to update the inventory list for one of three sampled residents (Resident 2) by failing to follow the facilities policy and procedure (P&P) titled, Personal Property. This deficient practice had the potential for theft or loss of Resident 2's personal belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) who had long and dirty fingernails, was provided nail care. This deficient practice placed Resident 3 at risk of skin breakdown and developing an infection.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by not notifying one of three sampled residents (Resident 3's) Representative 1 (R1) when Resident 3 was transferred to a General Acute Care Hospital 1 (GACH 1). This failure resulted in the violation of Resident 3's right to notify Resident 3's R1 of any changes of condition/status to Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a staff (Licensed Vocational Nurse 1 [LVN 1]) properly sanitized a glucometer machine (a small, portable machine that is used to measure how much glucose [a type of sugar] is in the blood) between two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to increase the risk of spreading infection between Resident 1 and Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 1 and Resident 2), who had diabetes mellitus (disease that results in too much sugar in the blood), received care, treatment, and services in accordance with the care plan, the physician's order, and the facility's policy and procedures by failing to ensure: 1. Medications and treatment were provided according to the physician's orders. 2. Residents' blood sugar level was documented in the clinical record. These failures had the potential to result in uncontrolled blood sugar levels, administration of inaccurate amounts of insulin (medication used to treat high blood sugar), and health complications resulting in hospitalization for Resident 1 and Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications and complete documentations for two of five sampled residents (Resident 1 and Resident 2) according to the facility ' s policy and procedure and failed to document by failing to ensure: 1. Medications and treatment were provided according to the physician ' s orders. 2. Residents ' blood sugar level was documented in the clinical record. These failures had the potential for Resident 1 ' s and Resident 2 ' s blood sugar level to not be controlled and monitored, for Resident 1 and Resident 2 to receive inaccurate amounts of insulin (medication used to treat high blood sugar), and possibly lead to health complications resulting in hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide range of motion exercises (activity aimed at improving movement of a specific joint, a point where two bones make contact) to 11 of 12 sampled residents (Resident 75, 183, 91, 167, 146, 27, 136, 163, 151, 40, and 103) as indicated in the facility's Rehabilitative (helping to restore to good condition) Nursing Care policy. This deficient practice resulted for Resident 75 to experience pain and decline in mobility that caused severe contractures (deformity and joint stiffness) of the resident's right hand and both legs.

Inspectors wroteBased on interview and record review the facility failed to ensure the Resident's responsible party (RP) receive information on resident's clinical condition, healthcare information and plan of care for one of 35 sampled Residents (Resident 187). This failure had the potential to violate the resident's or RP's rights to be informed and to choose the type of care or treatment to be received, or alternatives the resident or responsible party preferred.

Inspectors wrotec.1 A review of the Face Sheet indicated Resident 75 was admitted to the facility on [DATE]. Resident 75 diagnoses included were fracture (broken bone) of the right femur (thighbone), chronic obstructive pulmonary disease (COPD, progressive disease that gets worse over time and makes it hard to breath), dementia (gradual loss of brain function and a decline in mental functioning) and psychosis (severe mental disorder in which you lose touch with reality). A review of the MDS, dated [DATE], indicated Resident 75 had short and long-term memory problems, was able to make herself understood and had the ability to understand others. Resident 75 required total assistance with activities of daily living. During observation on 5/3/21, at 10:39 am, two staff were observed assisting Resident 75 with bed bath. During this observation, Resident 75 told the staff twice that she was feeling cold. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain normal water temperatures. This deficient practice had the potential for the residents to experience uncomfortable water temperatures.

Inspectors wroteBased on interview and record review, the facility failed to indicate in writing the address where three of three sampled residents (Residents 249, 250, and 253) were discharged to. This deficient practice had the potential for the residents who left the facility not knowing whether their destination was safe and not be able to receive the continuity of care they needed.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive, resident specific plan of care for nine of 35 sampled Residents (Residents 27, 48, 167, 75, 133, 91, 146 and 163) a. Resident 27 did not have a care plan to address hearing difficulties. This deficient practice had resulted in the resident's difficulty in miscommunication and a potential not to receive neccessary care and services. b. Resident 48's care plan was not implemented to monitor the resident for bleeding and bruising while receiving Xarelto ( a medication to prevent development of blood clot or blood thinner). c. Resident 167's care plan was not implemented to monitor the resident for bleeding and bruising while receiving Coumadin (a medication to prevent development of blood clot or blood thinner). [...]

Inspectors wroteBased on observation, interview, and record interview, the facility failed to provide assistance with communication for one of one sampled resident (Resident 187). This deficient practice had the potential for Resident 187 not to communicate effectively.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist three of three sampled residents (Residents 27, 91 and 187) with proper treatment and assistive device to improve hearing abilities. The residents were not referred to the physician to assess the cause of and treatment for hearing impairment. This deficient practice had resulted in Residents 27, 91 and 187 not able to hear staff effectively during care and had the potential to result in miscommunication about their healthcare plans that could result in decline in the quality of care and life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide care and services for 7 of 11 sampled residents (Residents 75, 136, 146, 163, 650, 653, and 103) with or at high risk for developing pressure injuries (area of damaged skin caused by staying in one position for too long) as indicated in the physician's order, plan of care and policy and procedures by failing to:. 1. For Resident 75, the staff did not apply a heal protector (devices that reduces pressure on bony areas) and did not reposition the resident at least every two hours. 2. For Resident 146 who had a stage 4 pressure ulcer (injury to the skin and underlying tissue, primarily caused by prolonged pressure on the skin), was not repositioned every two hours. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor, supervise and provide assistive device to prevent accidents and injuries for two of two sampled residents (Residents 649 and 174) by failing to: a. For Resident 649, the resident had recent history of fall and the pad alarm (a pad place on the bed that alarms when the person move off the bed) was found on the floor. b. For Resident 174, the resident had a physician's order to not give resident a straw due to the risk of aspiration (inhalation of food or fluids into the lungs) and the resident was observed to have a straw in her drink. These deficient practices had the potential to result in the aspiration for Resident 649 and fall with injury for Resident 174 that could lead to decline in the resident's well being of both residents.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing staff to provide range of motion, application of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), and ambulation to 129 residents requiring a Restorative Nursing Assistant (RNA, nursing aide program that helps residents to maintain their function and joint mobility) program. This deficient practice had the potential to decrease the residents' range of motion and mobility, which could affect the residents' overall function.

Inspectors wroteBased observation, interview and record review, the facility failed to ensure 4 of 5 sampled residents (Residents 96, 95, 117 and 146) were free of unnecessary medications. a. For Resident 96, the resident was not provided non pharmacological (non-medication options) interventions for inability to sleep, and all hours of sleep were not measured during the day, evening and nights while receiving Trazodone (a medication used to relieve falling or remaining asleep) for inability to sleep. This deficient practice had resulted in Resident 96's hours of sleep were not counted properly which had the potential to result in adverse side effect (untoward effect or reaction) to the medication. b. For Resident 95, the resident's gradual dose reduction (GDR, slowly reducing the frequency and dose of drug) was not performed while receiving Seroquel (medication that affects mental, mood and behavior). [...]

Inspectors wroteBased on Observation interview and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. There were 2 errors observed during medication pass observation with 25 opportunities which yield 7.69% error rate. a. For Resident 103, the Vitamin C ( a vitamin supplement) morning dose was omitted from the medication administered. This failure had the potential to cause a Vitamin C deficiency in resident 103 which could result in delayed wound healing, bruising, and painful and swollen joints. b. For Resident 101, the gastric tube (a tube surgically inserted into the stomach to deliver fluids and medications) was not flushed prior to medication administration. This deficient practice had the potential for the GT to clogged and adverse (undesired effect) drug reaction to the medications administered.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biological used in the facility are labeled in accordance with professional standards and failed to remove expired medications from medication carts and storage rooms. a. Resident 192's medication was found outside of its protective packet and with out an open and expiration dates. b. Resident 71's medication was found stored past the use by date. These failure had the potential for Resident 192 and Resident 71 receiving medications that past the use by date and were not stored properly and placed the residents at risk for receiving ineffective medications. c. Station 6's medication cart and Medication Storage room [ROOM NUMBER] had expired medications. These deficient practices had the potential for residents to receive expired medication which can affect the residents' well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food items were stored under sanitary conditions as indicated in the policy and procedure by failing to: 1. Ensure not to store a dented food can in the pantry. 2. Ensure to maintain the floors behind standing refrigerators clean. These deficient practices had the potential for residents to be at risk for contracting food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement, and evaluate the appropriate plan of action to correct identified quality deficiencies by failing to: 1. Ensure residents at risk of developing or with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints that could cause pain) were provided range of motion (ROM) exercises by the RNA (Restorative Nursing Assistant). The 11 of 11 sampled residents with contractures or at risk for developing contractures were not provided ROM exercises and/or placed assistive device to prevent contractures. There were 36 residents out of 107 residents developed contractures at the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary environment to help prevent the spread of infections during the Coronavirus-19 (COVID-19, a respiratory illness that can spread from person to person) as indicated in the facility's policy and procedure by failing to: 1. Ensure Resident 75's call light (device used by a patient to signal his or her need for assistance from professional staff), was disinfected after the call light was found on the floor. 2. Ensure contaminated dust mops were covered. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that promoted the dignity and respect during meals for one of 35 sampled residents (Resident 75) as indicated in the facility's policy and procedure. This deficient practice had the potential to negatively impact the resident's psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for one of 35 sampled Residents ( Resident 27). Resident 27 with hearing impairment was assessed and recorded as no hearing difficulties This had the potential for the resident not to receive the appropriate and necessary care, treatment and services, which can adversely affect quality of life

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate Resident 75's treatment for skin rash. This deficient practice had the potential for Resident 75 not to receive the appropriate care and treatment and inadequate monitoring of the resident's progress and changes in condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident with an indwelling catheter (known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) tubing was not kinked for one of one sampled resident (Resident 183). This deficient practice had the potential to result in recurrence of urinary tract infection (UTI-an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) that could to lead to urosepsis (a potentially life-threatening complication of urinary tract infection).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff assessed and placed dressing on hemodialysis catheter (hallow tube inserted into a large vein for exchanging blood to and from a blood filtering machine and a patient) access site for one of three residents (Resident 103). This failure place Resident 103 at risk for developing an infection of the skin where the hemodialysis catheter is inserted or infection of the blood stream.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the nurse staffing information on the posting was accurate for 3 of 5 days (5/3/21, 5/4/21, 5/5/21). This deficient practice had the potential to result in misinformation to the residents and the public regarding the facility's nursing staffing data.

Inspectors wroteBased on interview and record review, the facility failed to ensure an inventory list of personal belongings was completed for one of 35 sampled Residents (Resident 75). The facility also failed to follow the facility's policy on narcotic (controlled substance) medication administration for one of one sampled resident (Resident 710). These deficient practices placed Resident 75's personal property at risk for theft and loss and had the potential to result in Resident 710's controlled medication diversion (a medical and legal concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use).

Inspectors wroteBased on interview and record review, the facility failed to ensure the current physician certification for hospice (providing care for the sick or terminally ill) benefit was renewed for one of 4 sampled residents (Resident 75). This deficient practice had the potential for miscommunication regarding Resident 75's hospice care.

Inspectors wroteBased on interview and record review the facility failed to provide a functional phone connection for the residents and visitors. This deficient practice resulted for the residents' family members not to be able to communicate with the residents and with facility staff. a. During an interview on 5/7/21, at 8:53 a.m., RP 1 stated the biggest complaint about the facility was the terrible phone service. RP 1 attempted to call multiple times this past week, but the receptionist did not pick up. A review of the map indicated the facility had six nursing stations. A review of the facility's census, dated 5/3/21, indicated the facility had 212 residents. During an interview on 5/7/21, at 1:03 p.m., Administrator (ADM) stated the facility had only three telephone lines. Director of Nursing (DON) was aware the phone lines were problem since physicians had difficulty calling the facility. [...]