Kern River Transitional Care

Inspectors wroteBased on interview and record review, the facility failed to notify the family and physician of a change in condition for one of two sampled residents (Resident 1). This failure had the potential for delay in care, untreated, and worsening of skin condition.

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan for one of two sampled residents (Resident 1). This failure resulted in Resident 1 not receiving treatment and potential for worsening skin condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure vital documents were provided in primary language for one of three sampled residents (Resident 2). This failure had the potential for Resident 2 to not understand the provided vital information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician's orders were followed when:1. Oxygen was not administered as prescribed by the physician for one of three sampled residents (Resident 1).2. Medications were not administered timely for one of three sampled residents (Resident 4). 3. Medications were not administered for one of three sampled residents (Resident 4). These failures had the potential for Resident 1 and Resident 4 to suffer adverse outcomes.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Bowel Management Protocol, for one of six sampled residents (Resident 3) when Resident 3 was not administered needed medication. This failure had the potential for Resident 3 to experience pain and constipation.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled License Vocational Nurses (LVN) ( LVN 1, LVN 2, and LVN 3) had competencies for continuous positive airway pressure, (CPAP- is a common treatment for sleep apnea, a condition where breathing repeatedly stops and starts during sleep) and bilevel positive airway pressure (BIPAP is a type of non-invasive ventilation that provides breathing support by delivering air at two different pressure levels, one for inhalation and another for exhalation). This failure had the potential for the facility's residents who require the use of CPAP or BIPAP to have improper application.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of three sampled residents (Resident 1) was wearing non-skid socks (non-slip socks are designed with rubberized grips on the soles, offering the traction needed to walk safely. This feature is particularly vital for elderly residents or those with balance problems, significantly reducing the risk of falls and related injuries) according to the plan of care when Resident 1 was high risk for falls. 2. Follow their in-service on Falls to ensure a Registered Nurse (RN) initially assessed one of three residents (Resident 1) who was found on the floor when a Licensed Vocational Nurse (LVN) 1 did not wait for the RN to assess before transferring Resident 1 from the floor to the wheelchair and to the bed. [...]

Inspectors wroteBased on interview and record review, the facility failed ensure one of three sampled resident (Resident 1) responsible party (RP) was able to participate in treatment decisions. This failure resulted in a violation of Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) plan of care was coordinated with hospice (type of care that focuses on the comfort and quality of life of a resident with a serious illness that is approaching the end of life, often includes emotional and spiritual support for both the resident and their loved ones) care. This failure had the potential for Resident 1's care needs to go unmet.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Follow their policy and procedure titled Psychoactive/Psychotropic Medication Use, when Informed Consents (process to ensure the provider has discussed the risks, benefits, and alternatives with the patient and the patient agrees to the provider performing the intervention) were not provided by the physician or consistently witnessed by a licensed nurse for eight of 14 sampled residents (Resident 437, Resident 111, Resident 10, Resident 338, Resident 25, Resident 8, Resident 55, and Resident 36 ) on psychotropic medications, (medications to treat mental health disorders). This failure had the potential for residents or their responsible party to be unaware of alternatives to medications or side effects of medications. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure three of 32 sampled licensed vocational nurses (LVN 2, LVN 3, and TN 2) were competent (verified ability to perform skill) to perform care for one of one sampled resident (Resident 72) on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). 2. Ensure three of 32 sampled licensed vocational nurses (LVN 2, LVN 3, and treatment nurse [TN] 2) were competent to provide care for one of one sampled resident (Resident 36) with suprapubic catheter (a tube inserted into the bladder to drain urine). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and implement the Center for Disease Control and Prevention (CDC, nationally recognized health organization) infection control practices when: 1. Licensed Vocational Nurse (LVN) 2 did not follow Enhanced Barrier Precaution (EBP, precautions to reduce transmission of infectious organisms) protocols during closed contact with one of one sampled resident (Resident 72). 2. The X-ray Technician (XRT) stepped out of the room with contaminated gloves and isolation gown to answer a phone call after in close contact with one of one resident (Resident 96) on EBP. 3a. Treatment Nurse (TN) 1 threw the contaminated dressing with serosanguinous (thin, watery, and pinkish red in color fluid from a wound) drainage onto a regular trash bin. 3b. TN 1 did not perform hand hygiene before putting on a new pair of gloves. 3c. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that 108 out of 108 sampled Certified Nursing Assistants (CNAs) were attending at least 5 hours of dementia (a loss of mental function)-specific in-service training on an annual basis. This failure had the potential for CNAs to be uneducated how to meet care need of residents with dementia.

Inspectors wroteBased on interview and record the facility failed to provide the completed Baseline Care Plan (BCP-initial instructions for care of the resident) Summary was provided to two of six sampled residents (Resident 72 and Resident 96) or the resident's responsible party within 48 hours of admission. This failure resulted in Resident 72 and Resident 96 or the resident's responsible party to be unaware of the plan of care during the first 48 hours.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure : 1. Four of five sampled residents (Resident 132, Resident 35, Resident 437, Resident 34) medications were safely and securely stored from unauthorized personnel and other resident. This failure had the potential for medication to be accessed by unauthorized staff and residents. 2. The facility policy and procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies, for one of one sampled controlled substance destruction record. This failure had the potential for drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure Social Services Director (SSD) met the required qualifications to manage and coordinate social services for 126 residents living in the facility and to fulfill the duties of the SSD. This failure had the potential to result in residents not being referred to appropriate social service agencies for their needs, required social services assessments performed and completed timely, accurate documentation and follow-up with residents and resident representatives of the residents' social service's needs, and ensure the residents could attain and maintain highest practicable physical, mental, or psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI, process to identify problems and initiate improvement processes) committee failed to identify on-going issues, develop, and implement corrective action plans for Infection Prevention and Control practices (F636, F655, F656, and F868) and Social Services (F658, F790, F687, F842 and F623) not provided as identified by the survey team. These failures placed all 126 facility residents at risk for acquiring infectious diseases and not receiving medically necessary services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Infection Preventionist (IP) attended two of three sampled Quality Assessment and Performance Improvement (QAPI, committee that identifies quality deficits and implements corrective plans) committee's meetings during 2024 and 2025. This failure had the potential for the facility to not be aware of infection control issues and develop a plan to address infection control issues.

Inspectors wroteBased on interview and record review, the facility failed follow their policy and procedure (P&P) titled, Personal Property when one of one sampled resident (Resident 55) personal belongings were not recorded on the inventory sheet upon admission. This failure resulted in the loss of Resident 55's personal belongings and the potential to result in difficulty replacing the personal belongings reported as lost.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, when the facility did not send a notice of transfer to the Ombudsman (representatives who assist residents in long-term care facilities with issues related to day-to-day care, health, safety and personal preferences) for one of six sampled resident's (Resident 40). This failure had the potential to result in Resident 40 not having an advocate who could inform them of their admission, transfer, and discharge rights and options.

Inspectors wroteBased on interview and record review, the facility failed to review and accurately complete the annual Pre-admission Screening Assessment and Resident Review (PASARR-federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting) for three of 16 sampled residents (Resident 10, Resident 115, Resident 109). This failure had the potential for residents to be placed in an inappropriate setting and not receive required services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for four of four sampled residents (Resident 72, Resident 8, Resident 110 and Resident 13). This failure had the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Guidelines for Preventing Intravenous [in the vein] Catheter [small flexible tube to deliver fluids or medications directly into the bloodstream]-Related Infections, for two of two residents (Resident 110 and Resident 13) when IVs were not flushed (rinsed out), changed, or removed as ordered. This failure had the potential for increased risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary service for personal and oral hygiene for two of two sampled residents (Resident 72 and Resident 133) who were dependent on care being provided. This failure resulted in Resident 72 had the potential for Resident 133 to acquire oral infection, further tooth decay.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled Activity Program, for one of 49 sampled residents (Resident 109) when activities of interest were not provided to Resident 109. This failure resulted in Resident 109 to experience a diminished quality of life due to not participating in either individual or group activities and the potential to result in depression (sustained loss of interest).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policy and procedures (P&P) titled, Foot Care and Social Services when nursing assessments did not indicate foot skin or nail issues, foot care was not provided and a podiatry (treatment of foot disorders, ankle, and leg) referral was not completed for one of one sampled resident (Resident 72). This failure resulted in Resident 72's left toes to be red and swollen, skin dry and flaky, right and left feet toenails to be long, thick, hard, and yellow-orange, with blackish discoloration and debris in-between the toes.

Inspectors wroteBased on interview and record review the facility failed to ensure: 1. Licensed nurses were competent to assess and change suprapubic catheter (thin, flexible tube inserted directly into the bladder to drain urine) for one of one sampled resident (Resident 36). 2. The facility policy and procedure titled Suprapubic Catheter Care, met Society of Urologic Nurses and Associates (SUNA) Standards of Care. This failure had the potential to result in urinary tract infections, blockage, or leakage of urine, and other complications.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the communication and coordination between the facility and dialysis (a procedure to remove waste products and excess fluids from the blood when the kidneys stop working) center was complete with assessment of the dialysis access site (surgically created access) on the Nursing Hemodialysis communication observation /assessment, for one of three sampled resident (Resident 79). This failure had the potential to result in complications due to having no assessment of the dialysis site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist one of one sampled resident (Resident 133) with a dental appointment. This failure had the potential for Resident 133 to acquire oral infections, further tooth decay, and gum diseases.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical records for two of six sampled residents (Resident 72 and Resident 133) when: 1. One of one sampled resident's (Resident 72) Nursing Weekly Summary (NWS) did not accurately reflect the condition of the skin, toes, and toenail appearance. 2. One of one sampled resident's (Resident 72) Nursing Hemodialysis Communication Observation/Assessments were not completed on 3/27/25, 3/29/25, 4/3/25, 4/5/25, and 4/9/25. 3. One of one sampled resident's (Resident 133) Initial Social History Assessment was not completed. This failure had the potential to result in adverse consequences and lack of coordination and continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy & procedure (P&P) titled Binding Arbitration Agreement (BAA, resolve disputes between healthcare providers and residents) for two of twenty sampled residents (Resident 337 and Resident 115) when admission Coordinator (AC), had Resident 337 and Resident 115 sign their BAA without understanding the legal implications. This failure resulted in Resident 337 and Resident 115 to not fully understand the legal document they signed.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, for one of three sampled residents (Resident 1) when: 1. Care plan for refusal of care was not developed and implemented. This failure resulted in Resident 1 not receiving showers or baths for 13 days. 2. Respiratory Care plan was not developed and implemented. This failure had the potential for Resident 1's respiratory signs and symptoms to go unnoticed.

Inspectors wroteBased on interview and record review, the facility failed to obtain physician's order and document the removal of midline intravenous catheter (midline IV - a thin, flexible tube inserted into a vein in the upper arm; used to administer medications, fluids, or draw blood over a longer period) for one of three sampled residents (Resident 1). These failures had the potential for Resident 1 to have retained piece of the catheter, blood loss and incomplete medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were consistently implemented for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to experience accidents and injuries.

Inspectors wroteBased on interview and record review, the facility failed to implement its own Fall Management policy and procedure (P&P) for one of six sampled residents (Resident 1). This failure resulted in an incomplete post fall assessment for Resident 1 and had the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, when suspicion of financial abuse was not reported to the attending physician (AP) for one of three sampled residents (Resident 1). This failure had the potential for Resident 1's AP not to be aware of the suspicion and the potential for emotional distress for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of sexual abuse for one of three sampled residents (Resident 1) within 24 hours to the California Department of Public Health (CDPH) and complete an investigation within five business days. This failure had the potential for Resident 1 experiencing continued sexual abuse.

Inspectors wroteBased on interview and record review, the facility failed to notify the attending physician (AP) and responsible party (RP) and complete a change of condition (COC) for one of three sampled residents (Resident 1) when Resident 1 had two unwitnessed falls and COCs. This failure had the potential for Resident 1 ' s AP and RP to be unaware of Resident 1 ' s change of condition and had the potential for unmet care needs and treatments.

Inspectors wroteBased on interview and record review, the facility failed to ensure the fall risk care plan was revised for one of three sampled residents (Resident 1). This failure had the potential for harm and injuries to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure neurological checks (assessment of sensory and motor responses, especially reflexes, to determine whether the nervous system is impaired) were initiated and completed for one of three sampled residents (Resident 1) after Resident 1 had two unwitnessed falls. This failure had the potential for sign and symptoms of neurological deficits to go unrecognized for Resident 1 which had the potential for adverse outcomes.

Inspectors wroteBased on interview and record review, the facility failed follow its own policy and procedure (P&P) titled, Documentation Accuracy In The Health Record, for one of three sampled residents (Resident 1). This failure resulted in Resident 1 ' s medical record to be inaccurate.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) grievances were addressed and resolved. This failure resulted in violation of resident's rights to have Resident 1 grievance addressed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a change in condition was communicated to the primary care physician for one of four sampled residents (Resident 1). This failure had the potential to result in Resident 1's overall condition to worsen due to delay of care.

Inspectors wroteBased on interview and record review the facility failed to notify the physician of a change of condition for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 not having his care needs met.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person focused care plan for one of three sampled residents (Resident 1) when Resident 1 was non-compliant with the use of call light. This failure placed Resident 1 at risk for not having his care needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure the communication and coordination between the facility and dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working) center was complete with assessments of the dialysis access site (surgically created access) on the Pre (before) and Post (after) Dialysis Communication Form (PDCF) for one of two sampled residents (Resident 1). This failure had the potential to result in complications due to having no assessment of the dialysis site.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure titled Care Plans, Comprehensive Person-Centered, for one of two sampled residents (Resident 1). This failure has the potential for accidents and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1)'s call light was within easy reach. This failure had the potential for Resident 1's activities of daily living need not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and document behavioral episodes for one of three sampled residents (Resident 1). This failure had the potential for untreated Resident 1's worsening behavior.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure when medications were not documented immediately after being administered for two of three sampled residents (Resident 1 and Resident 2). This failure resulted in inaccurate medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the medication carts and medication room were free from expired medications. This failure had the potential for residents to receive expired medications and have adverse health outcomes. 2. Follow their policy and procedure (P&P) on medication labeling. This failure had the potential to result in medication errors. 3. Ensure an insulin (medication used to manage blood sugar levels) was dated. This failure had the potential for residents to receive insulin with decreased potency (strength of medication required to produce an effect).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain dignity for two of 57 sampled Residents (Resident 389 and Resident 84) when: 1. Resident 389 was dressed in donated clothing due to a delay in washing her personal clothing. 2. Resident 84's oral hygiene was not maintained. These failures had the potential to negatively affect Resident 389 and Resident 84's psychosocial wellbeing and Resident 84's dental health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician order (PO) was obtained and Self-Administration of Medication Assessment ([NAME]) was completed for one of one sampled resident (Resident 40). This failure had the potential for unsafe and inappropriate self-administration of medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 57 sampled residents (Resident 134) was notified of a room change. This failure had the potential for Resident 134, Resident 134's family and Medical Doctor (MD) not to be informed of reason for room change.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 57 sampled residents (Resident 41), was provided a homelike environment. This failure had the potential to negatively effect Resident 41's mental wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to update the Quarterly Minimum Data Set (MDS-resident assessment tool) Comprehensive Assessment (QMDSCA) for one of one sampled resident (Resident 48) with a new mental disorder diagnosis. This failure had the potential to inaccurately reflect Resident 48's clinical status and result in an inaccurate plan of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 36 and Resident 48) had a new Level I Preadmission and Resident Review (PASRR-screening tool used to determine specialized mental health services). This failure resulted in Resident 36 and Resident 48 not receiving recommendations for specialized services to best meet their needs.

Inspectors wroteThe facility failed to submit a Pre-admission Screening and Resident Review (PASRR-screening tool used to determine specialized mental health services) Level I screening prior to admission for one of one sampled resident (Resident 48). This failure had the potential for Resident 48 to not receive mental health services.

Inspectors wroteBased on interview and record review, the facility failed to update the comprehensive care plan for one of one sample resident (Resident 48) when a new mental health condition was diagnosed. This failure had the potential to negatively impact care.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. Staff followed the facility's policy and procedure (P&P) titled, Medication Administration for one of one sampled resident (Resident 134) when the first dose of Lorazepam (medication used to treat anxiety) was not administered until 21 hours after the physician order (PO). This failure had the potential for Resident 134 to suffer unnecessary agitation. 2. Staff followed the facility's P&P, titled Enteral [external] Tube Medication Administration for one of two sampled residents (Resident 18) with a Gastrostomy tube (G-tube, tube inserted directly into the stomach for nutrition and medication]. This failure had the potential to place Resident 18 at risk for not receiving physician ordered medication or nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to carry out fall prevention interventions identified in the care plan for a resident at high risk for falls when the bed was left in a high position on two occasions for one of one sampled resident (Resident 78). This failure had the potential for Resident 78 to fall and become injured.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care for an indwelling catheter (tube placed into the bladder to drain urine) to prevent infections and other complications for one of 13 sampled residents (Resident 25). This failure had the potential to result in infections and injury to the penis or bladder.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Food For Residents From Outside Sources for one of one sampled resident (Resident 40) when Resident 40's coffee creamer was not dated when opened or stored in the refrigerator. This failure had the potential to cause foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate medical record (MR) for one of 57sampled residents (Resident 48) when: 1. A mental health diagnosis of Post Traumatic Stress Disorder (PTSD- a mental health condition triggered by a traumatic event) was not added to Resident 48's diagnoses list. 2. A mental health diagnosis of psychosis (symptoms include confused thinking, false beliefs, and hallucinations [hearing, seeing, smelling, or tasting something that is not there]) was dropped from Resident 48's diagnoses list. These failures resulted in an incomplete and inaccurate medical record and had the potential to impact patent care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. One of one resident's (Resident 64) wheelchair was not clean or safe for use. 2. Housekeeping staff did not follow transmission-based precautions (TBP - guidelines for use of personal protective equipment when caring for resident with a contagious infection) for one of one sampled resident (Resident 85). 3. Water Management Program (WMP) did not assess risk, identify areas of concern, monitor and identify measures to prevent growth of opportunistic waterborne pathogens (germs that grow well in water) within the facility's water system for all residents, staff, and visitors. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure on Bowel Management Protocol for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to suffer pain and discomfort.

Inspectors wroteBased on interview and record review, the facility failed to ensure a bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) was offered to one of three sampled residents (Resident 1). This failure had the potential for Resident 1 and Resident 1's Representative to be unaware for the facility's bed hold policy.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) treatments were administered and documented as ordered. This failure had the potential for infection and worsening of Resident 1 ' s wounds and skin conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of nine sampled resident (Resident 1 Resident 2, and Resident 3) attending physician (AP) and resident ' s representative (RR) were notified of alleged abuse. This failure had the potential for Resident 1, Resident 2, and Resident 3 ' s AP and RP not to be aware of the alleged abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure call light was answered timely for one of five sampled residents (Resident 1). This failure had the potential to result in unmet care needs, and negatively impact safety, physical, mental, and psychosocial well-being for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications administered were documented for one of four sampled resident (Resident 2). This failure had the potential for medication error and had the potential for adverse outcome.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing staff to meet the daily needs for one of four sampled resident (Resident 1) This failure had the potential to result in unmet care needs, and negatively impact safety, physical, mental, and psychosocial well-being for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record was accurate for one of four sampled residents (Resident 3). This failure had the potential for Resident 3 to receive inappropriate treatments.

Inspectors wroteBased on interview and record review, the facility failed to provide one of four sampled resident's (Resident 2) quality care when the facility failed to implement the care plan for one Resident 1. This failure had the potential to affect Resident 2's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff member worked within scope of practice and maintained current and active certification or licensure. This failure resulted in unqualified staff administering and interpreting test results and had the potential for the facility ' s staff and residents to be exposed to a potentially serious infectious bacterial disease.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent abuse for one of 10 sampled residents (Resident 3). This failure resulted in Resident 3 to express feelings of sadness, cry, verbalize a fear of retaliation from staff and had the potential to affect other residents in a negative manner.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure all facility staff were trained on reporting abuse according to its policy and procedure (P&P) titled Abuse, Neglect, Exploitation, and Misappropriation - Reporting and investigating. This failure had the potential to result in residents abuse not reported. 2. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral problems according to its P & P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program. This failure had the potential for residents to be vulnerable to further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Report a suspicion of abuse for one of 10 sampled residents (Resident 1). 2. Report an allegation of abuse timely for one of 10 sampled residents (Resident 2). 3. Report a suspicion and allegation of abuse for one of 10 residents (Resident 3). These failures resulted in delayed investigation of abuse for Resident 2 and Resident 3 as well as had the potential for Resident 1, Resident 2 and Resident 3 to be at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Report investigation timely for one of ten sampled resident (Resident 2). 2. Investigate suspicion of abuse for one of ten sampled residents (Resident 1) 3. Thoroughly investigate allegations of abuse for one of ten sampled residents (Resident 2). 4. Screen four of eleven sampled direct care staff prior to hire. 5. Provide evidence of abuse training for one of eleven sampled direct care staff during new hire orientation. These failures had the potential to result in further abuse, abuse to go unnoticed, not reported, not investigated due to untrained staff for Resident 1, Resident 2, and all residents in this facility.

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan for one of nine sampled residents (Resident 2). This failure had the potential for physical and psychosocial change in Resident 2 to go unnoticed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for three of 59 sampled residents (Resident 98, Resident 108, Resident 216) when: 1. Resident 216 had a indwelling urinary catheter (IUC-tube placed in bladder to drain urine). 2. Resident 216 used a Trilogy machine (device used to help breathe). 3. Resident 98 had wounds. 4. Resident 108 was diagnosed with depression. These failures had the potential to result in staff being unaware of residents' needs.

Inspectors wrote1. Based on observation, interview, and record review, the facility failed to prevent the unintended weight loss for two of 59 sampled residents (Resident 92 and Resident 216) when: 1a. A care plan addressing weight loss was not developed and implemented for Resident 92. 1b. The nursing staff did not notify the Registered Dietician Nutritionist (RDN), Primary Care Physician (PCP), and the Responsible Party (RP) 1 of Resident 92's weight loss. 1c. Ensure the Interdisciplinary Team (IDT - a group of healthcare professionals who work together to provide the greatest benefit for the residents) analyzed the significant weight loss for Resident 92. 1d. RDN did not conduct a follow up evaluation when Resident 92's weight loss was noted. 1e. Facility did not notify the PCP and RP of Resident 216's weight loss. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 9 of 9 nursing staff (Certified Nursing Assistant (CNA) 1, CNA 2, Licensed Vocational Nurse (LVN) 2, LVN 3, Registered Nurse (RN) 1, RN 4, Restorative Nursing Assistant (RNA) 1, RNA 2, and RNA 3) completed required annual competencies/training. These failures had the potential for residents not to receive care in a safe and competent manner.

Inspectors wroteBased on observation and interview, the facility failed to ensure five of five confidential residents (Resident 400, Resident 401, Resident 402, Resident 403, Resident 404), were served palatable meals. This failure had the potential to result in decreased appetite, and adequate nutrition.

Inspectors wrote2. During a concurrent medication pass observation and interview on 5/12/21, at 1:25 PM, with Registered Nurse (RN) 3, in the medication cart outside Resident 27's room. RN 3 was observed preparing for administration of Gabapentin (used to treat nerve pain and seizures) via G-Tube (a tube inserted surgically through the abdomen into the stomach for nutrition and medications) for Resident 27. RN 3 did not performed hand hygiene before she put on gloves. RN 3 stated she should have performed hand hygiene prior to putting on the gloves. During a review of the facility's policy and procedure (P&P) titled, Administering Medications through an Enteral Tube [through the G-Tube], dated 11/18, the P&P indicated, Steps in the Procedure 1. Wash your hands. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a self-administration of medication assessment was completed for one of 59 sampled residents (Resident 100). This failure had the potential for unsafe and inappropriate self-administration of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 59 sampled residents (Resident 27) was provided access to call for assistance. This failure had the potential to put Resident 27's health and safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement baseline care plans (BCP) for three of 59 Residents (Resident 43, Resident 92, Resident 324) when: 1. Resident 92 had an external urinary catheter (EUC-a tube outside the body that drains the urine). 2. Resident 324 received intravenous hydration (IVF-liquid given into a vein to increase fluids) treatment. 3. Resident 43 had decreased range of motion in the right hand. These failures had the potential to result in staff being unaware of residents' needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Restorative Nursing Program (RNP-nursing interventions provided to ensure residents retain skills learned in therapy) and a splint evaluation were provided for one of 59 residents (Resident 43). This failure had the potential to contribute to Resident 43's, right hand contractures. During a review of Resident 43's Minimum Data Set (MDS-Standardized Assessment Tool), dated 3/9/21, the MDS indicated, Functional Limitations in Range of Motion (flexibility and mobility of joints) O (none) Upper extremity (shoulder, elbow, wrist, and hand). During a concurrent interview and record review on 5/13/21 at 8:38 AM, with Director of Rehabilitation (DOR), the RNP Referral, dated 1/12/21 was reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label the intravenous (IV) tubing (tube inserted into vein to administer fluids) according to the facility's policy and procedure for one of 59 sampled residents (Resident 52). This failure had the potential for Resident 52 to develop an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications requiring refrigeration were stored at the proper temperature. This failure had the potential to result in decreased efficacy of medications given to the residents.