La Brea Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, notify the physician, and obtain medical orders for one of five residents (Resident 1) reviewed for changes in condition after Resident 1 sustained an injury while trying to move out of his wheelchair to his bed on 7/20/2026 at approximately 11 AM according to the facility's policies and procedures (P&P) titled Change of Condition dated January 2026, Accidents dated January 2026, and Charting and Documentation dated January 2026. Licensed Vocational Nurse (LVN) 1 and Certified Nursing Assistant (CNA) 1 were aware Resident 1 reported hitting the resident's right leg during a transfer attempt and that Resident 1 had requested for ice to apply to the right leg. This failure resulted in delayed evaluation, treatment, and interventions to address Resident 1's complaint of pain to the right leg. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice by failing to assess and evaluate one of five residents (Resident 1) following an injury sustained during an unassisted transfer attempt. Specifically, the facility failed to perform a nursing assessment after Resident 1 struck the right leg on the bed, despite the resident complaining of pain and developing a bruise and palpable lump to the right leg according to the facility's policy and procedures P&P) titled Comprehensive Assessments dated January 2026. Licensed Vocational Nurse (LVN) 1 was aware Resident 1 reported hitting the resident's right leg during the transfer attempt and requested ice. This failure had the potential to delay identification of an injury and appropriate treatment for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate clinical records for one of five sampled residents (Resident 2) by failing to accurately document Resident 2's transfer status after the resident was sent to the hospital on 7/14/26 according to the facility's policies and procedures (P&P) titled Transfer or Discharge Documentation dated January 2026, and Census Report dated April 2007. This failure resulted in Resident 2 remaining on the facility census during the survey despite no documentation supporting Resident 2's whereabouts or admission status, creating the potential for inaccurate resident accountability, continuity of care, and medical record documentation.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect one of one sampled resident (Resident 31) from verbal abuse (using spoken, written, or gestured language to threaten, humiliate, or cause emotional pain to a resident) when on 7/8/2026 at 6:04 AM Certified Nursing Assistant 1 (CNA 1) told Resident 31 to shut up. This failure resulted in Resident 31 to be agitated (feeling very worried, upset, or restless) and placed Resident 31 and other residents (unidentified) at risk of further abuse and emotional harm.

Inspectors wroteBased on interview and record review, the facility failed to effectively manage the pain level for one of four sampled residents (Resident 1) according to the facility's policy and procedures (P&P), titled, Pain Assessment and Management, by failing to: -Ensure the licensed nurses (in general) followed up with the facility's Medical Director after the attending physician did not respond regarding Resident 1's left flank (the side area of the body between the rib cage and the hip) pain and Resident 1's refusal to take acetaminophen (over-the-counter medication used to lower a fever and relieve mild to moderate pain) on 5/13/2026 to 5/15/2026. This failure had the potential for Resident 1's pain level not to be controlled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and implement effective interventions to prevent elopement (when a resident leaves the facility grounds or a designated safe area without the staff knowing and/or without the supervision the resident needs) for one of three sampled residents (Resident 1) who had no capacity to understand or make decisions and had a history of elopement by failing to:1. Accurately assess and identify Resident 1's elopement risk on 9/17/2025, 12/19/2025, 3/19/2026, and 4/30/2026.2. Update Resident 1's care plan on 4/30/2026 after she (Resident 1) eloped from the facility. As a result, Resident 1 eloped from the facility on 4/30/2026 between approximately 2 pm to 3 pm, was found by law enforcement around 7 pm on 4/30/2026 and returned to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2) who were admitted in the facility with pressure ulcer/injury (damaged skin caused by staying in one position for too long) received care and services to promote wound healing by failing to:1. Ensure the wound care treatment were documented with complete assessments in Resident 1 and Resident 2's medical record as indicated in the facility's policy and procedures (P&P) titled, Dressings, Dry/Clean, and Wound Care.2. Ensure the medication Calcium Alginate (a natural, seaweed-derived dressing used for heavily draining wounds) was in place for Resident 1's skin treatment.3. Follow-up on wound care specialist (WCS) order and plan of care with Resident 2's skin treatment and wound management. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed as high risk for falls and dependent in Activities of Daily Living (ADLs), did not experience multiple falls, one resulting in injury, by failing to: 1. Initiate an individualized plan of care upon admission on [DATE] when Resident 1 was identified as having a high fall risk. 2. Update the care plan and interventions when Resident 1 had an unwitnessed fall on 11/16/2025. 3. Ensure staff adhered to the facility's policy and procedure titled Falls - Clinical Protocol (revised 12/2024), which requires staff and physicians to identify and implement interventions to prevent falls and mitigate clinically significant consequences. 4. Evaluate and analyze hazards and risks following repeated unwitnessed falls. [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow professional standards of practice by failing to manage, assess and monitor resident and implement the facility policy and procedure (P&P) titled, Nursing Care of the Older Adult with Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), for one of three sampled residents (Resident 2), when resident had a hyperglycemia (high blood sugar, occurs when there's too much glucose in the blood, often because the body lacks enough insulin or can't use it properly). This deficient practice placed Resident 2 at risk of developing complications due to inadequate monitoring of blood glucose.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents were free of unnecessary physical and chemical restraints (use of medication to manage a person's behavior or restrict their movement) with a medication Haloperidol (Haldol- is a first-generation or typical antipsychotic medication used to treat psychotic disorders and severe behavioral issues), for one of three sampled residents (Resident 3). This deficient practice resulted in unnecessary restraint and placed the resident at risk of potentially life-threatening results, including physical injury, cognitive decline, psychological trauma, and even death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to create an individualized care for one of three sampled residents (Resident 3) with specific goals and interventions for Resident 3's fall risk. This deficient practice could have potentially resulted in Resident 3's continued falls. During a review of the admission record for Resident 3 indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), history of falling, and Hyperlipidemia (HLD- a condition in which there are abnormally high levels of lipids [fats] in the blood) During a review of history and physical (H&P- is a thorough assessment a doctor does to understand a patient's health. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedures for change in condition for one of four sampled residents (Resident 3) when the resident refused their hemodialysis treatments three days in a row on 5/6/25, 5/7/25, 5/8/25. This failure resulted in the resident refusing their hemodialysis treatments and having no follow up or interventions made until his hospitalization on 5/9/25. During a review of Resident 3's admission Record, dated 7/15/25 indicated, the resident was admitted to the facility on [DATE] with diagnoses including; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to reassess and reevaluate to identify residents' needs and/or change in conditions, for two of four observed residents (Resident 45 and Resident 89). This failure had the potential for medication error and/or delay in treatment that may or may not affect Resident 89 and Resident 45' conditions. (Cross Reference F759)

Inspectors wrotec. During a review of Resident 105's admission Record, the admission Record indicated the facility admitted the resident on 11-6-2024 with diagnosis that included bed confinement status (a state where an individual is unable to leave their bed without assistance due to a medical condition, injury, or physical limitation), human immunodeficiency virus disease (HIV- a viral infection that weakens the immune system and can lead to one getting life-threatening infections), end stage renal disease (irreversible kidney failure), and actinic keratosis (a rough, scaly patch or bump on the skin caused by damage from ultraviolet (UV) radiation). During a review of Resident 105's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 4/14/2025 for a LALM every shift for wound management. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure nursing staff would document medication administrations properly for two of four sampled residents (Resident 89 and Resident 86). This failure had the potential for medication error and/or drug diversion (refers to the illegal and unauthorized transfer of legally obtained drugs from their intended use to an unintended use or recipient). 2. Ensure home medications brought in by one of one discharged sampled resident (Resident 900) were returned to the resident. This failure had the potential for drug diversion (involving the transfer of a legally-prescribed controlled substance from the individual for whom it was prescribed to another person) and/or misuse of personal property.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure its medication error rate was less than five (5) percents (%). Three medication errors out of 33 total opportunities yielded a medication error rate of 9.09%, in 3 of 4 sampled residents (Resident 114, Resident 89, and Resident 45) observed during medication administration (med pass). This failure of med pass error rate exceeded the 5 % threshold had the potential of adverse effects that may or may not affect Resident 114, Resident 89, and Resident 45's health condition. (Cross Reference F757 and F761)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the label on a bubble pack (a card that packages doses of medication within small, clear plastic bubbles or blisters) matched the physician's order for one of four sampled residents (Resident 114). This failure had the potential of medication error that may or may not affect resident's condition. (Cross Reference F759)

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and sanity food storage practices in the kitchen for124 of 135 residents who received food from the facility and including residents who had food stored in the resident refrigerator when: 1. One opened container of cottage cheese was observed unlabeled in the refrigerator. A plastic bag that contained a staff member's (unidentified) lunch was observed in the refrigerator. 2. The temperature of TCS foods (Time/Temperature control for safety food) checked was above 41 degrees Fahrenheit (F). TCS foods are foods that can support bacterial growth than can result in food borne illness unless stored, prepared and served safely. The temperature of a previously cooked rice from 6/16/2025 stored in the walk-in refrigerator checked using the facility thermometer was 45.5 degrees Fahrenheit (F). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program (is the practice of managing and regulating undesirable organisms, commonly known as pests, that pose threats to human health) for 136 residents who resided in the facility to destroy and prevent cockroaches in the facility This failure resulted in the presence of one live cockroach in the utility room (a room where medical supply is stored and the location of the resident refrigerator for outside food and the unit ice machine) and placed 136 residents at risk of serious disease that can be transmitted through various routes (direct contact or inhalation) and by contaminating human food with germs (small living things/cells, especially one which cause diseases) that pests pick up from drains, garbage dumps and outside grounds.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care in a manner that promoted or enhanced a resident's dignity for two of three sampled residents (Resident 6 and Resident 492) by failing to ensure to: 1. Provide Resident 6 with a privacy curtain (cloth barriers that surround a patient's bed) of adequate length. 2. Provide a cover for Resident 492's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) bag. These failures had the potential to cause emotional distress, affect the Resident 6's and Resident 492's self-esteem (how we value and perceive ourselves), and cause a loss of dignity (he quality or state of being worthy, honored, or respected) and decline in psychosocial (social factors and individual thought and behavior) wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 126) would not be allowed to keep ear drops (Debrox drops, earwax removal kit) medication at the bedside without a physician's order. This failure had the potential to result in unsafe medication application and/or over medicating for Resident 126.

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) discharge (the formal release from a facility) assessment was accurately performed for one of seven sampled residents (Resident 138). This failure had the potential to result in the inadequate care of Resident 138 during her discharge from the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatment) to meet the resident's needs for one of three sampled residents (Resident 44) by failing to create an appropriate care plan for Resident 44's tube feeding (a method of providing nutrition directly into the stomach or small intestine through a tube, when a person is unable to eat or drink enough to meet their nutritional needs). This failure had the potential for Resident 44 to receiving inadequate care.

Inspectors wrote2. During a review of Resident 45's order for diclofenac sodium (a medication used to relieve pain and inflammation in certain joints) external gel 1 %, the order (dated 8/24/2024) indicated apply to both [hands] topically two times a day for pain management. During an observation on 6/18/25 at 8:49 AM, Licensed Vocational Nurse (LVN 3) applied the diclofenac gel to both of Resident 45's knees. During an interview on 6/18/2025 at 11:32 AM, the Director of Nursing (DON) stated Resident 45's diclofenac gel order was written for the application to the hands and the nurse should contact doctor if Resident 45 had pain in the knees. During an interview, and a concurrent review of Resident 45's medication administration record (MAR) of June 2025, on 6/18/2025 at 12 PM, the DON reviewed Resident 45's MAR for the diclofenac gel. [...]

Inspectors wroteBased on interview and record review, the facility failed to rotate the insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection (the act of putting a liquid, especially a drug, into a person's body using a needle ) administration sites for one of one sampled residents (Resident 109). This failure had the potential for Resident 109 to develop skin infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the correct enteral tube feeding (way to get nutrients into the body through a tube that's inserted into the stomach or small intestine, bypassing the mouth) rate of 65 milliliter (mL, a unit of measure) per hour for one of three sampled residents (Resident 21). This failure had the potential for Resident 21 to experience malnutrion (is a serious condition that happens when a person's diet does not contain the right amount of nutrients).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an emergency kit (a special kit placed at the resident's bedside used in emergency situations such as bleeding from a dialysis fistula [surgically created connection between an artery and a vein, usually in the arm, that makes it easier to access your bloodstream for dialysis]) for two of five sampled residents (Resident 124 and Resident 491). This failure had the potential for Resident 124 and Resident 491 to experience uncontrollable bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 45) did not receive medication without a physician order and/or without adequate indication of use. This failure had the potential for medication error and delay in proper treatment that may or may not affect Resident 45's condition negatively. (Cross Reference 759)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 27 sampled residents (Resident 54 and Resident 39) were served food preferences listed on the lunch meal ticket (physician ordered diet with resident food preferences) when: 1. Resident 54 who had lactose intolerance (lactose a sugar found in dairy products such as milk) was served chocolate flavored ice cream, despite lactose being listed as an intolerance on the resident's lunch meal ticket/tray care. 2. Resident 39 was served pork despite cultural preferences for no pork or ham. These failures had the potential to result in decreased meal satisfaction, decrease caloric intake, Resident 54 and Resident 39 being upset and for Resident 54 to experience symptoms associated with lactose intolerance.

Inspectors wroteDuring a review of Resident 101's admission Record, the admission Record indicated the facility admitted Resident 101 on 11/5/2024 with diagnoses that included seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), HIV (Human Immunodeficiency Virus Disease (a virus that attacks the body's immune system), weakness, and anxiety disorder (mental health conditions that cause fear, dread and other symptoms) During a review of Resident 101's History and Physical (H&P) dated 11/7/2024, the H&P indicated Resident 101 had lack of coordination and needed safety precautions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accident and hazard free environment for one of three sampled residents (Resident 1). The facility failed to ensure: 1. Resident 1 ' s bed footboard was not broken and left on the floor for several hours. 2. Resident 1 ' s feet (at ankle level) were not dangling at the foot of the bed. 3. Staff did report and request maintenance for the broken footboard. This deficient practice had the potential for Resident 1 to sustain fall and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of three sampled residents (Resident 1) with dignity and respect by failing to safeguard Resident 1 ' s personal belongings. This failure resulted in the loss of Resident 1 ' s shoes which caused his feelings of being upset.

Inspectors wroteBased on observation, interview and record review, the facility failed to timely document administered medications per facility policy to three of four sampled residents (Residents 6, 7 and 8). This deficient practice had the potential to result in unsafe, and improper medication administration per facility policy.

Inspectors wroteBased on interview and record review, the facility staff failed to ensure physician (MD) notification was done for one of nine sampled residents (Resident 1's) change of condition (COC/CIC) by failing to notify MD when Resident 1 had multiple episodes of refusal of basic care. This deficient practice had the potential to result in possible delayed provision of necessary care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility staff failed to develop and implement a comprehensive care plan that meet the care/services based on the resident ' s individual assessed needs for one of nine sampled residents (Resident 1) by failing to ensure Resident 1 ' s episodes of refusal of basic care were care planned. This deficient practice had the potential to result negative impact on Resident 1 ' s health and safety, as well as the quality of care and services received. Cross Referenced F580.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary treatment and service to one of three sampled residents (Resident 4) consistent with the resident's needs and professional standard of care by failing to ensure low air loss (LAL) mattress was set up properly for Resident 4. This deficient practice can place Resident 4 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 observation, interview, and record review, the facility failed to provide necessary respiratory care services for one of two sampled residents (Resident 2) by failing to ensure the nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) for oxygen (O2) therapy was changed per facility ' s policy. This deficient practice had the potential to cause complications associated with oxygen therapy.

Inspectors wroteBased on interview and record review, the facility failed to effectively and timely manage/treat/assess the pain for two of three sampled residents (Resident 2 and Resident 3) . Resident 2 was experiencing severe pain of the left knee in the facility for two days Resident 3 was admitted to the facility for pain management (The process of providing medical care that alleviates or reduces pain). This deficient practice resulted in: Resident 2 was sent to a general acute care hospital (GACH) emergency room after the resident's family intervened and requested for the transfer to GACH. Resident 3 experiencing unnecessary pain affecting the resident's appetite and ability to sleep.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 2), who had severe left knee pain was appropriately assessed in a timely manner. This failure resulted in the delay of care for Resident 2 who had to suffer from pain and discomfort for two days.

Inspectors wroteBased on interview and record review the facility failed to ensure one for three sampled residents (Resident 1), Resident 1's Responsible Party (RP) was made aware of the reason Resident 1 was being discharged from the facility . This failure resulted in Resident 1's Responsible Party (RP) not being notified of the transfer and reasons why the Resident 1 was not to be readmitted to the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were free from physical abuse (deliberately aggressive or violent behavior by one person toward another that results in bodily injury) from Resident 3. Resident 3 slapped Resident 2 in the arm and assaulted Resident 1 in the activity room where facility staff was present and there was no documented monitoring of Resident 3, per the Mood Problem care plan interventions. This deficient practice resulted in Resident 1 sustaining a bloody lip with jaw pain, and was transferred to the General Acute Care Hospital for evaluation.

Inspectors wroteBased on interview and record review the facility failed to implement the comprehensive care plan interventions for two of three sampled residents (Resident 2 and Resident 3). Both residents were not monitored after an altercation with another resident, per the care plan interventions. This deficient practice had the potential to result in missed opportunity for any changes in the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide social services to one of three sample residents (Resident 1) by failing to follow up on an order for ophthalmology (eye care specialist) evaluation appointment. This deficient practice had the potential for delay in the delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop a complete baseline care plan for one of five sampled residents (Resident 3) within 48 hours of resident's admission. This deficient practice had the potential for delayed administration of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary treatment and services for two of five sampled residents (Resident 3 and Resident 5) consistent with the residents' needs and professional standards of practice, by failing to: -Ensure Resident 3 received wound treatment for right posterior hip unstageable (full-thickness skin and tissue loss in which actual depth of the ulcer is completely obscured by slough-yellow, tan, green or brown and/or eschar-tan, brown, or black, in the wound bed) pressure injury (localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear-layers are laterally shifted in relation to each other, and or friction-surfaces sliding against each other). [...]

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 three of five sampled residents (Resident 1, Resident 2, and Resident 4) by failing to ensure that a comprehensive (CP) was implemented for refusals of vaccinations (a medical treatment that helps body's immune system to recognize and fight disease). 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: a. Ensure the physician ' s order for transmission-based precaution are implemented for three of five sampled residents (Resident 4, Resident 5, and Resident 6) who tested positive for coronavirus (COVID-19 - an infectious disease that can cause respiratory illness in humans). b. Ensure the Dietary Staff 1 (DS 1) wear fit-tested for National Institute for Occupational Safety and Health (NIOSH - federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness) approved N95 or higher-level respiratory protection (mask that protect used by filtering out contaminants in the air) in the facility. These deficient practices had the potential to transmit infectious diseases and increase the risk of infection to the residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents, (Resident 1) ' s clinical record was updated per facility ' s policy and procedure by failing to ensure resident's clinical records were updated regarding Physician Orders for Life-Sustaining Treatment (POLST - is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency). This deficient practice violated resident ' s and/or representatives ' right to be fully informed of the option to formulate advance directive and POLST and had the potential to cause conflict with resident's wishes regarding health care.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) of incident reporting for unusual occurrence for one of one sampled resident (Resident 1) by failing to report an unusual occurrence to the State Survey Agency and send a written report within 24 hours of Resident 1 ' s death. This deficient practice resulted in a delay of an onsite inspection by the Department of Public Health and had potential to place other residents during an COVID-19 (an infectious disease that can cause respiratory illness in humans) outbreak.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) for four of five sampled residents (Resident 7, 9, 11 and 13). This deficient practice had the potential to result in medication errors and/or drug diversion (illegal distribution or abuse of prescription drugs).

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure one of five sampled residents (Resident 8) was free from significant medication error by failing to ensure the Ativan (lorazepam - used to relieve anxiety) 0.5 milligram (mg-unit of measurement) one tablet by mouth every 12 hours as needed for anxiety was not administered after 14 days ([DATE]) when the order expired. This deficient practice has the potential to result in Resident 8 in unintended complications related to the management of medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift were accurate for two of two sampled days (8/1/2024 and 8/2/2024). This deficient practice resulted in incorrect actual hours staffing information and had the potential to cause inadequate staffing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to manage pain on the hands, legs, and stomach for one of three sampled residents (Resident 436) by failing to: 1. Address the Resident 436's request for adequate pain management, 2. Evaluate the effectiveness of the resident's pain medication, 3. Notify the resident's physician that pain management intervention was unsuccessful and for consultation. This failure resulted in Resident 436's to continue experiencing severe, unrelieved and uncontrolled pain from 5/11/2024 to 5/22/2024. Resident was unable to walk due to leg pain, felt her pain was stressful, could not perform usual activities (decline in performing daily activities).

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of 12 sampled residents (Resident 1 and 15) had Advance Directives (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) or Advanced Directives Acknowledgement forms (a signed acknowledgment indicating the resident and/or resident representative were provided with information regarding creating an Advanced Directive) documented in the residents' active medical record. This deficient practice had the potential for Residents 90 and Resident 96 to be denied the right to request or refuse medical care and treatment or have those options honored in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review the facility failed to store and label food in accordance with professional standards and the facility's policy and procedure (P&P) titled Labeling and Dating of Foods reviewed 9/202 by failing to label food with the open date (date indicating packaging opened; used to determine amount of time food can be safely consumed). This deficient practice placed all 127 facility residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the rights of one of 32 (Resident 58) sampled residents shower preferences. This deficient practice resulted in Resident 58 feeling dirty and uncomfortable.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory information on the Nursing Facility (SNF) must issue this notice to a resident when it believes that Medicare may not cover their care or stay. The SNF must provide the notice to the resident before providing the non-covered care.) appeal process in a timely manner for one of three randomly selected residents (Resident 7). This deficient practice denied Resident 2 the right to accept or decline non covered specific skilled services or file an appeal. This placed Resident 7 at risk for an unexpected financial burden/crisis.

Inspectors wroteBased on interview, and record review, the facility failed to provide a bed hold notification (written notice of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) at the time of transfer to the hospital for one of two sampled residents (Resident 133). This deficient practice denied Resident 133 and/or the Responsible Party (RP) the right to be informed of their right to have the facility hold and reserve Resident 133's bed while absent from the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) for Apixaban (Eliquis, an anticoagulant medication [medication that help prevent blood clots]) 5 milligrams (mg) by mouth twice a day for anticoagulant (medication used to treat and prevent blood clots) one of four sampled residents (Resident 7). This deficient practice had the potential for Resident 7 to not be provided personalized care and experience negative effects from the anticoagulant medication such as bruising, internal bleeding, and uncontrolled bleeding.

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to revise the tube feeding (also known as enteral nutrition, is a way to provide nutrition, fluids, and medicines through a feeding tube placed into the stomach or small intestine) care plan to meet the individual needs for one of two sampled residents (Resident 76). This deficient practice had the potential to prevent Resident 76 from receiving care to address specific needs, which could lead to a decline in emotional and physical health.

Inspectors wroteBased on interview and record review, the facility failed to schedule the urology (medical conditions of the urinary tract) and gastroenterology (all the organs in the digestive system, including the GI tract (esophagus, stomach, and intestines) and biliary organs (your liver, bile ducts, pancreas and gallbladder) consults as ordered by the physician on 5/10/2024, for one of four sampled residents (Resident 99) in a timely manner. As a result, as of 5/22/2024 Resident 99's appointments had still not been scheduled. This deficient practice placed the resident at risk for worsening of symptoms, infections, organ failure, and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and per the physician's orders for one of three sampled residents (Resident 131) at risk for developing pressure ulcers by failing to ensure the resident's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) was set at the appropriate level. This deficient practice placed Resident 131 at risk for developing new pressure injuries and complications resulting from untreated or improperly treated pressure injuries which could result in systemic infections that could lead to death.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two sampled residents (Resident 37) received colostomy (an opening in the abdominal wall that's made during surgery, and it is used to move waste out of the body) care in accordance with the resident's comprehensive person-centered care plan (a set of instructions for providing individualized care to a resident for an identified area of concern) by failing to provide colostomy care during every shift and as needed, and monitor skin irritation as per the plan of care. This deficient practice had the potential for Resident 37 to suffer from infection, skin breakdown, and pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide one to one (1:1) feeding assistance as indicated in the care plan one of three residents (Resident 62) when: Restorative Nursing Assistant (RNA) 1 and (RNA) 2 (staff who provides care to help to restore and maintain function) did not provide 1:1 feeding assistance to Resident 62 during lunch on 5/21/24 and 5/22/2024. These deficient practices had the potential for Resident 62 and other 1:1 feeder at the facility to experience poor oral intake and be at risk for weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their infection prevention and control procedure by not displaying the proper isolation-based precaution sign and posting the specific type of isolation outside the door for one of one sampled resident (Resident 106). This failure resulted in posting incorrect isolation precaution instructions, incorrect personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious illnesses) outside the resident's door and had the potential for staff donning incorrect PPE and contracting and spreading infections to other residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 4) received care and services when providing parenteral fluids (intravenous [IV-a small, flexible tube placed into a small vein for intravenous therapy such as medication fluids] infusion of various solutions to maintain hydration, restore and/ or maintain fluid volume, reestablish lost electrolytes [substance that help regulate chemical balance in the body] or maintain nutrition) consistent with professional standards of practice by failing to ensure Resident 4 ' s Peripheral Inserted Central Catheter (PICC line- a type of a Central Venous Catheter [CVC-a catheter placed into a large vein]) was flushed with 10 milliliter (mL - unit of measurement) 0.9 percent (%) sodium chloride (NS-normal saline) prior to administering an antibiotic medication per facility policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document medication administration immediately after dose were administered for three of five sampled residents (Residents 1, 2, and 3). This deficient practice had the potential to result in medication administration error and risk for unsafe, improper medication administration use for Residents 1, 2, and 3.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the residents have the right to be free from sexual abuse for one of seven sampled residents (Resident 3). This deficient practice resulted in residents being subject to neglect and sexual abuse. Cross Reference F609 and F610.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy regarding reporting of residents ' allegation of sexual abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for two of seven sampled residents (Resident 2 and Resident 3). 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 sexual abuse for Resident 2 and Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report an allegation of sexual abuse within 2 hours or in accordance with state or federal law for two of seven sampled residents (Resident 2 and Resident 3). 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 sexual abuse for Resident 2 and Resident 3. Cross Reference F609.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of six sampled residents, (Resident 1) received treatment and care accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to ensure the physician ' s order was carried out. This deficient practice resulted to failure in the delivery of necessary care and services and resulted in Resident 1 ' s hospitalization.

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 six 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 four of six sampled Certified Nursing Assistant staff (CNA 1, CNA 2, CNA 4, and CNA 5) had a performance review every 12 months to provide in-service training based on the outcome of their performance review. This failure resulted in CNA 1, 2, 4 and 5 being denied a yearly performance review as required by the federal regulation.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled Certified Nursing Assistant staff (CNA 6) had an active license when employed at the facility. This failure resulted in CNA 6 not meeting the requirements of the federal regulation for nurse aide registry (certification) verification.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its policies and procedures on infection control to prevent the spread of coronavirus disease 2019 (COVID-19, a highly contagious infection affecting the respiratory system caused by a virus that can spread from person to person) by failing to: 1. Ensure all staff were tested for the COVID-19 before the start of each shift as recommended by the local health department. 2. Ensure certified nursing assistant (CNA 1) wore protective gown and gloves when providing care and when in close contact with the resident who was potentially exposed to COVID-19. 3. Ensure the cleaning cart were sanitized and used exclusively for the rooms that house the COVID-19 positive residents. These deficient practices had the potential for COVID-19 and other transmissible diseases to spread to residents and staff.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, free of odor, safe and home like environment for two of four sampled residents (Residents 1 and 4). This deficient practice resulted in Resident 1 feeling dizzy from the strong distinct odors and had also the potential of placing other residents at risk of cross contamination, spread of disease-causing organism, and accident/incidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for two of the four sampled residents (Resident 1 and 4) by failing to ensure Residents 1 and 4 Activities of Daily Living (ADL -which included showers and incontinence care [assistance with bladder and/or bowel function which includes supporting a person to maintain continence and manage incontinence]) care refusals were care planned and addressed during Interdisciplinary team meetings. These deficient practices resulted in Resident 1 and 4 ' s room to cause a strong odor that spread to the nursing station. The nurses shut the door which made Resident 1 feel dizzy from smelling the odor that he had to leave the room at 2 a.m.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to adequately assess stage Pressure Ulcers (PU-are skin and soft tissue injuries that form as a result of constant or prolonged pressure exerted on the skin) for two of three sampled residents (Residents 2 and 3). This deficient practice had the potential to result in improperly treating the wound which may lead to the wound getting worse for Resiednts 2 and 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received the care and supervision to prevent falls as evidenced by: -Failing to correctly assess Resident 1 as indicated on the Fall Risk Assessment and identify Resident 1 was at high risk for falls. -Failing to care plan for Resident 1's non-compliance with the front wheel walker and the resident's refusal of staff assistance with ambulation. As a result, on 11/7/2023, Resident 1 fell and sustained a hematoma (an abnormal collection of blood outside of the blood vessel) to the head and a femoral neck fracture (broken upper thigh bone) and an impacted subcapital right femoral neck fracture (break in the upper thigh bone).

Inspectors wroteBased on interview and record review, the facility failed to re admit one of three sampled resident (Resident 1) after hospitalization on 11/9/2023 at a General Acute Care Hospital (GACH) as indicated in the facility's policy and procedure (P&P) titled Bed-holds and Returns. As a result, Resident 1 remained in GACH 1 since 11/16/2023 and had the potential to cause psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate residents' needs were met by failing to ensure: 1. That the call light (A device used by a patient to signal his or her need for assistance from professional staff) for one of four sampled residents (Resident 3) was within reach per facility protocol. 2. Resident 1's who was incontinent (inability of the body to control the evacuative functions of urination or defecation) care was provided incontinence care in a timely manner. This failure resulted in Resident 3 feeling isolated and unable to call for assistance whenever she needed help.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one out of 5 Residents (Resident 4) was free from significant medication error by failing to administer the morning dose of Risperdal (a medication that works in the brain to treat schizophrenia. It is also known as a second-generation antipsychotic (SGA) or atypical antipsychotic), Aricept (used to treat dementia (memory loss and mental changes) associated with mild, moderate, or severe Alzheimer's disease), potassium chloride (a mineral supplement used to treat or prevent low amounts of potassium in the blood. A normal level of potassium in the blood is important), and Namenda (used to treat dementia associated with Alzheimer's disease [most common type of dementia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to answer the call light promptly per facility policy for four of 25 sampled residents (Residents 6, 8, 10 and 101). This deficient practice resulted in a delay for staff to answer the call light and had the potential to not address the needs for Residents 6, 8, 10 and 101 timely.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, free of odor, and home like environment for three of 25 sampled residents (Resident 25, 49 and 56). These deficient practices had the potential for cross contamination, spread of disease-causing organism, and negatively impact the quality of life for Residents 25, 49 and 56.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) settings were consistent with weight and physician's order for five of 25 sampled residents (Residents 45, 49, 60, 66 and 100) who had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment, and dependent on staff for activities of daily living (ADL, bed mobility, locomotion, surface transfer, eating, grooming, persional hygiene, toileting and or dressing) These deficient practice increased the risk for poor and or delayed pressure ulcer (also called pressure ulcers and decubitus ulcers -are injuries to skin and underlying tissue resulting from prolonged pressure on the skin) wound healing, and increased the risk to develop pressure ulcers /wounds for (Residents 45, 49, 60, 66 and [...]

Inspectors wrote2. A record review of the admission record indicated Resident 58 was re-admitted to the facility on [DATE]. Resident 58 diagnoses included but were not limited to hemorrhage (bleeding) of the rectum (the terminal part of the intestine from the sigmoid colon to the anus), dementia (loss of cognitive functioning-thinking, remembering, and reasoning), gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) and glaucoma (eye condition that can cause blindness). A record review of the Resident 58's MDS, dated [DATE], indicated Resident 58 had severe impairment in cognitive skills for daily decision making. The MDS also indicated Resident 58 was totally dependent on staff for help in bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. [...]

Inspectors wrote3. During a concurrent observation and interview on 12/7/2021 at 7:53 a.m., unlabeled opened dietary supplements were found in the drawer of Station A medication cart (Cart 2). Licensed Vocational Nurse 5 (LVN 5) stated that all opened medication bottles should have labels with date and initials when it was opened so staff could know when to dispose (get rid of) medications for safety and effectiveness. 4. During a concurrent observation and interview on 12/7/2021 at 7:55 a.m., unlabeled opened foil pack of DuoNeb were found in the drawer of Cart 2. LVN 5 stated that when opening DuoNeb, foil pack should be labeled with date and should be discarded within a week per manufacturer's policy. A review of manufacturer's product labeling, undated, indicated DuoNeb should be used within a week. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food distribution and hand hygiene practice when: 1. One staff working in the dish machine area did not wash hands and change gloves when removing the clean and sanitized dishes from the dish machine. 2. Two certified nursing assistants (CNAs) did not perform hand hygiene during delivery of food and drink to Resident 41 and Resident 102. These failures had the potential to cross contaminate (transfer of harmful bacteria from one place to another) dishes and cause food borne illness in 95 out of 109 residents who received food from the facility's kitchen, exposing residents to infectious microorganisms (bacteria, virus, or fungus).

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct Coronavirus - 19 (COVID-19 or COVID, a virus that causes respiratory illness that can spread from person to person) testing practices consistent with the current standard of practice and state guidelines as evidenced by failing to: 1) Label Resident 80's COVID-19 test specimen collection tube (culturette package) with Resident 80's identification. 2) Monitor the percentage of their residents and health care providers (HCPs, facility staff) that are fully vaccinated on a daily basis. These deficient practices had the potential resulting in transmission and spread of COVID-19 within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff did not stand over one of 10 sampled Residents (Resident 91) while assisting Resident 91 to eat at lunch time. This deficient practice violated the right to be treated with dignity and respect, and had the potential for psychosocial harm for Resident 91.

Inspectors wroteBased on interview and record review, the facility failed to reimburse one of one sampled resident (Resident 47) for a missing mouthguard (is a protective device for the mouth that covers the teeth and gums to prevent and reduce injury to the teeth, arches, lips, and gums). This deficient practice the potential to compromise the dental health for Resident 47.

Inspectors wroteBased on interview and record review, the facility failed to update the Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) within 14 days for significant change in status for one of 25 sampled residents (Resident 60). This deficient practice had the potential to affect the provision of necessary care and services for Resident 60.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) accurately reflected the resident's hospice status for one of 25 sampled residents (Resident 60). This deficient practice resulted in incorrect data transmitted to Centers for Medicare and Medicaid Services (CMS- a federal agency that administers the nation's major healthcare programs including Medicare, Medicaid) regarding resident's hospice status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plans on safety and peripherally (away from the center of the body) inserted central catheter (PICC- is a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart to administer intravenous [IV-inside a vein] fluids, blood transfusions, chemotherapy [medication to treat cancer], and other drugs) line care for two of 25 sampled residents (Resident 58 and 67). A review of facility's policy and procedures (P&P) titled Care Planning- Interdisciplinary Team, revised 1/2017, indicated that it is the policy of the facility that the interdisciplinary team is responsible for the development of an individualized resident centered comprehensive care plan for each resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and document Peripherally Inserted Central Catheter (PICC-a thin, soft tube that is inserted into a vein in the arm, leg or neck for long-term intravenous [IV] antibiotics, nutrition, medications, and blood draws) site for one of two sampled residents (Resident 67). This deficient practice had a potential for Resident 67's PICC line site not being properly monitored for possible infection.

Inspectors wroteBased on interview and record review, the facility failed to communicate the consultant pharmacist's recommendation, in the Medication Regimen Review (MRR), to the attending physician for one of five sampled residents (Resident 96). This deficient practice had the potential for unnecessary medication use, resulting in an adverse drug reaction to affect the health and wellbeing of Resident 96.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures for two of six sampled residents (Resident 31 and Resident 46) by failing to ensure: 1. The Hoyer lift (a mechanical lift that allows a person to be lifted and transferred with minimum physical effort) was cleaned after its use on Resident 31. 2. Licensed Vocational Nurse 7 (LVN 7) wore a Non-oil 95% mask (N95 - a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) and eye protection (goggles or face shields) during oral suctioning (use of a rigid plastic suction catheter to remove pharyngeal secretions through the mouth) of Resident 46. These deficient practices had the potential to spread infection in the facility and place residents at risk for infection.