Kennedy Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation involving an incident of unknown source resulting in serious bodily injury was reported to the California Department of Public Health (CDPH-state agency who ensures oversight of state and federal regulations to long term care facilities) immediately, but not later than two hours after becoming aware of the incident, for one of four sampled residents (Resident 1) by failing to report that Resident 1 eloped (unauthorized departure of a resident from an around-the-clock care setting) from the facility on on 5/5/2026 at 5:50 PM. Resident 1 remained missing overnight and was returned to the facility by two police officers on 5/6/2026 at 3:35 PM two police officers. [...]

Inspectors wroteBased on observation, interview, and record review, three of four sampled residents (Residents 1, 2, and 3), who were identified as at high risk for elopement (Refers to an unauthorized departure. It happens when a patient or resident leaves a hospital, clinic, or care facility without notifying the staff or before being officially discharged . This is especially critical when the patient requires supervision for their own safety) and with wandering behaviors (locomotion behavior associated with conditions like dementia or autism. It involves repetitive, aimless, or disoriented pacing, roaming, or leaving a safe area) the facility failed to: Ensure the reception/lobby area is monitored and supervised after 6 PM when the receptionist signs out/leaves for the day to prevent residents at risk for elopement from eloping the facility. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure nursing staff maintained current cardiopulmonary resuscitation (CPR) certification in accordance with the standards of nursing practice for one of five sampled employees, Infection Prevention Nurse (IP). This deficient practice was identified during an employee records review and had the potential to place residents at risk for delayed or ineffective response during resident emergencies including cardiac arrest and respiratory failure.

Inspectors wroteBased on interview, observation and record review, the facility failed to maintain a safe, and functional environment for residents, staff and visitors by failing to ensure one of two entry doors in the facility was free from mechanical and/or electrical failure and in a safe operating condition. This deficient practice resulted to the theft of Resident 1's mobile phone by an unhoused individual (HL 1) who entered the facility without staff awareness on 1/9/2026, placing all residents, staff, and visitors at risk of avoidable abuse and misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of four sampled residents, (Resident 1) by failing to: Ensure Resident 1 was assessed and evaluated after an incident of theft and misappropriation of property by an unhoused individual (HL 1) who gained access to the facility without consent on 1/9/2026. Ensure a complete documentation of the incident was completed and documented according to facility's policy and procedure (P&P) titled, Charting and Documentation, and Abuse, Neglect, Exploitation and Misappropriation Prevention Program. These deficient practices placed Resident 1 in delayed intervention to provide treatment and care and to ensure safety of Resident 1 and possibly all other residents, staff and visitors in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure adequate supervision and security measures by failing to:Protect one of four sampled residents (Resident 1), from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of property and personal belongings. Document and list inventory of Resident 1's personal belongings upon admission according to facility's policy and procedures (P&P) titled, Personal Property. These deficient practices resulted in the theft of Resident 1's mobile phone by an unhoused individual (HL 1) while Resident 1 was in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy regarding reporting of theft and misappropriation of property and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of four sampled residents (Resident 1). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of theft and misappropriation of property was investigated which can also lead to a delay in prevention of further misappropriation of property and undetected type of abuse for all residents, staff and visitors in the facility. Cross Reference F602Findings: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician order to administer medication based on professional standards of clinical practice for one of five sampled residents (Resident 1). For Resident 1, the facility failed to administer the Nicotine (an addictive poisonous chemical found in tobacco) Patch (medication used to help stop smoking cigarettes)14 milligrams (mg- unit of measurement) per 24hours (14mg/24hrs) for smoking cessation. This failure had the potential to result in unmet care needs, ineffective management of smoking cessation and compromise Resident 1's health. During a review of the admission Record indicated the facility admitted Resident 1 on 12/3/25 with diagnoses including tobacco use and generalized muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure over the counter medications (OTC) were labelled with the date when the containers were first opened for one of one medication cart reviewed. During observation on 12/30/25 at 9:56 a.m., one container of acetaminophen (medication for short term relief of minor aches and pain) and one container of docusate sodium liquid (DSS, medication to relieve constipation) had no date indicating when they were first opened. This deficient practice had the potential to administer the medications to residents beyond the recommended days of use after opening the container. During observation and concurrent interview on 12/30/25 at 9:56 a.m. with Licensed Vocational Nurse (LVN 2), the acetaminophen and DSS containers were found in the medication cart that had no dates indicating when they were initially opened. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their infection control policy for one of five sampled residents (Resident 2). Resident 2, who was on enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, microorganisms resistant to most antibiotics]), the facility failed to ensure protective gown was used when Resident 2 was repositioned in bed on 12/30/25 at 8:39 a.m. This deficient practice had the potential to spread infection to other residents and staff. During a review of admission Record indicated the facility admitted Resident 2 on 11/13/25 and re-admitted on [DATE] with diagnoses including cerebrovascular (CVA, loss of blood flow to a part of the brain) with left side weakness, reduced mobility and generalized muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' privacy and dignity by failing to ensure the indwelling urinary catheter (a soft hollow tube which is passed into the bladder to drain urine, for persons who cannot empty their bladder in the usual way) drainage bag was always covered for one of three sampled residents (Resident 1). This deficient practice had the potential to affect Resident 1's sense of self-worth and self-esteem. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents' information was not sent to the personal cell phones of facility staff members. This deficient practice had the potential for unauthorized release of residents' information to the public. During an interview on 9/11/25 at 9:06 a.m., restorative nursing assistant (RNA 1, a certified nursing assistant (CNA) with specialized training in rehabilitation skills) stated she received text messages on her personal cellphone from the rehabilitation department regarding residents who would need to be on the RNA program. RNA 1 stated the text messages would include the name of the residents and their room number. During an interview on 9/11/25 at 10:18 a.m. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice for one of three sampled residents, (Resident 1) by failing to follow and implement physician's order and when Resident 1's blood pressure was elevated according to facility's policy and procedure titled, Changes in Resident's Condition or Status. This deficient practice placed Resident 1 in delayed intervention to provide treatment for urinary tract infection (UTI- an infection in the bladder/urinary tract) as required per facility's policy and procedure upon changes in condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff follow physician's order and facility's policy with wearing personal protective equipment (PPE-a barrier precaution which includes the use of gloves, gown, mask, face shield, when anticipating coming in contact with blood, body fluids or other communicable toxins or agents) when providing care to one of three sampled residents (Resident 2) who was on an enhanced barrier precaution (utilized to prevent the spread of multi-drug resistant organisms) room. This deficient practice placed residents at a higher risk of acquiring and transmitting infections to other residents, staff and visitors in the facility. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen for 76 of 76 residents when: Improper Storage of Fooda. Improper Storage and labeling of Food b. Prepared leftover tuna stored in the refrigerator c. Dietary staff did not follow cool down methodd. Multiple food items with expiration datese. Dietary Cooks did not follow the thawing process 2. Equipment Cleanliness/Cross-contaminationa. The stove was dirtyb. The floor in front of the stove was dirtyc. Multiple large silver pans were dirty 3. Dietary staff was competent in the thawing process for large pork roast. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to answer call lights in a timely manner for six of six sample (Residents 18, 28, 49, 71, 75, and 106). This failure had the potential to cause a delay in care and services necessary for the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide each resident with a nourishing and palatable diet for five out of five sampled residents (Residents 17, 18, 28, 49, and 75). This failure had the potential to result in weight loss, functional decline, dehydration, and skin impairment for Residents 17, 18, 28, 49, and 75). Resident 17 stated not getting nourishing and palatable diet makes him angryFindings: During an interview on 8/5/25 at 9:02 A.M., Resident 49 stated the food is not palatable and the dietary department is serving chicken too often at least 4 times a week. Resident 49 stated he spoke with the facility Dietary Supervisor (DS) and expressed his concerns about the food and nothing has changed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve palatable food for seven of seven residents (Residents 7, 17, 18, 24, 28, 49, and 75) reviewed for food palatability reviewed for food palatability. This deficient practice had the potential to result in meal dissatisfaction, decrease food intake and placed residents at risk for unplanned weight loss for the residents. 1. During a record review, Resident 7’s admission Record indicated the facility originally admitted the resident on 2/27/2024 and readmitted the resident on 5/17/2025 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness and anemia (a condition where the body does not have enough healthy red blood cells). [...]

Inspectors wroteBased on interviews and concurrent record review, the facility failed to ensure staff completed annual and upon hire Tuberculin (TB - is a serious illness that mainly affects the lungs) skin test, staff had TB skin test results on file, and annual physical examination completed for four out of seven employees (Licensed Vocational Nurse (LVN 1 and 2, Occupational Therapist (OT - assess a person's physical, cognitive, and emotional abilities and develop treatment plans to improve their functional skills, adapting the environment or activities as needed), and Treatment Nurse). This failure had a high probability of TB transmission to residents, guests, and staff to result in the facility.

Inspectors wroteBased on observation and interview, the facility failed to allow one of six sample residents (Resident 49) to retain his personal possession(s). This failure resulted in Resident 49 feeling angry because he could not call his family member(s).

Inspectors wroteBased on interviews and concurrent record review the facility failed to conduct a background search for one out of seven employees (Housekeeping) prior to working in the facility: This failure had the potential to expose the residents to abuse.

Inspectors wroteBased on observations, interviews, and concurrent record reviews, the facility failed to implement the physician orders to administer Trazadone (medication used to treat depression) for one of one sampled resident (Resident 106). These failures resulted in Resident 106 inability to sleep and the resident feeling angry. Cross Reference F0760Findings: During a record review, Resident 106 admission record indicated Resident 106 was admitted to the facility on [DATE] with a diagnoses of human immunodeficiency virus disease (a virus that weakens the body's defense system also called HIV) and essential hypertension (high blood pressure). During a record review of Resident 106's Minimum Data Set (MDS- a resident assessment tool) dated 8/8/2025, indicated the resident was cognitively intact (mental ability to make decisions of daily living). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' Annual Minimum Data Set assessments (MDS, a standardized assessment and care screening tool) was completed in accordance with the timeline set forth by the Center for Medicare Services (CMS) system for one out of 13 sampled residents (Resident 11). This deficient practice had the potential to result in delayed services for Resident 11. During a record review, Resident 11's admission record indicated the facility originally admitted the resident on 6/2/2021 and re-admitted the resident on 6/23/2023 with diagnoses that included Alzheimer's Disease , chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should) and dementia (a progressive state of decline in mental abilities). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' Minimum Data Set assessments (MDS, a standardized assessment and care screening tool) were transmitted timely to the Center for Medicare Services (CMS) system for four out of 13 sampled residents (Resident 17, Resident 40, Resident 57 and Resident 63). This deficient practice had the potential to result in delayed services for Resident 17, Resident 40, Resident 57 and Resident 63. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' Minimum Data Set assessments (MDS, a standardized assessment and care screening tool) were transmitted timely to the Center for Medicare Services (CMS) system for 11 out of 13 sampled residents (Resident 8, Resident 10, Resident 11, Resident 17, Resident 40, Resident 43, Resident 51, Resident 52, Resident 57, Resident 63 and Resident 104). This deficient practice had the potential to result in delayed services for Resident 10, Resident 11, Resident 17, Resident 40, Resident 43, Resident 51, Resident 52, Resident 57, Resident 63 and Resident 104. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the tube feeding (TF - a form of nutrition that is delivered into the digestive system as a liquid) was administered as ordered for one of two sampled residents (Resident 27). This deficient practice had the potential to cause Resident 27 to take in an inadequate amount of calories and nutrition and weight loss. During a record review, Resident 27's admission record indicated the facility admitted the resident on 7/19/2024 with diagnoses that included protein calorie malnutrition (a condition in which a person does not consume enough protein and calories to meet their body's needs), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and chronic kidney disease (progressive damage and loss of function in the kidney). [...]

Inspectors wroteBased on observations, interviews, and concurrent record reviews, the facility failed to administer Trazadone (Medication to treat depression) per physician orders for one of one sampled resident (Resident 106)These failures resulted in Resident 106 inability to sleep and feeling angry. Cross Reference F0635Findings: During a record review, Resident 106 admission record indicated Resident 106 was admitted to the facility on [DATE] with a diagnoses of human immunodeficiency virus disease (a virus that weakens the body's defense system also called HIV) and essential hypertension (high blood pressure). During a record review of Resident 106's Minimum Data Set (MDS- a resident assessment tool) dated 8/8/2025, indicated the resident was cognitively intact (mental ability to make decisions of daily living). [...]

Inspectors wroteBased on interviews and concurrent record review, the facility failed to ensure three out of seven employees (Licensed Vocational Nurse (LVN) 1, Housekeeping, Activities Assistant, and Occupational Therapist (OT - assess a person's physical, cognitive, and emotional abilities and develops treatment plans to improve their functional skills, adapting the environment or activities as needed) completed their competencies annually and or upon hire. This failure had the potential for the staff not to provide the appropriate nursing skills and related care and services for all residents in accordance with resident care plans and the facility assessment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in one of 35 multiple resident bedrooms (room [ROOM NUMBER])This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the health caregivers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call system was functional including the audible sounds to alert the staff for one out of five sampled residents (Resident 2). This deficient practice had potential in a delay in meeting the residents' needs for assistance and could lead to frustration, falls and accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment by failing to ensure two of two shower rooms (Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER]) were clean and free from urine smell. This failure resulted in a foul-smelling environment and the adjacent hallway.

Inspectors wroteBased on observation, interview, and record review, facility failed to : I. Ensure one of four sampled residents (Resident 6) ' s medications were properly stored and documented according to facility ' s policy and procedures (P&P). II. Ensure the medications were administered timely as ordered by the physician for three of three sampled residents (Resident 6, Resident 8 and Resident 9) according to facility ' s P&P. This deficient practice increased the risk for accidents, unintended complications from receiving more or less than the required medications dose and jeopardized resident ' s health and safety by failing to administer necessary medications in accordance with the physician order.

Inspectors wroteBased on interview and record review, the facility failed to provide foot care consistent with professional standards to maintain skin integrity for one of four sampled residents (Resident 1) by failing to: 1. Ensure that the Magnetic Resonance Imaging (MRI - uses a strong magnetic field and radio waves to create detailed images of the inside of the body, aiding in the diagnosis and monitoring of various conditions) recommended by the Wound Physician Specialist (WPS) to rule out (R/O) osteomyelitis (a bone infection that can occur when bacteria spread to the bone, causing pain, swelling, and potentially leading to serious complications if left untreated) on 2/12/2025 after Resident 1's left plantar foot (located on the bottom of the foot) wound has reopened. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of four sampled residents (Resident 1) by failing to: a. Developed and implemented an individualized CP for Resident 1 ' s left lower foot wound when Resident 1 was readmitted on [DATE]. b. Developed an individualized CP for Resident 1 ' s complaint of pain and discomfort. c. Developed an individualized CP for Resident 1 ' s refusal of turning and repositioning schedules to prevent skin breakdown. d. Implementing a person-centered CP when Resident 1 had episodes of aggressiveness toward staff. These deficient practices had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the skin assessments were accurate upon admission ad the skin impairment did not get worse for one of three sampled residents (Resident 5). This deficient practice had the potential to delay the provision of necessary care and services and deterioration of residents ' current wounds.

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident receives appropriate treatment and services to increase, prevent, or maintain the range of motion (ROM- the extent of movement of a joint) and mobility for one of four sampled resident (Resident 1) according to facility ' s policy and procedure (P&P) titled, Repositioning. This deficient practice had the potential to place Resident 1 at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on interview and record review, the facility failed to effectively manage one of four sampled residents, (Resident 1 ' s) pain by not properly identifying the characteristics of pain with consistent approach and a standardized pain assessment instrument appropriate to resident ' s cognitive level according to the facility ' s policy and procedure titled, Pain - Clinical Protocol. This deficient practice resulted in Resident 1 experienced unnecessary pain.

Inspectors wroteBased on interview and record review, facility failed to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to one of one sampled resident (Resident 1) by failing to address behavioral health care needs and implementing a person-centered care plan when Resident 1 had episodes of aggressiveness toward staff. This deficient practice had the potential to negatively affect the delivery of behavioral health care and services to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide preventive care consistent with professional standards of practice to one of four sampled residents (Resident 1) who was at risk for development of pressure injuries, by failing to: 1. Ensure the appropriate setting of the low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was properly set up according to physician ' s (MD) order. 2. Ensure Resident 1 ' s weight was monitored and recorded according to facility ' s policy and procedure (P&P). These deficient practices placed Resident 1 at risk of poor wound healing of the current pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and possibly development of a new pressure injury.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of four sampled residents, Resident 1 ' s court delegated general power of attorney (POA - authorizes someone else to handle certain matters, such as finances or health care, on someone ' s behalf. If a power of attorney is durable, it remains in effect if the person become incapacitated for any reason, including illness and accidents) was informed of Resident 1 ' s health care decision. This deficient practice violated Resident 1 ' s legal POA to be notified and placed the resident at risk for making informed decisions he was not able to recognize based on the medical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a Director of Nursing (DON) works onsite for at least 8 consecutive hours a day from 11/2024 to 1/3/2025. This deficient practice had the potential for facility ' s inability to manage and oversee nursing services provided to the residents.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of two sampled residents (Resident 4) by failing to ensure that a comprehensive (CP) was developed after Resident 2 had a change of condition for dislodgment of nephrostomy tube (a thin, flexible tube inserted into the kidney through the skin to drain urine directly into a collection bag). This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's peripheral catheter (is a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) dressing was labeled and documented as indicated in the facility policy for one out of two sampled resident (Resident 2). This deficient practice had the potential to place residents at risk for developing infections at the IV site.

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 five out of four sampled residents (Resident 1) by failing to ensure the staff was not standing over the Resident 61 while feeding and assisting her during a meal. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to implement its policy and procedures (P&P) titled Resident Rights, reviewed on 4/17/2024. By failing to inform one of four sampled residents (Resident 1 ' s) legal representatives of a change in the condition or status of the resident on 8/6/2024. This deficient practice violated the resident and legal representative right to be notified and participate in changes to the plan of care.

Inspectors wroteBased on interview and record review the facility failed to ensure medical records were readily available and producible upon request for one of four sampled residents (Resident 1) as per facility policy procedures (P&P) titled Access to Personal and Medical Records, reviewed on 4/17/2024. By failing to: 1. Ensure Resident 1's medical records were kept up to date with the most recent Durable Power of Attorney (POA - authorizes someone else to handle certain matters, such as finances or health care, on someone ' s behalf. If a power of attorney is durable, it remains in effect if the person become incapacitated for any reason, including illness and accidents) for healthcare doucmentation. 2. Provide Resident 1's DPOA with a medical record release form when requested. [...]

Inspectors wroteBased on observation, interview and record review, the follow it ' s Policy and procedure by failing to report an Unusual Occurrence (Resident elopement) within 24hrs to the State Survey Agency for one out of 3 sampled residents (Residents 1). This deficiency practice placed the health and safety of Resident 1 at risk of exposure to heat or cold exposure, dehydration, other medical complications and being struck by a motor vehicle.

Inspectors wroteBased on interview and record review, the facility failed to provide monitoring and supervision for one of three sampled residents (Resident 1) by failing to ensure Resident 1 did not elope from the facility (leaving the facility premises safe area without the facility's knowledge and supervision). This deficiency practice placed the health and safety of Resident 1 at risk of exposure to heat or cold exposure, dehydration, other medical complications and death.

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 his/her individuality for five of 18 sampled residents (Residents 27, 37, 50 61, and 81) by failing to: A. Ensure staff did not stand over Resident 61 while feeding and assisting the resident during a meal. Facility failed to ensure staff are not standing over resident while feeding for Resident 61 B. Assist Resident 27 with setting-up dinner tray on the resident's bedside table. C. Assist Resident 81 clean-up food crumbs on the resident's clothes and bed linen after the resident had finished eating dinner. D. Ensure staff did not speak in a language not understood by Residents 50 and 37 in accordance with the facility's employee handbook updated 6/2021. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the residents and/or responsible party (RP) was informed and consented in advance, of the risks and benefits of pneumonia (PNA-infection that inflames air sacs in one or both lungs and can be life-threatening to anyone but particularly to infants, children, and people over [AGE] years old) vaccines and immunization (a simple, safe, and effective way of protecting people against harmful diseases, before they come into contact) for one of five sampled residents (Resident 52). This deficient practice violated the resident's right to make an informed decision regarding the use of vaccinations and immunizations.

Inspectors wrote3. A review of the Resident 51's admission Record indicated the facility admitted Resident 51 on 05/17/2019 with diagnoses cerebral infarction (stroke- damage to tissues in the brain), malignant neoplasm of the prostate (a cancerous tumor in the gland of the male reproductive system.), overactive bladder (has an urgent need to urinate multiple times per day and/or night), dysphagia (difficulty with swallowing) abnormality with gait and mobility (alterations in the way of walking) and hypertension (high blood pressure). A review of Resident 51's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 05/11/2024, indicated Resident 51 had severe cognitive impairment (The mental ability to make decisions of daily living), required partial/moderate assistance with eating and upper body dressing. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a safe, comfortable, and homelike environment for three out of 18 sampled residents (Resident 44, 74 and 59) by failing to: 1. Ensure residents' rooms were kept with comfortable sound levels maintained for two of three sampled residents (Resident 59 and 74). 2. Ensure the window blind, bedside drawer and electric wall plug were maintained and in functional working condition for one of three sampled resident (Resident 44). These deficient practices had the potential to negatively impact the resident's quality of life and placed Residents 59, 74, and 44 an increased level of discomfort and inability to sleep during the night.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide preventive care consistent with professional standards of practice to three of three sampled residents (Residents 1, 16, and 292), who was at risk for developing of pressure injuries (Damage to an area of the skin caused by constant pressure on the area for a long time), by failing to: 1. Ensure Resident 292 had bilateral heel protectors (devices that include foam or gel that are used to help prevent heel pressure ulcers) placed while in bed per physician's order (MD order). 2. Ensure the appropriate settings for the low air loss mattress (LALM-a mattress designed to prevent and treat pressure wounds) for Residents 1 and 16 according to MD's order and/or the facility's policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that two of five sampled residents (Residents 26 and 52) psychotropic (A drug or other substance that affects how the brain works and causes changes in mood) medication regimens were managed and monitored to promote or maintain the highest practicable mental, physical, and psychosocial well-being by failing to: 1. Ensure implementation of the facility's pharmacy recommendation for Resident 26's Risperdal (anti-psychotic medication) use. 2. Ensure the informed consents were in placed timely for Resident 52's physician's order for psychotropic medications. These deficient practices had the potential to place Resident 26 and 52 at risk of receiving unnecessary medications and/or overuse of medication and adverse consequences while using the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. Ensure one of five sampled residents (Resident 66) who was on a transmission-based isolation for extended spectrum beta-lactamase (ESBL - an enzyme found in some strains of bacteria that can't be killed by many of the antibiotics that doctors use to treat infections) was placed into a private single room. b. Ensure staff wore appropriate Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses, PPE may include respirators, gloves, overalls, boots, disposable gowns, and goggles) when providing care to one of four sampled residents (Resident 192) who is on a transmission-based precaution room. c. Ensure one of five sampled residents, (Resident 292), who had an active infection of Escherichia coli in urine (E. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together) failed to ensure that a resident would not be allowed to keep medications at the bedside without a physician's order and/or without being assessed to determine if the resident is capable to self-administer medications for one of 18 sample residents (Resident 292). This deficient practice had a potential for resident 292 to self-medicate himself and delayed necessary health intervention.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed, offered or followed up regarding Advance Directive (ACHD - written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) in a timely manner for four of 18 sampled residents (Resident 61). This deficient practice had the potential to cause conflict with Resident 61's wishes regarding health care.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan (CP) that met the care/services based on the resident's individual assessed needs for one of six sampled residents (Resident 16) by failing to ensure that a comprehensive CP was developed and implemented for Resident 16's low-air-loss (LAL - a mattress designed to prevent and treat pressure wounds) mattress. This deficient practice had the potential to result in a negative impact on residents' health and safety and the quality of care and services received increasing the risk for Resident 16 to develop pressure ulcers/injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 61 and Resident 63), who were at high risk for fall and injuries and who required extensive assistance during repositioning according to the residents care plan. This failure had the potential to place Residents 61 and 63 at risk for falls or injury possible fracture (break in bone) while being transferred from wheelchair to the bed solely by Certified Nursing Assistant 3 (CNA 3).

Inspectors wroteBased on interview and record review the facility failed to ensure the call lights were answered timely for three of six residents sampled (Residents 37, 50 and 59). This deficient practice resulted in a delay to services and care required by Residents 37, 50, and 59.

Inspectors wroteBased on observation, interview and record review, the facility failed to post in a visible and prominent place daily; the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift for three of three sampled days (7/19/2024, 7/20/2024, and 7/21/2024). This deficient practice had the potential to prevent residents and visitors from knowing the accurate and final Direct Care Services Hours Per Patient Day (DHPPD) and had the potential to cause inadequate staffing.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident 29's Yupelri (Revefenacin-medication being given via inhalation [inhaling medication in the form of gas or vapor] used to help muscles around the airways of the lungs to relax) inhalation solution was stored properly per manufacturer's policy. This deficient practice had the potential to compromise the safety and effectiveness of medication, resulting in medication error when administered to Resident 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide palatable flood for two of six residents sampled (Residents 59 and 84). This failure resulted in bland, unpalatable food being served to the residents and surveyors.

Inspectors wroteBased on observation, interview, and record review, the facility failed implement appropriate sanitation and food handling practices by failing to discard expired food stored in the resident's nutrition refrigerators. This deficient practice had the potential to result in unsafe food management.

Inspectors wroteBased on observations, interviews, and record review the facility's governing body (individuals such as facility owner(s), Chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility) failed provide effective leadership oversight of processes and policies and procedures by failing to ensure the administrator was onsite and available via phone on a full-time basis. This deficienct practice had the potential to not meet/address direct the day-to day functions of the facility in accordance with current federal, state, and local standard, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care is provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in one of 35 multiple resident bedrooms (room [ROOM NUMBER]) This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the health caregivers.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control measures necessary to prevent the spread of infections by failing to ensure the staff wore full personal protective equipment (PPE-mask, gown, eye protection, gloves) per facility policy and procedures (P&P) titled Enhanced Barrier Precautions (EBP) with an effective date of 4/1/2024 before providing care and treatment for one of one sampled resident (Resident 1) requiring enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes). This deficient practice had the potential to result in the spread of disease and infection to all 90 residents, visitors, and staffs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice and implement the facility policy and procedure (P&P) titled, Administering Medications for one of four sampled residents (Resident 3), when resident refused her eyedrop medication. This deficient practice has the potential to result in Resident 3 in unintended complications related to the management of glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care consistent with professional standards to maintain skin integrity to one of four sampled residents (Resident 2) by failing to: 1. Ensure Resident 2's received foot care and surgical wound skin treatment as ordered by the physician. 2. Implement the facility's policy and procedures (P&P) titled, Wound Care to promote healing of Resident 2's surgical wound. These deficient practices had the potential to result in Resident 2 in unintended complications related to the management of his surgical wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all drugs and biologicals to meet the needs of each resident for one of four sampled residents (Resident 2) by failing to ensure that Resident 2's medications were not left unattended at the bedside. This deficient practice had the potential to result in Resident 2 in unintended complications related to the management of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge summary was documented by the physician for one of five sampled residents (Resident 5). This deficient practice resulted in incomplete records for Resident 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Direct Care Service Hours Per Patient Day (DHPPD - refers to the actual hours of work performed per patient day by a direct caregiver) was posted daily. As a result, the actual hours of work performed per patient day by a direct caregiver were not readily accessible to residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to effectively manage a resident's pain by not ordering and following up on physician ' s order upon admission of Resident 1 on 1/22/2024 for one five sampled residents (Resident 1). This deficient practice resulted in Resident 1 experienced unnecessary pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its diet menu instructions with garlic bread for six out of six sampled residents (Residents 1, 2, 3, 4, 5, 6). This had the potential for residents to not receive the nutrition they need.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy regarding reporting of residents ' allegation of abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for two of five sampled residents (Resident 3 and Resident 4). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 3 and 4.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report an allegation of abuse within 2 hours or in accordance with state or federal law for two of two sampled residents (Resident 3 and Resident 4). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 3 and Resident 4. Cross Reference F609.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of five sampled residents (Resident 1) by failing to develop a comprehensive care plan for Resident 1 ' s self-administration medications and own medications at bedside. This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Cross Reference F761.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of six sampled residents (Resident 1) medications were properly stored and secured per facility ' s policy. This deficient practice had the potential to lead to medication under and/or overdosing which could result in serious injury, harm, and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy on Answering the Call Light by failing to ensure the call light (a device used by a resident to call for help) for 2 of 5 sampled residents (Resident 4 and Resident 5) were answered timely. This deficient practice resulted to a delay in answering Resident 4 ' s and Resident 5 ' s request for help.

Inspectors wroteBased on interview and record review, the facility failed to accommodate resident allergies, intolerances and preferences for 1 of 5 sampled residents (Resident 5) by failing to ensure: 1. A dietary screening assessment was performed when Resident 5 was admitted to the facility. 2. Resident 5 does not receive foods she is allergic to. This deficient practice had the potential for the resident to experience an allergic reaction and had the potential for the resident to consume less food than their body needed, which could lead to weight loss and malnutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food served was palatable and at the proper temperature. The deficient practice had a potential for resident in the facility not to eat the served food and had the potential to cause weight loss and dehydration that may result in nutritional requirements not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program according to their policy and procedure by failing to ensure the Hoyer cloth slings (patient lift slings) are properly stored in a clean storage area. This deficient practice placed residents and staffs at risk at a higher risk of acquiring and transmitting infections to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' privacy and dignity by failing to ensure the urinary catheter (foley catheter - a soft hollow tube which is passed into the bladder to drain urine, for persons who cannot empty their bladder in the usual way) drainage bag was always covered for one of one sampled resident (Resident 1). This deficient practice had the potential to affect Resident 1's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of five sampled residents (Resident 1) by failing to develop a comprehensive care plan for Resident 1's indwelling urinary catheter (foley catheter - a hollow tube left implanted in a body canal or organ, especially the bladder, to promote drainage). This deficient practice had the potential to result negative impact on residents' health and safety, as well as the quality of care and services received. Cross Reference F550.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure precautions were taken for resident ' s individual safety, as well as the safety of others in the facility for one of four sampled residents (Resident 3). The facility was aware Resident 3 used a personal lighter and cigarettes and oxygen concentrators were stored together in Resident 3 ' s room. This deficient practice had the potential for fire related accidents in the facility among residents, staffs, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one out of one sampled resident (Resident 3) by failing to: 1. Ensure Resident 3's nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) was changed per facility ' s policy. 2. Ensure Resident 3's NC was not on the floor. 2. Ensure a physician's order are in place for oxygen therapy. These deficient practices had the potential for the residents to develop respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of four sampled residents (Resident 2, Resident 3, and Resident 4) who were admitted to the facility with wounds received the necessary care and services for wound care treatment as evidenced by: 1. Failing to transcribe and document the wound care specialist and medical doctor ' s recommendation on wound care treatment for Resident 2 ' s right leg chronic wound and Resident 3 ' s left ankle diabetic ulcer. 2. Failing to ensure wound care treatments were documented for Resident 4. These deficient practices had the potential to worsen Resident 2, Resident 3 and Resident 4 ' s wound and place Resident 2, Resident 3, and Resident 4 at risk for infection.

Inspectors wroteBased on observation, interview and record review, the nursing staff failed to answer the call light or call bell promptly for one of three sampled resident's (Resident 1). This deficient practice had the potential to result in a delay in receiving the necessary care and services and to cause the resident to suffer harm and injury.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan to address Resident 1's refusal to be repositioned and for perineal (between the legs) care for one of two sampled residents (Resident 1). This deficient practice had the potential to result in a delay in the treatment plan, lead to inadequate care, and potentially cause injury to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) were provided necessary treatment and services to prevent formation of and promote healing of pressure sore (a wound caused when an area of skin is placed under constant pressure) by: -Failing to transcribe physician's orders for Resident 1's left heel pressure sore. -Failing to document and treat wound care provided for Resident 1's left heel wound from 8/25/2023 through 8/29/2023. -Failing to develop a care plan for Resident 1's left heel pressure sore for 18 days. These deficient practices had the potential to delay provision of necessary care to promote Resident 1's wound healing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light (a device used to notify the nurse that the resident needs assistance) weas within reach for three of 42 sampled residents (Residents 44, 55 and 327). This deficient practice had the potential to delay care and emergent service necessary for Residents 44, 55 and 327.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the call light (a device used to notify the nurse that the resident needs assistance) was within reach for three of 42 sampled residents (Resident 44, 55 and 327) as indicated in the care plan. 2. Ensure that low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was set as per the weight for one of four sampled residents (Resident 25). 3. Monitor and assess the enteral tube feeding (Nutrition taken through a tube directly to the stomach or small intestine) dressing per physician's order to prevent skin breakdown for one of seven sampled residents (Resident 14) as indicated in the care plan. 4. Develop and implement a person-centered care plan for Resident 56's new start of an anti-depressant medication. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to meet professional standards of quality for five of five sampled residents (Residents 25, 37, 56, 68 and 327) by failing to: 1. Ensure to document anticoagulant (Medication used to prevent blood clots) side effects for Resident 37, 56 and 68. 2. Ensure residents received the necessary care and treatment as per physician' order by the physician for two of five sampled residents (Residents 25 and 327) These deficient practices had the potential to result in unintended adverse effects (harmful effect resulting from a medication or other intervention) related to the use Anticoagulation therapy and had the potential to affect negatively the delivery of care services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed staff did not administer 28 doses of expired insulin (a medication used to treat high blood sugar) between [DATE] and [DATE] for one of two residents for whom expired medication was found (Resident 15). This deficient practice increased the risk that Resident 15 may have experienced medical complications due to receiving insulin that had become ineffective possibly resulting in hospitalization or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure expired insulin (a type of medication used to treat high blood sugar) was removed from the medication cart for Residents 15 and 44 in one of two inspected medication carts (Station 1 Medication Cart.) 2. Ensure medications requiring refrigeration were stored in the refrigerator per the manufacturer's requirement for Resident 55 in one of two inspected medication carts (Station 1 Medication Cart.) 3. Ensure one opened vial of eye drops were labeled with an open date per the manufacturer's requirement for Resident 4 in one of two inspected medication carts (Station 1 Medication Cart.) 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper sanitation and food handling practices by failing to: 1. Ensure the scoopers for food thickener and flour were kept in a protected container or cover per facility's policy 2. Ensure dry food bin containers for condiments/ salad dressing packets, peanut butter single used cup and crackers were kept clean and sanitary. 3. Ensure the refrigerator and freezer temperature log was completed from the evening of 11/18/21 through the morning of 11/22/21. 4. Ensure the chlorine-based red sanitation bucket had a chlorine concentration between 50 parts per million (ppm) to 100 ppm on two separate occasions. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for two of 42 sampled residents (Resident 14, 25) As a result, two Certified Nursing Assistants (CNA) did not perform hand hygiene prior to entering and exiting residents' rooms; one Housekeeper did not remove glove and perform hand hygiene prior to exiting resident's room. These deficient practices had the potential to result in the spread of diseases and infection to residents, staffs and visitors.

Inspectors wroteBased on observation and interview, the facility failed to ensure that a urinary catheter bag (A device to collect urine from the bladder) had a cover to ensure privacy and dignity for one of five sampled residents (Resident 52). This deficient practice had the potential to lowered self-esteem and violated the right to be treated with respect and dignity for Resident 52.

Inspectors wroteBased on observation, interview, and record review, the facility failed to draw the privacy curtain or close the room door during application of a medication patch to the right hip for one of four residents (Resident 6) per facility's policy and procedures titled quality of life-dignity. The deficient practice had the potential for embarrassment, humiliation, and a lowered self-esteem for Resident 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 12), was transferred from Geri chair ([or geriatric chairs] are large, padded chairs with wheeled bases, and are designed to assist seniors with limited mobility) to a bed using a two-person assist with mechanical lift. This deficient practice had the potential to result in falls or injuries to Resident 12 and/or the Certified Nursing Assistant (CNA 3) who transferred Resident 12 from the Geri chair to bed solely.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the appropriate setting of the low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was properly set up for Resident 25 and 327 according to the residents' needs and professional standard of care. This deficient practice placed the residents at risk of poor wound healing of the current pressure ulcer and had a potential to develop new pressure sores/wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the gastrostomy tube site (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) was cleansed daily and as needed with dressing care as ordered for one of eight sampled resident (Resident 14) who were fed by enteral means. This deficient practice had the potential to result in developing an infection due inadequate GT site and dressing care.

Inspectors wroteThe facility failed to implement its policies and procedures which addressed action and documentation by the facility staff and/or the prescriber in providing the rationale for disagreeing on pharmacy recommendations from the pharmacist medication regimen review (MRR) for two of 42 sampled residents (Resident 37 and 56). This deficient practice increased the risk for adverse medication outcome from possibly unnecessary medication use, leading to negative impact on residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 28 total opportunities contributed to an overall medication error rate of 7.14% affecting two of four residents observed for medication administration (Residents 24 and 34.) The deficient practices of failing to administer medications with good technique or in accordance with the attending physician's orders increased the risk that Residents 24 and 34 may have experienced health complications related to incorrect medication administration which could have negatively impacted their health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 36 resident rooms met the square footage requirement of 80 square feet (sq. ft.) per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.