Kei-Ai Los Angeles Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three residents (Residents 1 and 2) were treated with respect and dignity and failed to honor residents' right to refuse care from the outside contracted phlebotomist on 3/11/2026 at 4 AM during a blood draw procedure at resident's bedside. This failure resulted in:Resident 1 reported that the phlebotomist was unprofessional, harsh, and rude during the procedure. Resident 1 stated that despite verbally telling the phlebotomist to stop, he continued inserting the needle, causing distress and discomfort. Resident 2 reported the phlebotomist was rough and unprofessional. As a result of this experience, Resident 2 refused further services from the phlebotomist, which led to a delay in necessary lab work, treatment, and diagnosis. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse and failed to report, investigate, and take action on allegations of abuse reported to facility staff on 3/11/2026, involving an outside contracted phlebotomist for two of three residents (Residents 1 and 2) reviewed for abuse concerns. This failure resulted in:Resident 1 reported that the phlebotomist was unprofessional, harsh, and rude during the procedure. Resident 1 stated that despite verbally telling the phlebotomist to stop, he continued inserting the needle, causing distress and discomfort. Resident 2 also reported the phlebotomist was rough and unprofessional. As a result of this experience, Resident 2 refused further services from the phlebotomist, which led to a delay in necessary lab work, treatment, and diagnosis. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician as indicated in the interdisciplinary team (IDT, comprises professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) meeting documentation for one of three sampled residents (Resident 1) reviewed for notification requirements. This failure resulted in Resident 1 experiencing emotional distress, uncertainty, and Resident 1 remains without physician review or documented medical evaluation related to discharge appropriateness from 2/19/2026 to 3/1/2026. During a record review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of chronic kidney disease (damage to the kidneys so they cannot filter blood the way they should). [...]

Inspectors wroteBased on interview and record review the facility failed to develop and document discharge goals and failed to provide a documented rationale for determining discharge was not feasible for one of three sampled residents (Resident 1) reviewed for discharge planning. This failure resulted in Resident 1 verbalizing experiencing emotional distress due to the facility's failure to clearly communicate discharge goals, discharge planning, and delays in progressing toward discharge. During a record review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of chronic kidney disease (damage to the kidneys so they cannot filter blood the way they should). During a record review of Resident 1's Minimum Data Set (MDS- resident assessment tool) , dated, indicated Resident 1 had capacity to make decisions. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1. Notify Resident 262's physician when Spironolactone (a blood pressure medication prescribed for congestive heart failure, or CHF-a condition in which the heart cannot pump blood effectively) was unavailable on 02/16/2026.2. Positively identify Residents 260 and 262 before giving medications, increasing the risk of medication errors and harm.3. Maintain accurate emergency medication kit (Ekit, a secured, organized container holding essential, often pre-packaged, drugs and supplies designed for rapid access to treat specific health conditions, emergencies, or, in hospice settings, to provide immediate comfort care) usage records for all residents, putting residents at risk of not receiving needed medications during emergencies.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of seven residents (Resident 260, 129, 8, and 83) were free of a significant medication error (any preventable error in medication administration that can result in resident discomfort, jeopardizing health and safety, or requiring medical intervention). [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure safe and sanitary food storage practices when: 1. Seven packages of turkey breast exceeding storage period (the amount of time a food product remains safe to eat and keeps its best quality) were stored in the facility's Walk-in refrigerator. 2. The temperature of the resident refrigerator located next to the nurse's station on the first floor was not maintained in a safe temperature range and was not monitored for unsafe refrigerator temperatures. These deficient practices had the potential to result in harmful bacteria growth that could lead to foodborne illness in 275 out of 283 residents who received food from the facility and including residents who had food stored in the resident refrigerator.

Inspectors wroteBased on interviews and record reviews the facility failed to renew psychotropic medications (drugs that alter brain chemistry) consents for one of two residents (Resident 13), As evidenced by: 1. Failing to renew Resident 13's Lamotrigine (medication used to stabilize moods to manage bipolar disorder [a mental health condition that causes extreme mood swings]) consent from 1/31/2023.2. Failing to renew Resident 13's Trazadone (medication used to improve mood and sleep).3. Failing to renew Resident 13's aripiprazole (medication used to treat mental health conditions like schizophrenia [a serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior] and bipolar disorder) consent from 12/10/2024. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) for two out of five sampled residents (Resident 49 and Resident 308) were accurate, by failing to: 1. Document a diagnosis of bipolar disorder (a mental health condition that causes extreme mood swings) on Resident 49's MDS dated [DATE].2. Ensuring Resident 308's MDS dated [DATE] accurately reflected Resident 308's discharge status. These deficient practice resulted in an inaccurate MDS assessments and had the potential to negatively impact Resident 49's plan of care and delivery of services as well as the submission of incorrect regulatory and reimbursement (the act of paying someone back money) data for Resident 308.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the needs for one of three sampled residents (Resident 193), by failing to create and implement a care plan for Resident 193's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). These deficient practices had the potential for Resident 193 to receive inadequate care and/or supervision which could affect the residents' quality of care and cause the resident harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to update and revise the range of motion (ROM - uses guided exercises to help joints move properly, reducing stiffness and increasing flexibility after injury, surgery, or illness) care plan for one out of one sampled resident (Resident 12). This deficient practice had the potential to prevent Resident 12 from receiving care to address their specific needs, which could lead to a decline in emotional and physical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the appropriate Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries, localized damage to the skin and/or the he non-hardened, flexible area beneath your skin usually over a bony area) settings for two of six sampled residents (Resident 42 and Resident 193). This failure had the potential to increase the risk of skin breakdown (damage to the skin and underlying tissue, ranging from red, irritated skin to deep, open wounds/bedsores) and development of pressure ulcers/injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for Resident 42 and Resident 193.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 79) identified as at risk for falls was free from risks of falling, by failing to ensure the resident's bed was placed in the lowest position. This deficient practice placed Resident 79 at increased risk for falls and complications related to fall injuries such as fractures, cuts, and internal bleeding.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide necessary respiratory care services for one of one sampled residents (Resident 120), by failing to ensure Resident 120's oxygen nasal cannula tubing (a lightweight, flexible plastic tube with two small prongs that sit just inside your nostrils to deliver supplemental oxygen) was not resting on the floor while Resident 120 was using the oxygen nasal cannula. This failure had the potential for Resident 120 to experience respiratory infections (infections of parts of the body involved in breathing) associated with using an unsanitary (dirty, unhealthy, or unclean in a way that could endanger health) oxygen nasal cannula tubing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's medication error rate (the percentage of errors observed during medication administration) was less than five percent (%). Two medication errors out of a total of twenty-six opportunities contributed to an overall medication error rate of seven-point six nine percent (7.69 %), affecting one of four sampled residents (Resident 260) who was observed during medication administration (med pass). The facility failure to assess Resident 260's systolic blood pressure (SBP - the pressure in the arteries when the heart beats [bpm]) and/or heart rate (HR - the number of times the heart beats per minute) prior to administering Labetalol and Lisinopril (medications used to treat hypertension [HTN - high blood pressure]) to the resident as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage, labeling, and/or disposal of medications, by failing to ensure an open box of Advair Diskus (a medication that contains both an anti-inflammatory medicine (fluticasone propionate) and a long-acting bronchodilator (salmeterol) with a shorten expiration date (the medicine will become less effective or unsafe sooner than the date originally printed on the bottle) once opened, had an open date (the date the medication was first opened) for one of four sampled residents (Resident 334), as per the manufacturer's label for Advair Diskus dated 6/2023. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain infection control measures necessary to prevent the spread of infections for two out of nine sampled residents (Resident 262 and Resident 292), by failing to: Ensure Licensed Vocational Nurse 3 (LVN 3) performed hand hygiene (cleaning your hands to remove dirt, viruses, and bacteria, primarily through washing with soap and water or using alcohol-based sanitizer) before administering medications and coming in direct contact (physically touching someone or interacting face-to-face, allowing for the potential for immediate transfer of germs) with Resident 262. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an appropriate discharge plan for one of the four sampled residents (Resident 1) who was transferred to General Acute Care Hospital (GACH) on 7/29/2025 for further psychiatric evaluation and was not permitted to return to the facility per their policy. This deficient practice resulted in Resident 1 to unnecessary remain in GACH four months after he was cleared for discharge. [...]

Inspectors wroteBased on interview, and record review the facility failed to make prompt efforts to resolve grievance for one of four sampled residents (Resident 1). The facility failed to address Resident 1's complaints regarding inadequate assistance from staff and nursing care. This deficient practice violated the residents' right to have his grievances addressed promptly. During a review of the admission Record indicated the facility admitted Resident 1 on 7/18/25 with diagnoses including esophagitis (inflammation of the lining of the esophagus [muscular tube that connects the throat to the stomach], duodenal ulcer (sores on the lining of the stomach) and generalized muscle weakness. During a review of the Minimum Data Set (MDS, resident assessment tool) dated 10/22/25 indicated Resident 1 was cognitively intact. Resident 1 used the walker and wheelchair for mobility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order before applying topical (a medication applied to the skin) ointment in accordance with professional standards of practice for one of five sampled residents (Resident 1). For Resident 1, the facility failed to obtain a physician order before applying zinc oxide (a protective skin cream that works by creating a physical barrier on top of the skin) topical ointment to Resident 1's Moisture Associated Skin Damage (MASD, moisture associated skin damage caused from prolonged exposure to moisture) in the buttock skin folds on 11/18/25 at 9:10 a.m. This deficient practice had potential to place Resident 1 at risk for receiving unnecessary medication and experiencing adverse effects. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents' medical records are complete and accurate for two of three sampled residents (Resident 1 and Resident 2). The facility failed to:1. Document in Resident 1's medical record that a nurse-to-nurse report was given on 9/8/25 when Resident 1 was discharged to Facility A on 9/8/25. 2. Document in Resident 2's medical record that a nurse to nurse report was given on 9/17/25 when Resident 2 was discharged to Facility B on 9/17/25. These deficient practices resulted in inaccurate and incomplete records for Resident 1 and Resident 2. 1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary restraints (a method or device that restricts a patient's freedom of movement or normal access to their body) by failing to: 1. Ensure Certified Nursing Assistant 2 (CNA2) did not wrap a linen sheet around Resident 1's legs and tied it to Resident 1's bedframe to restrict Resident 1's movement on 9/11/2025. This failure resulted in Resident 1's movement being restricted and had the potential for Resident 1 to develop an injury, impaired circulation (a condition where blood flow is reduced or blocked in certain areas of the body), skin breakdown (damage to the skin that can lead to open wounds and infections), and/or pain.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of staff to resident abuse to the California Department of Public Health (CDPH) and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within two hours from when one of three sampled residents (Resident 1) was found with a linen sheet wrapped around Resident 1's legs and tied to his bedframe. This failure had the potential to result in a delay of an onsite inspection by CDPH and had the potential for Resident 1 to experience ongoing abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its policies and procedure (P&P) on infection control to prevent the spread of coronavirus disease 2019 (COVID19, a highly contagious infection affecting the respiratory system caused by a virus that can spread from person to person). The facility failed to:1. Ensure all personnel wear N95 masks (disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) during the COVID19 outbreak.2. Ensure the N95 was properly worn.3. Remove gloves promptly after contact with resident items. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to update the residents regarding their discharge plan for one of two sampled residents (Resident 1). For Resident 1, the facility failed to notify and update Resident 1 regarding Resident 1's plan for discharge. This deficient practice resulted in Resident 1 stating that she wanted to go home and felt frustrated for not knowing what the discharge plan for her was. During a review of the admission Record indicated the facility admitted Resident 1 on 8/23/22 and re-admitted on [DATE] with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells) and hypertension (HTN-high blood pressure). During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 5/28/25 indicated Resident 1 was cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility failed to create an effective discharge plan for one of two sampled residents (Resident 1). For Resident 1, the facility failed to:1. Update Resident 1's discharge care plan. 2. Include Resident 1 in the discharge planning process. These deficient practice resulted in Resident 1 stating that there was a lack of communication regarding her discharge from the facility. During a review of the admission Record indicated the facility admitted Resident 1 on 8/23/22 and re-admitted on [DATE] with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells) and hypertension (HTN-high blood pressure). During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 5/28/25 indicated Resident 1 was cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility failed to notify and update the resident's responsible party (RP) for one of three sampled residents (Resident 1). For Resident 1, the facility failed to:1. Notify and update Resident 1's RP on 7/12/25 when Resident 1's transportation to take him home was delayed. 2. Review and respond accordingly to the voicemail left by Resident 1's RP. These deficient practices resulted in Resident 1 feeling anxious to go home and Resident 1's RP stated she was waiting and worried because Resident 1 had not arrived home. 1. During a review of the admission Record indicated the facility admitted Resident 1 on 6/14/25 with diagnoses including fracture (break in the bone) of the right femur (thigh bone), Parkinsons disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and muscle weakness. [...]

Inspectors wroteBased on interview and record review the facility failed to revise and update the care plan for one of four sampled residents (Resident 1). For Resident 1 the facility failed to update the care plan when Resident 1's Alprazolam (medication used to treat anxiety disorder) was discontinued on 4/10/25. This deficient practice resulted in inaccurate reflection of the actual care provided to Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy on infection control for cleaning and disinfection of re-usable devices. During observation on 6/24/25 at 10:13 a.m., five oxygen concentrators (type of medical device used for delivering oxygen to individuals with breathing-related disorders) that were not sanitized (reduces the number of germs on objects and surfaces to levels considered safe) were observed in the supply room. This deficient practice had the potential to contaminate the clean supplies of the unit used by other residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the medications were not left unattended at the bedside table according to the professional standard of practice for medication administration for one of three sampled residents (Resident 1). On 6/6/25 at 9:52 a.m., a medication cup with pills was observed at the bedside table of Resident 1. The facility failed to remain with Resident 1 to ensure Resident 1 had taken all her medications and not leave medications at the bedside. This deficient practice had the potential for Resident 1 to not take all her medications and for other residents to consume the medication left at the bedside.

Inspectors wroteBased on interview and record review the facility failed to implement the care plan for one of two sampled residents (Resident 1). For Resident 1, the facility failed to monitor Resident 1 ' s intake and output as indicated in the care plan. This deficient practice had the potential for the facility not to be able to meet the hydration and nutritional needs of Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure the physician order was transcribed accurately for one of two sampled residents (Resident 1). For Resident 1, the facility failed to ensure the gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding start and stop times were accurately documented. The Physician Order dated 4/15/25 at 3 p.m. indicated to give Resident 1 GT feeding of Nutren (tube feeding formula) at 50 milliliters per hour (ml./hr., measure of flow rate) and water at 40 ml/hr. for 16 hours. However, the order indicated to start at 6 p.m. and stop at 6 a.m., (12 hours instead of 16 hours). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident call light system (a communication tool used in medical facilities to facilitate communication between residents and healthcare providers; by allowing residents to signal when they need assistance. The system typically includes call buttons or pull cords in resident rooms or bathrooms, often with visual indicators like dome lights outside the rooms to alert staff) remained functional on 5/3/2025 - 5/4/2025 for 71 out of 71 residents on the second floor of the facility. By failing to ensure staff reset bathroom call lights after being triggered. This deficient practice had the potential to result in injury or harm due to residents not being able to call for facility staff as needed for help and/or during an emergency.

Inspectors wroteBased on observation, interview and record review the facility failed to implement the comprehensive care plan for one of six sampled residents (Resident 1). For Resident 1, the facility failed to apply floor mat at the right side of Resident 1 ' s bed as indicated in Resident 1 ' s care plan for falls. This deficient practice had the potential for Resident 1 to sustain an injury when Resident 1 falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff maintain current basic life support (BLS, set of emergency procedures designed to sustain life in victims experiencing cardiac arrest [when the heart stops beating suddenly]) certification for one of five sampled healthcare workers (Certified Nursing Assistant 1 [CNA 1]). CNA 1 ' s BLS certificate expired on [DATE]. This deficient practice had the potential for CNA 1 not to recognize residents who may need immediate emergency intervention.

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision to prevent accidents for one of six sampled residents (Resident 1). For Resident 1 the facility failed to: 1. Ensure the sensor pad alarm (device that detects when weight is removed from the pad, triggering an audible or visual alarm) placement was monitored and functioning. 2. Ensure staff respond immediately when the sensor pad alarm triggers an audible alarm. These deficient practices resulted in Resident 1 having unwitnessed falls on 2/6/25, 2/7/25 and 2/9/25 and had the potential for Resident 1 to sustain major injury such as fracture (break in the bone).

Inspectors wroteBased on interview and record review, the facility failed to provide laboratory services to one of six sampled residents (Resident 2). For Resident 2, the facility failed to follow physician order to do blood tests that included complete blood count (CBC, blood test that measure the number and types of cells in the blood) and comprehensive metabolic panel (CMP, blood test that measures 14 components of the blood that would assess including liver and kidney function) every Friday. Resident 2 had blood tests done on 6/28/24 (Friday) but failed to repeat the blood test the following Friday on 7/5/24. This deficient practice had the potential for the facility to fail to determine if Resident 2 ' s kidney function was worsening.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a history of falls, was cognitively impaired (had impairment in the ability to think, understand, and reason), had poor safety awareness, and required assistance with transferring and toileting was provided with the necessary care and services necessary to prevent falls. By failing to: 1. Follow the Physician's Order dated 11/27/2024 for Resident 1 to receive visual checks every 30 minutes for fall management after Resident 1 had an unwitnessed fall on 11/25/2024. 2. Review and update the High Risk for Falls Care Plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) after a second fall and change in condition on 12/6/2024. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain the discharge order from the primary physician in accordance with professional standard of practice for one of three sampled residents (Resident 1). For Resident 1 the facility failed to: 1. Obtain discharge order from Resident 1 ' s primary physician before discharging Resident 1 on 1/23/25. The facility entered a telephone order from the primary physician on 1/22/25 that Resident 1 was for discharge home on 1/23/25. However, the primary physician did not give the discharge order. 2. Ensure accurate entry in Resident 1 ' s Progress Note on 1/21/25 at 9:01 pm that an order was obtained to discharge Resident 1 home on 1/23/25. The entry did not indicate which physician gave the discharge order. These deficient practices resulted in inaccurate record for Resident 1 and falsification of physician orders.

Inspectors wroteBased on interview and record review the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding risks, benefits and alternatives offered) for one of five sampled residents (Resident 1). For Resident 1, the facility failed to obtain informed consent before starting Resident 1 on the following psychotropic medications (drugs that affect the mind, emotions and behavior) on 12/19/24. 1. Trazadone 12.5 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) orally at bedtime for depression. 2. Wellbutrin extended release (XL) 150 mg. orally one tablet daily for depression. 3. Duloxetine 30 mg. orally two capsules two times a day for depression. 4. Brexpiprazole one mg. [...]

Inspectors wroteBased on interview and record review the facility failed to provide toileting (maintain perineal hygiene after voiding or bowel movement) and personal hygiene for one of five sampled residents (Resident 1). For Resident 1, who was frequently incontinent (involuntary loss of control) of bowel and bladder and refused personal and toileting hygiene multiple times after each episode of incontinence, the facility failed to: 1. Involve Resident 1 ' s responsible party (RP) to discuss the plan of care regarding Resident 1 ' s refusal of personal and toileting hygiene after each episode of incontinence. 2. Notify the physician regarding Resident 1 ' s refusal of hygiene care. These deficient practices resulted in Resident 1 with unpleasant smell, poor hygiene and had the potential for Resident 1 to develop infection and pressure ulcer (wounds that occur from prolonged pressure the skin).

Inspectors wroted. A review of Resident 60's admission record indicated Resident 60 was admitted to the facility on [DATE], with diagnoses including dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), and urinary incontinence (involuntary leakage of urine from the bladder). A review of Resident 60's History and Physical (H&P) report completed on 11/5/2024, indicated Resident 60 was alert, confused, and responded to simple questions. The H&P indicated Resident 60 did not have the capacity to understand and make decisions. A review of Resident 60's MDS dated [DATE], indicated Resident 60 usually understood others and was usually able to express ideas and wants. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and directly notify the primary physician of a significant change in condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one of nine sampled residents (Resident 130) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move) on 12/20/2024 regarding Resident 130's inability to walk with the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of one resident (Resident 38) had an accurate assessment documented in the resident's medical record to support the administration of the psychotropic medications (drugs that affect the brain and nervous system to treat mental illness). This deficient practice caused an increased risk for Resident 38 to receive unnecessary medications.

Inspectors wroteA review of Resident 44's admission Record indicated the facility admitted the resident on 3/03/2021 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 44's Minimum Data Set (MDS - a resident assessment tool) dated 3/07/2024, indicated while in the facility it was somewhat important to participate in religious services or practices and do her favorite activities. A review of Resident 44's Activity Assessment Form dated 3/08/2024, indicated the resident's preferences included turning on television or music, Christian service 1x week, and bingo games at bedside. The assessment indicated the residents desired outcome from involvement within the activity program was pleasure and comfort. [...]

Inspectors wrotec. A review of Resident 44's admission Record indicated the facility admitted the resident on 3/03/2021 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 44's Minimum Data Set (MDS - a resident assessment tool) dated 3/07/2024, indicated while in the facility it was somewhat important to participate in religious services or practices and do her favorite activities. A review of Resident 44's Activity Assessment Form dated 3/08/2024, indicated the resident's preferences included turning on television or music, Christian service 1x week, and bingo games at bedside. The assessment indicated the residents desired outcome from involvement within the activity program was pleasure and comfort. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to five of nine residents (Resident 37, 127, 44, 36, and 128) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to: 1. Provide Resident 37 with active range of motion ([AROM] performance of ROM of a joint without any assistance or effort of another person) to both arms, five times per week, in accordance with the physician's order, dated 12/26/2024. 2. Provide Resident 37 with sit-to-stand transfers using a front-wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking), five times per week, in accordance with the physician's order, dated 12/26/2024. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide therapy services, including Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) and Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) to one of nine sampled residents (Resident 96) with range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns in accordance with Resident 96's physician signed care plans for OT and PT. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure four of nine sampled residents (Resident 96, 130, 44, and 37) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) had complete clinical records. 1. Resident 96's clinical records did not include the Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Discharge Summaries on 6/14/2024. 2. Resident 96's clinical records did not include the Occupational Therapy Discharge Summary on 11/2/2024 and PT Discharge Summary on 11/4/2024. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to respect the resident's right to dignity and respect for one sampled resident (Resident 82), by failing to utilize the facility's translation services to communicate with non-English speaking Resident 82. This deficient practice had the potential to negatively affect Resident 82's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 173's) care plan for alteration in comfort was updated quarterly. This deficient practice had the potential to slow or stop Resident 173's progress toward achieving the highest practicable level of functioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 238) identified as at risk for seizures was free from accidents by failing to ensure a physician's ordered bilateral (both sides) padded side rails were placed on Resident 238's bed. This deficient practice placed Resident 238 at increased risk for falls injuries during a seizure (a disorder in which nerve cell activity in the brain is disturbed, causing seizures/convulsions).

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure one of eight sampled residents (Resident 96) had physician orders to receive oxygen therapy via nasal cannula as needed for shortness of breath. This deficient practice had the potential to cause complications associated with oxygen therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. Two of five staff (Licensed Vocational Nurses [LVN 6] and 1 Registered Nurse [RN 3]) had a completed annual performance evaluation. 2. One of five staff (Registered Nurse [RN 4]) had a completed annual competency evaluation. 3. One of five staff (Certified Nursing Assistant [CNA 7]) had an active certified nursing assistant certification. This deficient practice had the potential for all 294 residents to not receive appropriate services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six Certified Nursing Assistants (CNA 5) had a completed annual performance evaluation as per facility policy and procedures titled Performance Evaluations, revised June 2010. This deficient practice had the potential for all 294 residents to not receive appropriate services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Administer medication as per physician's orders for two of three sampled residents (Resident 256 and Resident 205). By failing to: a. Ensure Resident 256's Lidocaine External Patch (a medication applied topically to relieve pain) 4 percent (% - a unit of measurement for strength), apply to left knee topically one time a day for pain management and remove per schedule, order date 11/24/2024, and Lidocaine External Patch 4%, apply to right knee topically one time a day for R knee pain and remove per schedule, order date 10/27/2024 were removed on 1/6/2025 and new patches applied as per physician's orders. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for two of three sampled residents (Residents 256 and 205) by failing to administer Resident 256's psyllium husk (a fiber laxative used to relieve constipation), and Resident 205's aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) in accordance with physician's orders. These failures of medication administration error rate of 6.06% exceeded the five (5) percent threshold.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 256) was free from significant medication errors by failing to administer Resident 256's lidocaine patch (a medication applied topically to relieve pain) in accordance with physician's orders. This failure of not administering Resident 256's medication in accordance with the physician orders or professional standards of practice had the potential to result in hospitalization due to adverse effects such as abnormal breathing, abnormal heartbeat, numbness, and tingling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure storage, labeling, and/or removal of expired, undated and/or discontinued medications including insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication), Calcitonin (a medication administered into the nostrils to treat osteoporosis [a bone disease with low bone mineral density]) salmon (synthetic origin) nasal spray, Zytiga (generic name - abiraterone acetate, a medication used to treat cancer [a disease caused by uncontrolled division of abnormal cells in a part of the body]) and Stiolto Respimat (generic name - a combination of two medications containing tiotropium bromide and olodaterol used to treat chronic obstructive pulmonary disease [COPD - a chronic lung disease causing difficulty in breathing]), in accordance with [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen, by failing to: 1. Discard expired food and/or drinks. a. One medium sized container of cottage cheese with dates 12/30-1/4/25 exceeding storage period for cottage cheese was stored in the reach in refrigerator. b. Five expired single serve cartons of milk with dates 1/5/25 were stored in the reach in refrigerator. 2. Label food taken from freezer with dates the foods were thawed. a. Nutritional Supplement labeled store frozen with manufacturers instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster areas was maintained in sanitary manner. One of five garbage dumpster was overfilled with trash bags and uncovered. The floor area around the trash dumpsters was not clean, there was disposable gloves, paper, and food. This deficient practice had the potential for harborage and feeding of pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for 3 of 6 residents (Resident 96, 228, and 74) with infection control concerns by failing to ensure staff and visitors wore eye protection, including a face shield or eye goggles, while providing care to the residents, who were under observation for exposure to Coronavirus Disease 2019 (COVID-19, a highly contagious viral disease that can cause respiratory illness), in accordance to the signage posted upon entering the room and Federal guidance. This failure had the potential to spread COVID-19 throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment, by failing to provide one of five sample resident (Resident 38) a stable toilet seat with side rails. The deficient practice had the potential for Resident 38 to fall and sustain an injury.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive Minimum Data Set ([MDS] a resident assessment tool) for two of 9 sampled residents (Resident 37 and 130) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move). a. For Resident 130, the facility failed to complete a timely assessment after admission to hospice (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) on 10/15/2024. b. For Resident 37, the facility failed to complete a timely initial assessment after admission to the facility on 9/18/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete the Quarterly Minimum Data Set ([MDS] a resident assessment tool) in a timely manner for two of nine residents (Resident 96 and 127) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move). This failure delayed the information submission to the Federal database.

Inspectors wroteBased on observation, interview, and record review the facility failed provide adequate supervision when using mechanical lift for one of three sampled residents (Resident 1). For Resident 1, the facility failed to provide two persons assist while using the easy stand (mechanical device used to lift individuals directly from the wheelchair, bed, or other seated surface into standing position) to transfer Resident 1 from the bathroom to Resident 1 ' s bed on 12/31/24. This deficient practice had the potential for Resident 1 to fall or sustain injury while using the easy stand.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure stored food items have expiry dates. During observation in the food storage area on 12/31/24, several canned vegetables and food items did not have expiry dates. This deficient practice had the potential to serve expired food to all residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), who had a diagnosis of unspecified severe dementia with psychotic disturbance (the loss of the ability to think, remember, and reason to levels that affect daily life and activities, as well as psychotic disturbances like hallucinations, delusions, paranoia, or suspiciousness). The facility did not monitor or care plan Resident 2's behavior of yelling and angry outbursts. As a result, on 10/23/2024 at around 4:40 PM, Resident 2 had a physical altercation with Resident 1 over his preferred chair which resulted in Resident 1 sustaining a skin tear on the left thumb.

Inspectors wroteBased on interview and record review, the facility failed to provide timely orders for the necessary treatment and care needs for one of three residents (Resident 1), who sustained a skin tear on her left thumb. This deficient practice had the potential for Resident 1's skin tear to worsen and develop infection.

Inspectors wroteBased on interview and record review, the facility failed to inform the family or resident representative of an alleged abuse allegation for one of three sampled residents (Resident 1). The facility also failed to document in the resident medical record, events, incidents or accidents involving the resident, per the facility policy. This deficient practice caused an increased risk in abuse or potential abuse for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), alleged abuse allegation was reported to local authorities and State Agency in a timely manner. This failure resulted in the breach of the facility's abuse policy.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received dignity and respect in full recognition of their individuality for one of two sampled residents (Resident 1). Resident 1, who had a language barrier, was not able to fully communicate her needs and staff did not use the facility translation services to assist the non-English speaking resident. This deficient practice had the potential to negatively affect Resident 1's psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had dysphgia (difficulty swallowing), received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs. Resident 1 had a change in condition (COC) and received a medication for nausea and vomiting, but there was no documentation regarding the COC and no documentation to indicate if the medication was effective. This deficient practices had the potential for Resident 1 to receive a delay in the treatment and services to treat her nausea and vomiting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nursing staff had the specific skills sets necessary to care for Resident 1, who had symptoms of nausea and vomiting and vomitted on 9/27/2024. This deficient practice had the potential for Resident 1 to receive a delay in the treatment and services to treat nausea and vomiting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and/or revise a behavioral care plan for bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) for one of two sampled residents (Resident 1), who had behavioral patterns manifested by angry outbursts and verbal abuse. This deficient practice had the potential to negatively affect the provision of care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had diagnosis of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), was provided with the necessary behavioral health care services as indicated in the comprehensive assessment. The facility failed to: -Monitor Resident 1 for schizophrenic behavior. -Develop and implement a person-centered care plan for Resident 1's schizophrenia diagnosis. -Develop individualized interventions related to the Resident 1's schizophrenia diagnosis. -Identify Resident 1's individual responses to stressors and utilize person-centered interventions to support Resident 1. This deficient practice caused an increased risk in the mental and psycho-social well being of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had diagnosis of vascular dementia (a type of dementia that occurs when the brain's blood supply has been damaged, causing a lack of oxygen and nutrients to brain cells and marked by memory disorder, personality changes, and impaired reasoning), history of falls, and a high fall risk, was provided with the necessary care needs and services. The facility failed to: -Develop an appropriate care plan for Resident 1's Dementia through an Interdisciplinary Team (IDT) approach, with appropriate interventions including implementation of individualized care and maximizing the resident's safety. -Provide for Resident 1, 2:1 staff supervision (ratio of 2 residents and 1 one certified nursing staff) due to impulsive behavior, per the care plan interventions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement care plan for one of three sampled residents (Resident 1). For Resident 1, the facility failed to: 1. Develop a care plan addressing Resident 1 ' s behavior of removing his clothes and incontinence briefs. Resident 1 remained undressed. 2. Develop and implement interventions to maintain Resident 1 ' s privacy and dignity. These deficient practices had the potential to affect Resident 1 ' s psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to ensure one of two sampled residents (Resident 1), who had a history of falls and was assessed as a high risk for falls, received the care and services necessary to prevent accidents and falls by failing to: 1. Monitoring for effectiveness and modifying plan of care interventions for fall based on the identified risk of the resident. 2. Ensure not to leave Resident 1 unattended after a fall on 7/22/2024 at 8:49 PM. As a result, on 7/22/2024, Resident 1 had two consecutive (one after another) falls. Resident 1 was transferred to a General Acute Care Hospital (GACH) 1 where Resident 1 was diagnosed with a fracture (crack or break) of the right hip.

Inspectors wroteBased on interview and record review the facility failed to inform the resident representative when there was a change in billing for one of one sampled resident (Resident 1). For Resident 1, who does not have the capacity to understand and make decisions, the facility failed to notify Resident 1 ' s family member (FM) regarding the change in billing for Resident 1 on 7/9/24. The facility instead presented the Notice of Last Covered Date (advance notice of non-coverage) to Resident 1 and obtained his signature on 7/9/24. This deficient practice resulted in Resident 1 and Resident 1 ' s family member (FM) not given their right to be notified of the last covered date and had the potential for Resident 1 to not to meet the deadline for appeal.

Inspectors wroteBased on interview and record review the facility failed to ensure discharge planning was in place for one of one sampled resident (Resident 1). For Resident 1 who was for discharge on [DATE], the facility failed to: 1. Ensure discharge plan was in place when Resident 1 was admitted and as Resident 1 ' s needs changed. 2. Ensure the interdisciplinary team (IDT, group of professionals working together toward a common goal for the resident) evaluate Resident 1 ' s discharge plan prior to discharge. 3. Include Resident 1 ' s family member (FM) in determining the discharge plan and goals. These deficient practices had the potential for Resident 1 to have unsafe discharge and Resident 1 ' s FM stated being worried and scared about Resident 1 ' s discharge.

Inspectors wroteBased on interview and record review the facility failed to ensure the medical record are accurate and complete for one of one sampled resident (Resident 1). For Resident 1, the facility failed to: 1. Accurately reflect in Resident 1 ' s medical record Resident 1 ' s family member (FM) request to transfer Resident 1 to another facility on 7/15/24. 2. Ensure the Resident 1 ' s medical record reflects the notification of Resident 1 ' s FM of Resident 1 ' s last covered date of services on 7/9/24. These deficient practices resulted in incomplete and inaccurate record for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to provide sufficient certified nursing assistants (CNA) during the night shift (11 p.m. to 7 a.m.) on 7/11/24 and morning shift (7 a.m. to 3 p.m.) on 7/12/24. On 7/11/24 during the night shift CNAs had to take care of 17 to 18 residents and on 7/12/24 during the day shift CNAs had to take care of nine residents. The CNAs stated they felt rushed and unable to give quality care to the residents that they were assigned to take care of. This deficient practice had the potential for the facility not to meet the physical and psychosocial needs of each resident.

Inspectors wroteBased on interview and record review the facility failed to report to the state survey agency (SA) a fall with major injury for one of two sampled residents (Resident 1). For Resident 1, the facility failed to notify the SA when Resident 1 had an unwitnessed fall on 6/14/24 and was sent to the general acute hospital (GACH 1) for evaluation. GACH 1 informed the facility that Resident 1 did not have a fracture and sent Resident 1 back to the facility on 6/14/24. However, on 6/15/24, Resident 1 ' s left arm was found swollen, with discoloration and painful to touch. Xray of the left arm dated 6/15/24 indicated Resident 1 had fracture of the left elbow. This deficient practice resulted in delay of investigation if there was an occurrence of neglect or abuse for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to provide the seven-day bed hold (holding or reserving a resident ' s bed while the resident is absent from the facility for therapeutic leave or hospitalization) for one of four sampled residents (Resident 1). Resident 1 was sent to the general acute hospital (GACH 1) on 5/28/24. The facility re-admitted another resident (Resident 2) to Resident 1 ' s bed on 5/29/24 while Resident 1 ' s bed was still under the seven-day bed hold period. This deficient practice resulted in Resident 1 not given her right to go back to the same bed she had within the seven-day bed-hold period and as indicated in Resident 1 ' s Bed Hold Notification Informed Consent.

Inspectors wroteBased on interview and record review the facility failed to implement their admission policy for one of five sampled residents (Resident 1). For Resident 1 who was cognitively intact (ability to think, remember, being aware of the surroundings and using judgment) the facility admitted Resident 1 to the facility's special care unit for residents with Alzheimer's Disease (a brain disorder that slowly destroys memory, thinking skills and eventually the ability to carry out the simplest tasks) and dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities). This deficient practice resulted in Resident 1 stating that her roommate (Resident 2) did not want Resident 1 in the room and Resident 1 stated she was scared of Resident 2.

Inspectors wroteBased on interview and record review the facility failed to ensure the case manager (CM, healthcare professionals that specializes in coordinating and managing healthcare services) hired by the facility had the proper licensure and certification as indicated in their policy for one of two sampled employees (CM 1). The facility hired case manager (CM 1) who did not have a nursing degree from an accredited college or university, or a graduate of an approved licensed vocational nurse (LVN) program. This deficient practice had the potential to affect the care of residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to maintain complete record for one of five sampled residents (Resident 3). For Resident 3, the facility failed to ensure the medication administration record (MAR) was signed as soon as the medication were given to Resident 3 on 4/9/24. This deficient practice resulted in inaccurate documentation and record for Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report to the local California Department of Public Health (CDPH) within two hours of the suspected Certified Nursing Assistant (CNA) 1 to resident physical abuse that occurred on 3/21/2024 for one of three sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the California Department of Public Health (CDPH) to ensure circumstance were investigated. This also had the potential to place Resident 1 at further risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from accidents for one of four sampled residents (Resident 1) by failing to ensure bed was in low position and floor mat was placed next to he bed for Resident 1. This deficient practice placed Resident 1 at increased risk for falls and complications related to fall injuries.

Inspectors wroteBased on interview and record review the facility failed to ensure licensed vocational nurses (LVN) have the specific competency and skills set necessary to care for residents' needs, as identified through residents' assessments and plan of care, for one of two LVNs (LVN 1) reviewed for annual competency skills check. This deficient practice had the potential to place residents at risk for not receiving necessary care and services and the potential for injury.

Inspectors wroteBased on interview, and record review, the facility failed to provide supervision for one of three sampled residents (Resident 458), who had dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), psychosis (a mental disorder characterized by a disconnection from reality), Alzheimer's Disease (the most common type of dementia, a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), and history of falls, with a history of hip fracture, status post hemiarthroplasty (partial hip replacement) on 11/27/2023, received care, treatment, and services in accordance with professional standards of practice by failing to: -Provide a 1:1 sitter as ordered, and care planned. [...]

Inspectors wroteBased on interview and record review, the facility failed to perform annual staff competencies for four of five sampled staff (Certified Nursing Assistant [CNA] 4, CNA 5, CNA 6, and CNA 7. This deficient practice had the potential to result in residents to not receive the appropriate level of care needed affecting quality of care and potentially leading to resident harm.

Inspectors wroteBased on interview and record review, the facility failed to perform annual performance evaluations for four of five sampled staff (Certified Nursing Assistant [CNA] 4, CNA 5, CNA 6, and CNA 7. This deficient practice had the potential for residents to not receive the appropriate level of care needed affecting quality of care and potentially leading to resident harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared by methods that conserved flavor and served at appetizing temperatures for 259 out of 275 residents who received food from the kitchen and for one resident (Resident 170) who complained the food was cold. This deficient practice had the potential to result in meal dissatisfaction, decrease food intake and placed residents at risk for unplanned weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen by failing to: -Ensure the 30 chocolate flavored nutritional supplements and 22 vanilla flavored supplements stored in the reach in refrigerator with no thaw date and labeled Store frozen with the manufactures instruction to use within 14 day of thawing, were monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. This deficient practice had the potential to result in food borne illness in 80 residents who are on nutrition supplements at the facility. -Ensure the storage period of one large package of Ready to Eat sliced ham deli meat received on 12/2/2023 did not exceed the storage period for deli meat stored in the walk-in refrigerator. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 232) was not allowed to keep medications at the bedside without a physician's order and without assesing the resident's ability to self-administer medications. This deficient practice had a potential to result in the resident to self-medicate himself and for other residents to take unprescribed medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident 146) had an adaptive call light. This deficient practice placed the resident at risk of not receiving the necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to provide one of three sampled residents (Resident 169) the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN - provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility) and Notice of Medicare Non-Coverage (NOMNC - notification of termination of covered care) forms. For Resident 169, who did not have the capacity to understand or make decisions, the facility failed to mail the beneficiary forms by certified mail with return receipt to Resident 169's responsible party. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and care screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for two out of two sampled residents (Residents 219 and 224). This deficient practice had the potential to result in delayed services for the residents.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for the administration of antibiotics for one sampled resident (Resident 225). This deficient practice placed the resident at risk of not receiving the necessary care and services.

Inspectors wroteBased on observation, interview and record review, facility failed to label the tube feeding with the date, time, and initials for one of six sampled residents (Resident 110). This deficient practice had the potential for the residents to develop tube feeding associated complications such as infection or diarrhea, and lead to serious illness, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's Oxygen Administration policy and procedure for two of two sampled residents (Resident 210 and Resident 248). These deficient practices had the potential to cause complications associated with oxygen therapy.

Inspectors wroteBased on interview and record reviews, the facility failed to implement an effective pain management plan for one of three sampled residents (Resident 132 ). This deficient practice had the potential to negatively affect the resident's psychosocial wellbeing and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow its Social Assessment, policy and procedure for one of three sampled residents (Resident 48). This deficient practice had the potential for the resident not to attain the highest practicable physical, mental, and psychosocial well-being and delay in the delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to follow their Antipsychotic Medication Use, policy and procedure for one of six sampled residents (Resident 123), as evidenced by failing to indicate a stop date and/or duration for how long the resident was to receive an as needed psychotropic medication (medication that affects the mind, emotions, and behavior). This deficient practice had the potential to result in administering unnecessary psychotropic drugs for Resident 123 that could lead to side effect and adverse consequence such as a decline in quality of life and functional capacity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed fortified diet (increase caloric intake) guidelines during lunch preparation and tray line observation for one of 35 sampled residents by failing to: -Ensure a fortified diet was prepared and served to Resident 178, who had requested food only from the Japanese menu and was on a fortified diet. This deficient practice had the potential to result in decreased caloric intake and lead to undesirable weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff adhered to the facility's infection control policy and procedures by ensuring facility staff conducted hand hygiene prior to entering and after exiting a resident's room. This deficient practice had the potential to result in the spread of infection and placed facility residents and staff at risk to become infected and seriously ill, leading to hospitalization and/or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of Tuberculosis (TB- is a serious illness which may be fatal that mainly attacks the lungs but can affect almost any part of the body. It is caused by a bacterium called Mycobacterium tuberculosis which is spread through the air from one person to another if the infected person coughs, speaks, laughs, sings, or sneezes) by failing to: 1. Ensure that one of seven sampled residents (Residents 4) was screened for TB (Mantoux tuberculin skin test [TS]) and an Interferon Gamma Release Assay [IGRA] blood test) upon admission. The facility was aware Resident 4 had tested positive for TB positive while at a general acute care hospital (GACH) 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain temperatures of resident four (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) out of six sampled rooms between 71 and 81 degrees Fahrenheit (F, scale of temperature). This deficient practice has the potential for the residents to experience hypothermia (a potentially dangerous drop in body temperature, usually caused by prolonged exposure to cold temperatures).

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Fall Risk Assessment was completed within the required timeframe for one of 4 sampled residents (Resident 1) from 5/22/2021 to 10/2/2022. This deficient practice had the potential to negatively affect the provision of necessary care for Resident 1.