Laguna Hills Health and Rehabilitation Center

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of seven sampled residents (Resident 1). * The facility failed to ensure Resident 1's elevated temperature reading was reported to the physician. In addition, the facility failed to ensure Resident 1's abnormal lab results were reported to the physician. These failures had the potential for the resident to not receive the necessary care and interventions and negatively affect the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to inform the residents' responsible parties of a change of condition for two of nine sampled residents (Residents 5 and 6). * The facility failed to notify Resident 5 and 6's responsible parties when the residents had fall incidents. These failures resulted in the responsible parties not being informed timely of the residents' change of condition.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to one of nine sampled residents (Resident 8). * The facility failed to ensure a root cause analysis for Resident 8's right humeral fracture was completed. Additionally, there was no documented evidence to show how to provide care for Resident 8's fracture. This failure posed the risk of staff not providing appropriate care for Resident 8.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure three of three nursing staff (CNAs 2 and 3, and LVN 4) interviewed demonstrated the competencies and skill sets needed to provide safe nursing care to the residents who were on anticoagulant medication. * CNAs 2 and 3 failed to explain failed to explain how to handle and care for residents that are on anticoagulant medication. * LVN 4 failed to explain what the main side effects to monitor for when the residents were on an anticoagulant medication. These failures had the potential for the residents to receive inadequate care and posed the residents at risk for adverse consequences.

Inspectors wroteBased on observation, interview, medical record review, and the facility P&P, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of the pressure ulcer for one of three sampled residents (Resident 1). * The facility failed to provide the necessary skin treatment when Resident 1 was admitted to the facility with MASD to the perineum and the buttocks on 4/29/26, and when Resident 1 was readmitted with pressure injury. In addition, the facility failed to assess Resident 1's pressure injury, obtain an order for the pressure injury, and ensure Resident 1's low air loss mattress setting was correct. These failures had the potential for the resident's existing pressure injury to worsen and developed additional wounds.

Inspectors wroteBased on observation, interview, medical record review, and the facility P&P review, the facility failed to provide the necessary care and service for one of three sampled residents (Resident 1) who was on anticoagulant medication. * The facility failed to ensure Resident 1 was monitored for the side effects of anticoagulant medication use. This failure had the potential delay in the identification of the side effects due to anticoagulant medication use and for the resident to receive necessary care and interventions.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were stored in a safe manner for two of two nonsampled residents (Residents 5 and 6). * The facility failed to ensure the medications for Residents 5 and 6 were not left unattended on top of Medication Cart A. This failure had the potential for the medication to be accessed by an unauthorized individuals.

Inspectors wroteBased on interview, closed record review, and facility P&P review, the facility failed to ensure the discharge information and assessments were completed for one of seven sampled residents (Resident 1). * The facility failed to ensure the information in Resident 1's Discharge Instruction Form/Recapitulation of Stay was complete. In addition, the facility failed to provide documentation to show Resident 1 was given the instructions and medications upon discharge. These failures had the potential for Resident 1 to not receive a complete discharge information, instructions, and medications which could potentially affect the resident's health.

Inspectors wroteBased on interview, closed medical record review, and the facility P&P review, the facility failed to provide the necessary services to maintain the resident's highest practicable well-being for one of seven sampled residents (Resident 3). * The facility failed to initiate a change of condition assessment and notify the physician when Resident 3 had a second fall on 3/29/26. In addition, the facility failed to update Resident 3's care plan with the interventions to prevent injury and further fall. These failures had the potential for Resident 3 to not receive the appropriate care and interventions which could negatively affect the resident's health and well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide an adequate and written notice of the room change for one of five sampled residents (Resident 1). * The facility failed to communicate the room change to Resident 1 in her primary language. In addition, the facility failed to provide Responsible Party 1 a written notice of Resident 1's room change. These failures had the potential for resident's rights to be violated.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of nine sampled residents (Resident 1) was free from abuse. * CNA 5 borrowed $500 from Resident 1, which caused Resident 1 to feel worried and emotional when the money was not returned on time. CNA 5 then asked Resident 1 to lie and say the money was payment for work CNA 5 had done for the resident. This failure negatively affected Resident 1's emotional wellbeing.

Inspectors wroteBased on interview and medical record review, the facility failed to conduct the status post change of condition assessments for one of nine sampled residents (Resident 1). * The facility failed to conduct any follow up nursing assessments on Resident 1 who had a change of condition involving an incident where a CNA borrowed money from Resident 1. This failure posed the risk for changes in Resident 1's psychosocial well-being not identified and potentially delayed the necessary care and treatment for the resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement their P&P to ensure timely reporting of a reasonable suspicion of a crime related to injuries of unknown source in accordance with Section 1150B of the Act for one of six sampled residents (Resident 4). * The facility failed to report timely to the CDPH, L&C Program, Long-Term Care Ombudsman office, and local law enforcement agency when Resident 4 was discovered with a discoloration to her right eyebrow region. This failure had the potential to compromise or impede the protection of Resident 4 and the other residents at the facility.

Inspectors wroteBased on interview and closed medical record review, the facility failed to provide one of six sampled residents (Resident 1) sufficient preparation and orientation to ensure a safe discharge from the facility. * The facility failed to inform Resident 1 her insurance would not cover the cost of her physician ordered DME (a hospital bed and wheelchair), prior to her discharge from the facility. This failure had the potential to compromise Resident 1's ability to make an informed decision regarding her discharge plan of care, potentially leading to financial hardship, physical and psychosocial distress.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to ensure a notice of transfer/discharge was provided to the resident or the resident's responsible party for one of six sampled residents (Resident 2) prior to the resident's discharge from the facility. * The facility failed to provide the written notice pf transfer/discharge to Resident 2 or the resident's responsible party prior to the resident's discharge from the facility. In addition, the facility failed to ensure a copy of Resident 2's notice of transfer/discharge was provided to the State Long-Term Care Ombudsman prior to the planned discharge date . This failure had the potential to violate Resident 1's rights to appeal their discharge.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the environment remained free from accident hazards for one of four final sampled residents (Resident 42) and two nonsampled residents (Residents 26 and 166) reviewed for accidents. * The facility failed to post signage on Resident 42's room to indicate the oxygen was in use. * The facility failed to ensure the resident rooms contained secured closet/storage cabinets for 103 of 103 resident rooms. * A pair of long scissors was observed on Resident 166's overbed table. These failures posed the risk for injuries to the residents, staff, and visitors.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure Station A ice machine drainpipe maintained an air gap (space between the water outlet and the flood level of the drain that prevents backflow of waste water from the drain) at the floor sink drain. This failure had the potential to result in waterborne illnesses in a highly susceptible resident population. * The facility failed to ensure proper storage of refrigerated food in the kitchen. * The facility failed to ensure the kitchen equipment was clean and in good condition. * The facility failed to ensure the broom and dustpan were stored in a sanitary manner. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure one of 169 residents (nonsampled Resident 17) was provided care in a manner that promoted dignity and respect. * The facility failed to provide Resident 17 with privacy during bedside toileting. This failure had the potential for the resident to experience a decline in her psychosocial well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were safely administered to two of 33 final sampled residents (Residents 158 and 174). * Resident 158 had a bottle of Total Beets (dietary supplement) 650 mg chewable at the bedside. Resident 158 did not have a physician's order to self-administer the Total Beets 650 mg or to keep any medication at the bedside. * Resident 174 had the bottle of Instaflex Advanced (dietary supplement) at the bedside. Resident 174 had no physician's order to keep any medication at the bedside. These failures had the potential to negatively impact Resident 158 and 174's physiological well-being and the potential for the residents to administer the medications inaccurately.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodation to meet the needs of two of two final sampled residents (Resident 8 and 49) reviewed for communication needs. * The facility failed to ensure the appropriate communication devices were used by staff to meet Residents 8 and 49's daily needs. This failure had the potential to negatively impact the resident's psychosocial well-being and result in delayed provision of care.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure all grievances filed during 2025 were available for review to ensure they were followed up on appropriately. * The facility did not file and kept copies of the residents' grievances. This failure resulted in the state agency being unable to verify grievances were follow-up on per policy.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents reviewed for unnecessary medications (Residents 13 and 61) and one of one final sampled resident reviewed for behavioral-emotional management (Resident 133) were free from unnecessary psychotropic drugs. * Resident 13 did not have the monthly behavior summaries for the targeted behaviors for the Prozac (antidepressant) and divalproex sodium (an anticonvulsant medication also used for behaviors associated with bipolar disorder) medications. In addition, the facility failed to monitor the resident for orthostatic hypotension related to the resident's Zyprexa (antipsychotic medication) use when the resident was readmitted on [DATE]. * The facility failed to ensure the monthly behavioral summary was completed for Resident 61's Zyprexa medication. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate an allegation of facility staff to resident physical abuse, for one of two residents (final sampled resident, Resident 73) reviewed for abuse * Resident 73's roommate (Resident 170) alleged she witnessed a female staff member hit Resident 73 on the arm during care. The facility failed to conduct an interview with the RN assigned to care for Resident 73, during the time in which the alleged incident occurred. Additionally, the facility failed to conduct an interview with the CNA assigned to the station, which Resident 73 resided in at the time of the allegation. * The facility failed to interview other residents residing in the facility to determine if other residents were potentially the victim of physical abuse. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the PASRR Level 1 screening contained accurate information specific to mental illness for one of two final sampled residents (Resident 13) reviewed for PASRR. * Resident 13 had a diagnosis of schizophrenia (chronic mental illness that impairs thought, perception, and behavior, making it difficult to function in daily life) however, PASRR Level 1 screening showed Resident 13 had no diagnosis of a mental illness. This failure had the potential for Resident 13 not receiving a Level II Mental Health Evaluation, which posed the risk for Resident 13 not receiving recommendations for specialized services that supplement nursing facility care to address resident mental health needs.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement a plan of care to reflect the individual care needs for three of 33 final sampled residents (Residents 8, 158, and 174) and two nonsampled resident (Residents 52 and 166). * The facility failed to develop a comprehensive person-centered care plan addressing Resident 8's change of condition dated 8/12/25, regarding Resident 8's right posterior forearm with popped boils, and redness and tenderness on the surrounding site. * The facility failed to develop a comprehensive person-centered care plan to reflect the individualized care needs of Resident 52's abdominal fold moisture associated skin damage (MASD) and treatment. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary treatment and services for one of five final sampled residents (Resident 1) reviewed for unnecessary medications. * The facility failed to ensure Resident 1's orthostatic BP (blood pressure) was accurately monitored as ordered by the physician. This failure had the potential to negatively affect Resident 1's health and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure injuries (localized area of skin damage and underlying tissues caused by prolonged pressure or shear forces) for two of three final sampled residents (Residents 7 and 37). * The facility failed to ensure Resident 7's low air loss (LAL) mattress setting was set for the resident's weight. * The facility failed to ensure Resident 37's LAL mattress unit was not on the statique mode and failed to ensure the LAL mattress setting was appropriate for Resident 37's weight. Additionally, the facility failed to ensure Resident 37's heel protectors were in place as per the resident's care plan. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided to prevent the decline in the ROM functions for one of two final sampled resident (Resident 61) reviewed for ROM functions. * The facility failed to ensure the RNA services were provided as ordered by the physician for Resident 61. This failure had the potential for decline in the residents' ROM functions and mobility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure five of five final sampled residents (Residents 16, 47, 96, 108, and 158) and one nonsampled resident (Resident 115) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Resident 16 was administered the continuous oxygen at two liters per minute via the nasal cannula as per the physician's order. * The facility failed to ensure Resident 47 was administered with oxygen as ordered by the physician. * The facility failed to ensure Resident 96's oxygen tubing was not touching the trash bin at the bedside. In addition, the facility failed to ensure the nebulizer mask and tubing were labeled, dated, and not touching the floor. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for two of two final sampled residents (Residents 8 and 58). * The facility failed to ensure Resident 8's physician's order for 1000 ml fluid restriction was followed and carried out accordingly. * The facility failed to ensure Resident 58's physician's order for 1500 ml fluid restriction was followed and carried out accordingly. In addition, the facility failed to monitor the resident's fluid intake accurately. These failures had the potential for the residents not being provided with the appropriate care and treatment, and the possibility of medical complications related to dialysis.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of four final sampled residents (Residents 10 and 130) reviewed for grab bar use remained free from accident hazards associated with the use of elevated grab bars. *The facility failed to ensure the less restrictive interventions were used prior to the installation of the grab bars for Residents 10 and 130. This failure had the potential to put the residents at risk for entrapment and serious injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for four of 33 final sampled residents (Residents 8, 37, 58, and 174) to ensure the accurate administration of the medications. * The facility failed to ensure the accurate documentation of the controlled medications for Resident 174. This failure posed the risk of diversion of controlled medications and medication administration errors. * The facility failed to ensure Resident 8, 37, and 58's insulin injection sites were rotated. These failures had the potential to negatively affect the residents' health conditions and posed the risk for possible complications.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of five residents (Resident 1) reviewed for unnecessary medications were properly monitored for the signs and symptoms of bleeding related to the use of anticoagulant (prevents blood clots) medication. * The facility failed to ensure Resident 1 was monitored for the signs and symptoms of bleeding for the use of heparin (anticoagulant medication) medication. This failure had the potential for the resident to develop significant side effect of bleeding and negatively affect the resident's health condition and well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications. * The facility stored the tuberculin (used in a skin test to help diagnose tuberculosis (TB) infection in persons at increased risk of developing active disease) solutions past the 30 days from the time it was opened. * The tuberculin solutions stored in the refrigerator in Medication Room A and B were not labeled with an open date. * A container of Super Sani Cloth Wipes was observed with faded expiration date inside Medication Room A * Resident 1's ice cream was stored inside the medication refrigerator in Medication Room A. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 166 residents who received food from the kitchen during the dining observation received the appropriate diet as ordered by the physician. * The facility failed to ensure Resident 132 was served the super soup with lunch as ordered by the physician. This failure posed the risk of the resident's nutritional needs not being met.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * The line listings for May and June 2025 which documented residents who received antibiotics and were listed as not meeting McGeer's Criteria were inaccurately reported during the Infection Control Committee meeting. In addition, a resident with an MDRO (Multidrug-Resistant Organism) infection was not accurately documented in the report. In addition, the facility failed to identify, track and monitor infections in the facility from January to April 2025. * There was no documented evidence of recommendations to address the high incidence of of E. Coli and proetues miraabilis. [...]

Inspectors wroteBased on interview, medical record, facility document review, and facility P&P review, the facility failed to implement the facility's antibiotic stewardship program. * The facility failed to ensure the residents' physicians were informed when the residents who received antibiotics (Residents 190 and 191) did not meet the McGeer's Criteria, as documented for May 2025 line listing. In addition, the facility failed to follow-up on the urine laboratory results for one sampled resident (Resident 37) and one nonsampled resident (Resident 28), as documented for June 2025 line listing to determine if the antibiotic use met the McGeer's criteria. This failure had the potential for inaccurately identifying for true infections and potentially inhibiting the residents' physicians from discontinuing unnecessary antibiotic treatments.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete for three of four final sampled residents (Residents 8, 72, and 130) reviewed for the grab bar use. * The facility failed to ensure the entrapment assessments of the grab bars were accurate and complete for Residents 8, 72, and 130. In addition, the quarterly entrapment assessments were not completed for the listed residents. This failure had the potential to negatively impact the residents, resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain and maintain a copy of the advance directives (a legal document stating a person's wishes about receiving medical care if the person is no longer able to make medical decisions) for one of two final sampled resident (Resident 61) reviewed for advance directives. * The facility failed to obtain a copy of Resident 61's advance directives. This failure had the potential for the resident's decisions regarding their healthcare and treatment options not to be honored.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medical record was safeguarded to protect the confidential health information of the residents for one of eight medication carts (Medication Cart A). * The facility failed to ensure the computer monitor for Medication Cart A, which showed resident information, was not left unattended. This failure had the potential for the residents' personal and health information to be accessed by the unauthorized users.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for two of 33 final sampled residents (Residents 8 and 42) were revised to reflect the residents' current care needs and interventions. * Resident 8's plan of care for dialysis site was not revised to address Resident 8's change of condition dated 8/11/25, to show the dialysis site was noted with green discharge. * Resident 42's care plan for respiratory problem was not revised to address the resident's shortness of breath condition and use of the oxygen. These failures posed the risk of not providing the residents with individualized and person-centered care.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in two of three garbage dumpsters. * Two of three garbage dumpsters were observed overfilled with trash, causing the lids to not fully close. This failure had the potential to attract pests/rodents that carry diseases.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following:1. Active involvement of required individuals in developing the Facility Assessment;2. A plan to maximize recruitment and retention of direct care staff; and3. A contingency plan for staffing needs. This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for three of 33 final sampled residents (Residents 3, 169 and 174) were accurate. * The facility failed to ensure Resident 3's physician's orders for tube feeding specified a start time. * The facility failed to ensure Resident 169's RNA documentation was coded accurately. * The facility failed to ensure Resident 174's MAR was accurate. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident received the treatments and services in accordance with the professional standards of practice when one of five sampled residents (Resident 1) did not receive the wound treatments and medications as ordered by the physician. In addition, the facility failed to notify the physician of the missed medication administrations. These failures had the potential to result in negative health outcomes to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 10 sampled residents (Resident 5) remained free from the accident hazards. The facility failed to implement the floor mat as per the physician's orders and plan of care. This failure had the potential to place Resident 5 at risk for serious injuries.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one of 10 sampled residents (Resident 6). * The facility failed to conduct the complete pain assessment for Resident 6 prior to the administration of pain medication. In addition, the facility failed to follow the physician's order regarding pain management for Resident 6. These failures put the resident at risk for the resident's pain being improperly managed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for two of 10 sampled residents (Residents 4 and 6) were accurate. * The facility failed to ensure Resident 4's Fall Risk Assessments and Neurological Assessments were completed accurately after Resident 4 had a fall. Additionally, the facility failed to ensure Resident 4's Change in Condition evaluations were completed accurately. * The facility failed to ensure Resident 6's TAR was complete. These failures had the potential for Residents 4 and 6's care needs not being met as their medical information were inaccurate.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record was complete and accurately documented for one of nine sample residents (Resident 1). * The facility failed to ensure the documentation on the TAR for Resident 1 was complete and accurate. This failure had the potential for the resident's care needs not being met as the medical record was incomplete.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the reasonable accommodations to meet the care needs for one of 10 sampled residents (Resident 7). * The facility failed to ensure Residents 7's call light was kept within the resident's reach. This failure had the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care and services to the resident.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report the allegation of staff-to-resident abuse timely as per the facility's P&P for one of 10 sampled residents (Resident 4). This failure had the potential for a resident abuse not being identified and reported at a facility with a highly vulnerable resident population and posed the risk of continued abuse of the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for oneof 10 sampled residents (Resident 8) to help attain and maintain their highest practicable physical well-being. * The facility failed to notify the physician of the resident's three-pound weight loss in one week as care planned. This failure had the potential to negatively affect the resident's health and well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment were implemented. *CNA 3 failed to perform hand hygiene after removing his gloves. This failure posed the risk of the development and transmission of infections in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the need for one of nine sampled residents (Resident 3). * The facility failed to ensure Resident 3's scheduled medications for the morning shift were administered within 60 minutes of the scheduled time as per the facility's P&P. This failure had the potential to negatively impact Resident 3's health outcomes.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain a clean AC unit for one sampled resident (Resident 6) and one nonsampled resident (Resident C). This failure had the potential to negatively affect the residents' health and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 5) was properly discharged from the facility. This failure had the potential to place Resident 5 at risk for not receiving proper care while at home.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 5) was free from the unnecessary drugs. * Resident 5 was administered oxycodone-acetaminophen oral tablet 10-325 mg (narcotic pain medication to manage pain) when Resident's 5 pain level was below the ordered parameters to administer the medication. This failure had the potential for Resident 5 to receive unnecessary medication and experience adverse effects from the medication.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure the facility's four of four dryers and two of 35 final sampled residents (Residents 13 and 87) were free from accident hazards. * The facility failed to ensure the lint screen on all four dryers were brushed and cleaned after every load or every hour per the facility's P&P. In addition, the facility failed to ensure there were no exposed foam in one dryer causing the lint to stick to the foam, and the lint was not removed thoroughly. These failures had the risk for causing fire in the facility. * The facility failed to provide one to one feeding and supervision with meals for Resident 13 and failed to ensure Resident 13 was not given whole pills. [...]

Inspectors wroteBased on observation, interview, facility document review and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: 1. Food stored in the walk-in refrigerator was not labeled or dated. Additionally, food requiring monitoring of cool down temperatures was not monitored. 2. The food contact surfaces were not clean or in a cleanable condition. 3. The hair restraints were not worn by two of 20 kitchen staff and two non-kitchen staff who entered the kitchen. 4. The water temperature of the manual ware washing sink was less than 110 degrees F. 5. The process for a two-compartment ware washing sink was not followed. 6. The mops was not stored in a sanitary condition. 7. The nonfood contact surfaces of kitchen were not clean. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection prevention control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. * The facility failed to maintain an accurate infection control surveillance program for July 2024. The facility conducted surveillance only on the residents who exhibited signs and symptoms of an infection and were prescribed antimicrobial medications. The facility failed to ensure the residents exhibited signs and symptoms of an infection but were not prescribed antimicrobial medications (including residents diagnosed with Candida Auris infection) were included in the facility's infection control surveillance log, and in the monthly infection surveillance report. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the facility's ice machines were maintained in proper working condition when: - One of two ice machine was not clean. - Two of two ice machines were not sanitized according to the manufacturer's instruction guide. - Two of two ice machines did not have backflow prevention. These failures posed the risk of equipment to not function properly, which could negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs for three sampled residents (Residents 13, 22, and 166) and three nonsampled residents (Residents 50, 77, and 109). * The facility failed to ensure Residents 50 and 77 were provided with assistance in a timely manner. * The facility failed to ensure Residents 109 and 166's call lights were answered in a timely manner. * The facility failed to ensure Residents 13, 22, and 50's call lights were within the resident's reach. These failures had the potential to negatively impact the residents' psychosocial well-being or result in a delay to provide care.

Inspectors wroteBased on interviews, medical record review, and facility P&P review, the facility failed to ensure the physician and resident's responsible party were notified of the significant unplanned weight loss for one of 35 final sampled residents (Resident 25). This failure resulted in a delay in the communication of Resident 25's significant unplanned weight to the physician and responsible party, which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure the discharge process was properly followed for one of three sampled residents (Resident 150) reviewed for transfer and discharge. * Resident 150's medical record failed to show the physician's documentation Resident 150 was ready for discharge. This failure had the potential for an unsafe discharge from the facility for the resident.

Inspectors wroteBased on interview and medical record review, the facility failed to accurately coded the MDS assessments for four of 35 final sampled residents reviewed for the MDS assessments (Residents 52, 66, 127, and 161). * Resident 52's three MDS assessments were coded incorrectly for the resident's weight. * Resident 66's MDS was coded incorrectly regarding the resident's two falls. * Resident 127's MDS was coded incorrectly for the PASRR Level II screening. * Resident 161's MDS was not coded for the use of the CPAP machine. These failures had the potential for not providing necessary care and services to meet the care needs for these residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the care plans for four of 35 final sampled residents (Residents 23, 73, 87, and 161) were developed and implemented. * The facility failed to develop a care plan for Humulin R insulin (medication used to lower blood sugar levels in the body) per sliding scale for Resident 87. * The facility failed to develop a care plan problem to address Resident 23's use of blood glucose (a simple sugar which is an important energy source in living organism) monitoring device. * The facility failed to develop a care plan problem to address Resident 161's use of CPAP machine at the bedside. * The facility failed to develope a care plan problem to address Resident 73's use of the following medications: Cymbalta, Insulin Lispro, Plavix, Seroquel, and Trazodone. [...]

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of 35 final sampled residents reviewed for care plans (Resident 46) was revised to reflect the residents' current care needs and interventions. * Resident 46's care plan for risk for aspiration and tube feeding intolerance was not revised to address the correct enteral feeding formula, free water, and infusing rate ordered. This failure posed the risk of not providing the resident with individualized and person-centered care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for four of 35 final sampled residents (Residents 13, 23, 120, and 122). * The facility failed to ensure Resident 13's pacemaker (a small device placed in the chest to control abnormal heartbeat) was monitored for complications related to his pacemaker and failed to ensure the information regarding Resident 13's pacemaker was in his medical record as per the facility's P&P. * The facility failed to ensure a physician's order was obtained, the assessment was completed, and the appropriate instructions were obtained to maintain the appropriate care of a blood glucose monitoring device for two final sampled residents (Residents 23 and 120). [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services related to pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) were provided for one of three final residents (Resident 13) reviewed for pressure injuries. * Resident 13's wound treatments was not performed as per the physician's orders. * The facility failed to ensure Resident 13's heels were offloaded (suspension of the heel in the air by placing pillows under the lower leg so as not to place pressure on the Achilles tendon and the heel to prevent or heal ulcers, wounds, and other conditions) as per the physician's order. These failures have the potential to delay Resident 13's wound healing.

Inspectors wroteBased on interview, medical record review, and P&P review, the facility failed to ensure the nutritional status was assessed per the facility's P&P for one of 35 final sampled residents (Resident 25.) This failure posed the risk of nutritional interventions not being implemented in a timely manner.

Inspectors wroteBased on interview, and medical record review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of one sampled resident (Resident 161) reviewed for IV care. * The facility failed to ensure a physician's order was obtained for the peripheral intravenous access sites rotation every 72 hours and as needed. This failure had the potential to delay the identification of intravenous complication of the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure seven of eight final sampled residents (Residents 1, 46, 53, 81, 107, 142, and 161) with respiratory orders were properly maintained and administered as ordered. * The facility failed to ensure Resident 1's oxygen tube was dated and labeled. * The facility failed to ensure Resident 81's CPAP mask had a storage bag. * The facility failed to ensure Resident 107 received oxygen as ordered, oxygen nasal cannula was properly labeled and had an oxygen storage bag. * The facility failed to ensure Resident 142's oxygen tubing was labeled, dated, and placed in a plastic bag when not in use. * The facility failed to ensure Resident 161 had a physician's order for CPAP use with a CPAP machine at the bedside. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management for two of three final sampled residents (Residents 13 and 824) reviewed for pain management. * The facility failed to accurately document monitoring of highest level of pain and failed to administer pain medication according to the physician's order for Resident 824. * The facility failed to administer pain medication according to the physicians' orders for Residents 13. These failures put Residents 13 and 824 at risk for ineffective pain management.

Inspectors wroteBased on interview, and medical record review, the facility failed to accurately administer the midodrine (for low blood pressure medication) medication during the dialysis (a process of removing excess water solutes and toxins from the blood in people whose kidneys can no longer perform these functions naturally) days for one of two sampled residents (Resident 128) reviewed for dialysis care. In addition, the facility failed to monitor the orthostatic hypotension (blood pressure drops when the resident was standing and sitting down) blood pressure accurately related to the hypotensive medication use. These failures posed the risk for medical complications for Resident 128 on the scheduled dialysis days.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the narcotic medication count matched the narcotic count sheet, disposed narcotic count sheets were signed by two license nurses, and the blood pressure medication for Resident 32 had monitoring parameters as evidence by: * The facility failed to ensure the narcotic medication count matched the narcotic count sheet for four out of 14 final nonsampled residents (Residents 43, A, B, and C). * The facility failed to ensure the disposed narcotic count sheets were signed by two license nurses as per the facility's P&P for one of 35 final sampled residents (Resident 128) and three of 14 final nonsampled residents (Residents 76, 165, and 475). [...]

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to act upon the Consultant Pharmacist's recommendations timely for one of five residents reviewed for unnecessary medications (Resident 25.) * Resident 25's Consultant Pharmacist's recommendations were not followed up on timely for June and July 2024. This failure had the potential for not addressing the care needs for this resident.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure two of 35 final sampled residents (Residents 13 and 46) were free from unnecessary drugs. * Resident 46 was administered carvedilol (blood pressure medication) when the resident's blood pressure or heart rate was below the parameters prescribed by the physician. * Resident 13 was administered carvedilol (medication to treat high blood pressure) on numerous occasions when Resident13's systolic blood pressure was below the parameter prescribed the physician. These failures had the potential for the residents to receive unnecessary medications and develop significant side effects such as bradycardia (abnormally low heart rate) and/or hypotension (abnormally low blood pressure).

Inspectors wroteBased on interview and medical record review, the facility failed to ensure an appropriate diagnosis for the use of the psychotropic medication for one of five residents reviewed for unnecessary medications (Resident 25). * Resident 25's order for risperidone (an anti-psychotic medication) had an unapproved/inappropriate diagnosis. This failure had the risk of inappropriate psychotropic medication use for the resident.

Inspectors wroteBased on observation, interview, medical record review, and the facility P&P, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 6.06%. * The facility failed to ensure LVN 10 administered Resident 4's calcium-vitamin D3 600-12.5 mg-mcg (vitamin supplement) and sennosides 8.6 mg (stool softener medication) as ordered. This failure had the potential to cause negative outcome for Resident 4.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store the drugs, biologicals, and medical supplies in a safe manner as evidenced by the following: * The facility failed to ensure one of 14 medications for Resident 32 was not left unattended on top of the medication cart. * The facility failed to dispose of the expired medications inside Medication Room C. * The facility failed to ensure the oral and external medications were stored separately for Resident 159. * The facility failed to ensure the unlabeled medications were not kept in the medication cart, OTC medications were properly labeled with the date opened, and expired medications and opened medical supplies were properly disposed. * The facility failed to ensure the medication destruction container was not overfilled and properly disposed of medications and biologicals. [...]

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the DSS met the educational requirements for the position. This failure to employ staff with the skills and educational requirements to effectively implement departmental processes in accordance with standards of practice, had the potential to jeopardize the health and well-being of the 166 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure one of 20 kitchen employee (DA 1) was competent in the position related duties when the manual ware washing procedure was not followed. This failure had the potential for food preparation equipment, dishware and utensils to not be cleaned and sanitized correctly.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the menus were followed for the residents who consumed food provided by the kitchen. * The puree recipe was not followed for puree chicken. * There were no recipes for the daily soup. These deficient practices had the potential to place the residents at risk of compromised nutritional status as a result of the food not meeting their nutritional needs.

Inspectors wroteBased on observation, interview and facility P&P review, the facility failed to ensure the facility staff and resident visitors were educated on safe food handling practices when food from the outside was brought to the facility for resident consumption. This failure had the potential for unsafe food handling which could lead to food borne illness in the xx residents who resided in the facility.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to provide the necessary care and services for one of three residents (Resident 159) reviewed for hospice services. * The facility failed to ensure Resident 159's hospice record was included in the resident's medical record. Resident 159's hospice nurse and aide visit progress notes were not found in Resident 159's the medical record. This failure posed the risk for delay in communication between the hospice provider and facility which may affect Resident 159's care.

Inspectors wroteBased on interview, facility document review, and facility P&P review the facility failed to monitor and address the use of antibiotics when the resident's condition did not meet McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for one of 35 final sampled residents (Resident 136) and two nonsampled residents (Residents 12 and 142). This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.

Inspectors wroteBased on observation, interview and the facility's P&P review, the facility failed to ensure the call light system was functioning for one of 172 residents in the facility (Resident 128). This failure had the potential for a delay of the resident alerting the staff for assistance.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure a clean homelike environment for two of 35 final sampled residents (Residents 87 and 127). * Resident 127's room, Room A, had a piece of missing floor trim and cracked and missing drywall. * The facility failed to ensure Resident 87's curtains were free of dark red stains. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 13) was provided care in the manner that promoted dignity and respect. * The facility failed to ensure an effective communication with Resident 13 in a language understood by the resident. This failure had the potential to negatively impact the resident's emotional well-being, and a risk for not providing the appropriate treatment for Resident 13.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of 35 final sampled residents (Resident 13). * The facility failed to ensure Resident 13 was provided with his preferred activities in his primary language. This failure had the potential for Resident 13 to experience feelings of social isolation and depression.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure dietary texture guidelines were followed for one of 35 final sampled residents (Resident 13) who was on a pureed diet, and honey/ moderately thick liquid consistency. * The facility failed to ensure Resident 13 was served with a well mixed of honey/moderately-thick house shake. This failure had the potential to lead to choking or aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airway) for Resident 13.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the resident's rights for one of nine sampled residents (Resident 1) to be free from the verbal abuse by the facility staff (CNA 5). This failure had the potential to cause serious psychosocial harm to Resident 1.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when CNA 1 witnessed CNA 5 verbally abusive toward Resident 1 and failed to report it to the supervisor during her shift. This failure had the potential for delaying the assessment and provision of care for Resident 1 and not protecting the resident for further abuse.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of one of eight sampled residents (Resident 3). * The facility failed to ensure Resident 3's call light was within the resident's reach. This failure created the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care.

Inspectors wroteIntakes: CA00894957, CA00896581, CA00896799, CA00896945 Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the copy of the resident's medical record was provided upon request within two working days for one of eight sampled residents (Resident 2). * The facility provided Resident 2's medical records to the legal representative approximately 36 days after the initial request was received. This failure had the potential for violating Resident 2 and their legal representative rights to access their medical health information.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices were implemented as evidenced by: * Two of eight linen carts were left uncovered. * Employee personal belongings were in the clean linen folding area. * Two of eight linen carts had used and dirty items on top of them. * Resident E removed the towels from the linen cart and put them back into the linen cart. These failures had the potential for spread of infection.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the safe, sanitary, and comfortable environment was maintained when the heavily stained linens and towels were provided to the residents. This failure had the potential for unsanitary conditions and a negative effect on the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure one of the two sampled residents (Resident 1) was wearing an aspen collar when discharged to the acute care hospital. This had the potential to negatively affect resident's well-being and placed the resident at risk for further injury.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the call lights were answered in a timely manner forfive of 10 sampled residents (Residents 5, 6, 7, 8,and 10) * Residents 5, 6, 7, 8, and 10 expressed their concerns regarding the call lights not being answered in a timely manner. This failure had the potential for not providing the necessary care and services timely to meet the residents' care needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure the food preferences were honored for one of 10 sampled residents (Resident 7). * Resident 7 was served gravy with her meal when she disliked gravy. This had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 5) was provided social services to coordinate Resident 5's medical appointment with an outside provider. This failure resulted in Resident 5 missing her medical appointment and feeling frustrated.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to convey the remaining of trust fund to the responsible party within 30 days upon the death of the resident as per the facility's P&P for one of three sampled residents (Resident 3). This failure had the potential for loss of the resident's fund.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide written information regarding the rights to formulate the advance healthcare directives (legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) for 10 of 35 final sampled residents (Residents 28, 33, 34, 47, 48, 57, 64, 66, 127 and 146). This failure had the potential for the residents' decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the staff implemented the proper storage, labeling, and disposal of medications in a safe manner as evidenced by: * The facility failed to dispose of the expired medications in Medication Room A. * The facility failed to ensure an unopened insulin was stored properly when the unopened insulin was observed inside Medication Cart A. * The facility failed to dispose of the expired medications inside Medication Cart A. * The facility failed to ensure the medications administered orally were stored separately from the externally used medications in Medication Cart A. * The facility failed to ensure the medications administered orally were stored separately from the externally used medications in Medication Room C. [...]

Inspectors wroteBased on observation, interview, facility document review, facility P&P review, and manufacturer's instruction manual review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department. * [NAME] 1 was unable to demonstrate the correct procedure of the thermometer calibration. This had the potential for inaccurate food temperature readings and could lead to foodborne illnesses in a highly susceptible population of residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed. * The wrong scoop size was used to serve the mechanical soft pasta and chicken tenders. * The wrong scoop size was used to serve the chocolate cake. * The meal ticket for Resident 48 was not updated. Resident 48's meal ticket showed the resident was on 1800 cc fluid restriction. Resident 48's physician's order for the fluid restriction was discontinued on 2/17/23. These failures had the potential for the residents to not receive adequate nutrition and appropriate servings to meet their individual needs.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure proper labeling and dating of opened food items in the freezer. * The facility failed to ensure the proper labeling and dating of the foods in refrigerator was in placed for the residents' food brought in by visitors. In addition, the facility failed to ensure the food items were discarded after 72 hours. * The facility failed to ensure the proper storage of the employees' belongings in the kitchen was being observed by the staff. * The facility failed to ensure the use of hair restraints was implemented by the dietary staff working in the kitchen. * The facility failed to ensure the plate warmer and egg slicer were clean. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for all 25 residents with grab rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to properly obtain the informed consents (permission granted in the knowledge of the possible consequences) for the use of psychotropic medications (medications affecting brain activity) and treatments from the responsible party (person designated to make decisions on behalf of the residents) for two of 35 final sampled residents (Residents 70 and 136). This failure posed the risk for Residents 70 and 136 and their responsible parties to not be informed of their medications and the potential side effects.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 28) and three nonsampled residents (Residents 52, 65, and 117) were assessed to determine if it was safe for them to self-administer their medications prior to self adminisering their medications. This failure had the potential for the medication interactions and inappropriate use of medications. * The medication tube labeled zinc oxide (medicated cream/ointment) and medication cup filled with white cream were observed at Resident 28's bedside table. * A bottle of calcium carbonate (antacid) was observed at Resident 52's bedside table. Resident 52's family member brought the calcium carbonate for the resident. Resident 52 was not assessed for self-administration of medications. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the care needs for five of 35 final sampled residents (Residents 57, 66, 91, 135, and 682). * The facility failed to ensure Resident 682's bed was adjusted to a preferred height to transfer from bed to wheelchair and vice versa with assistance. * The facility failed to ensure Residents 57's call light was answered in a timely manner. * The facility failed to ensure Residents 66, 91, and 135's call lights were within the residents' reach. These failures had the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care and services to the residents.

Inspectors wroteBased on interview, facility P&P review, and facility document review, the facility failed to address the concerns [NAME] forth in the resident council meetings (a group of residents gathered to discuss interest and issues noted in the facility) and failed to notify the residents (Residents 16, 55, 78, 328, and 682) who filed the grievances regarding the outcomes of investigation. These failures had the potential for the residents' identified issues to go uncorrected.

Inspectors wroteBased on observation, interview, document review, and facility P&P review, the facility failed to ensure the residents' medical records were safeguarded to protect the confidential health information for five nonsampled residents (Residents 14, 26, 39, 119, and 125) and one closed record sampled resident (Resident 112). This failure had the potential for the residents' personal and health information to be accessed from the unauthorized users.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to thoroughly investigate the allegations of abuse made by two of the 35 final sampled residents (Resident 38 and 153). * The facility failed to thoroughly investigate Resident 38's allegation of abuse. This failure put Resident 38 at risk of not being protected against the alleged abuse and and other vulnerable residents at risk for abuse. * The facility failed to ensure the allegation of abuse made by Resident 153 was thoroughly investigated. This failure had the potential to put Resident 153 and other vulnerable residents at risk for abuse.

Inspectors wroteBased on interview, medical record review, and the facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for four of 35 final sampled residents (Residents 137, 478, 680, and 682). * The facility failed to develop a care plan problem for Resident 137's use of psychotropic medication and Resident 478's use of antibiotic medication. * The facility failed to develop a care plan problem to address Resident 680's infections. * The facility failed to ensure Resident 682's activities care plan problem address her impaired vision and preference of large print reading materials. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive plans of care for one of 35 final sampled residents (Resident 66) was revised to reflect the residents' current care needs and interventions. The facility failed to ensure Resident 66's plan of care was revised to address Resident 66's continuous oxygen use. This posed the risk of not providing Resident 66 with individualized and person-centered care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide an ongoing in activity program to meet the needs and interests of four of 35 final sampled residents (Residents 47, 77, 153, and 682). This failure had the potential to affect the residents' psychosocial well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for five of 35 final sampled Residents (Residents 40, 66, 91, 127, and 153). * The facility failed to ensure Resident 153's physician's orders to place the neck brace at all times and keep the knee immobilizer in place were discontinued. This failure had the potential risk of not providing appropriate care for Resident 153. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for two nonsampled residents (Residents 92 and 127). * Resident 127 had the right hip surgery with the immobilizer to the right knee. There was no revision of plan of care to address the use of immobilizer. There was no call, don't fall sign posted as per the care plan problem. * The facility failed to ensure Residents 92's bed was left in a low position and fall prevention mattress were in place as per the resident's care plan. These failures put the residents at high risk for falls and serious injuries.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the indwelling urinary catheter (tube placed in the bladder to drain urine) care to one of 35 final sampled residents (Resident 70) as ordered by the physician. This failure posed the risk of infection.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for two of 35 sampled residents (Residents 31 and 478). In addition, the facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record for Residents 31 and 478. These failures had the potential to delay the identification of catheter related complications for these residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure seven of 35 final sampled residents (Residents 31, 37, 49, 64, 66, 478, and 685) and one nonsampled resident (Resident 688) were provided with the appropriate respiratory care when: * The facility failed to ensure Resident 685's oxygen nasal cannula tubing was labeled and dated as per the physician's order. * The facility failed to ensure Resident 688 had a physician's order for administration of oxygen and oxygen nasal cannula tubing was labeled and dated. * The facility failed to ensure Residents 31 and 478's nasal cannula (flexible tube to deliver oxygen into the nose) tubings were dated as per the facility's P&P. *The facility failed to provide Resident 66 with continuous oxygen as per the physician's order. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for three of 35 final sampled residents (Residents 34, 146, and 682). * The facility failed to ensure the physician's order for 1000 ml fluid restriction (a diet which limits the amount of daily fluid consumption) was followed and carried out accordingly for Resident 682. * The facility failed to ensure the physician's order for 1500 ml fluid restriction was followed and carried out accordingly for Residents 34 and 146. These failures had the potential for medical complications related to not following the physician's order for fluid restriction.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to complete the assessments, attempt the least restrictive alternative measures, and obtain the physician's orders and informed consents prior to the use of side rails for three of 35 final sampled residents (Residents 64, 66, and 146). This failure had the potential to put the residents at risk for serious injuries.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for one nonsampled resident (Resident 18). In addtion, the facility failed to ensure the emergency kit for oral medications was replaced in a timely manner, creating the risk for not having a medication available in case of emergency. * The facility failed to ensure Resident 18's hydrocodone-acetaminophen (narcotic pain medication) was accurately reconciled. The hydrocodone-acetaminophen tablets removed showing on the Antibiotic or Controlled Drug Record did not match the electronic MAR as administered to Resident 18. This failure had the possibility of diversion of controlled medications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations from drug regimen review were acted upon for three of 35 final sampled residents (Residents 66, 96, and 127). * The Pharmacy Consultant's recommendation to verify the diagnosis for the prescribed Depakote (anticonvulsant medication used to treat mania associated with bipolar disorder, seizures, and migraine headache) medication for Resident 66 was not acted upon. * The Pharmacy Consultant's recommendation to change the instruction for the lactulose (laxative) medication administration for Resident 127 was not acted upon. * The facility failed to ensure the drug regimen review recommendations in July and August 2023 were acted upon for Resident 96. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 35 final sampled residents (Resident 53) was free from the unnecessary drugs. * Resident 53 was administered carvedilol (medication to treat high blood pressure) on numerous occasions when Resident 35's heart rate was below the parameter prescribed the physician. This failure had the potential for Resident 35 to develop significant side effects such as bradycardia (slower than normal heart rate).

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure five of 35 final sampled residents (Residents 64, 66, 70, 136, and 137) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * Resident 136 had an order for Risperdal (antipsychotic medication). The facility failed to ensure Resident 136's physician's order for Risperdal had a proper diagnosis. In addition, the facility failed to ensure Resident 136's monthly behavior summary was completed for the use of Lexapro (medication used to treat depression) and Risperdal. * The facility failed to ensure Resident 70's monthly behavior summary was completed for the use of bupropion (medication used to treat depression) and Remeron (medication used to treat depression). [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 30.77%. Two of two licensed nurses (LVNs 13 and 14) were found to have made errors during the medication administration to two nonsampled residents (Residents 85 and 683). * LVN 14 failed to properly administer the eye drops and potassium chloride (mineral supplement used to treat or prevent low amounts of potassium in the blood) to Resident 683. In addition, Resident 683 received partial doses for four medications when residual of the medications were left over in the medication cups. * LVN 13 failed to ensure Resident 85's senna (medication used to treat constipation) tablet was administered as ordered. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 681) was free from a significant medication error. * The facility failed to ensure Resident 681 received dorzolamide-timolol eye drop (to treat glaucoma) as ordered by the physician on multiple occasions. This failure placed Resident 681 at risk for medical complications.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure one nonsampled resident (Resident 72) was provided with the prescribed therapeutic diet (correct liquid consistency). * Resident 72 was prescribed with pureed/level 4 with pudding extremely thick liquid consistency. Resident 72 was served with pureed with nectar mildly thick liquid consistency. This failure posed the risk of aspiration and resident's nutritional needs not being met.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the infection control practices were observed as evidenced by: * The facility failed to ensure the infection control practices were maintained in the facility's laundry room area when a food tray with traces of food was observed in the clean linen area. * During the medication administration observation, LVN 13 failed to properly disinfect the blood pressure equipment while obtaining the vital signs for Resident 85. In addition, LVN 13 failed to perform hand hygiene during the medication administration for Resident 85. * The facility failed to ensure Resident 141's transmission-based precaution physician's orders were accurate. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review the facility failed to monitor and address the use of antibiotics when the resident's condition did not meet McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for one of 35 final sampled residents (Resident 136) and two nonsampled residents (Residents 12 and 142). This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of 35 final sampled Residents (Residents 96 and 101) and one nonsampled resident (Resident 2) were assessed for the COVID-19 vaccination status, or offered the COVID-19 vaccine. This failure put the residents at risk for increased risk of infection and transmission of COVID-19.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the effective pest control program to prevent the presence of flies in the kitchen. This failure had the potential to lead to food-borne illnesses (illnesses caused by food contaminated with bacteria, viruses, parasites or toxins) in the facility residents who eat food prepared in the kitchen.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to send a copy of the notice of transfer/discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for one of three closed record sampled residents (Resident 112). This failure posed the risk of the LTC Ombudsman not being aware of the circumstances of the resident's transfer/discharge should an appeal be filed or requested by the resident or their representatives regarding the transfer.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS for one of 35 final sampled residents (Resident 136) was accurate. This posed the risk for the resident to not have an individualized plan of care based on the resident's specific needs.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food served was palatable. The chocolate cake was dry in texture. This had the potential for the residents to not eat the food served and could affect their nutritional status.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for two of the 35 final sample residents (Residents 49 and 127) were complete and accurate. * Resident 49's Pneumococcal Vaccination Consent and Influenza Vaccination Consent Forms were incomplete. * The facility failed to ensure accurate documentation for Resident 127 following a fall incident on 8/23/23. Resident 127 was documented to have been transferred to the acute care hospital emergency department on 8/23/23 at 0445 hours, but Resident 127 was actually transferred to the acute care hospital emergency department on 8/23/23 at 1610 hours. These failures had the potential for the resident's care needs not being met as the medical information was incomplete and inaccurate.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen equipment was maintained in a safe operating condition. * The facility failed to ensure Freezer #6 and the small reach-in freezer were free of ice buildup. This failure posed the risk of equipment to not function properly, which could negatively impact the residents' well-being.