Lakewood Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan to address one of three sampled residents' (Resident 1) behavior of ambulating (walking) unassisted. This deficient practice resulted in Resident 1 ambulating 127 feet (ft, a unit of measurement) and sustaining a right humeral head fracture (a break in the bone near the shoulder) and had the potential to result in Resident 1 sustaining additional injuries and falls. Cross Reference F689.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to a resident in the hallway while ambulating (walking) unassisted 127 feet (ft, a unit of measurement) and conduct a Fall Risk Evaluation accurately and completely for one of three sampled residents (Resident 1). These deficient practices resulted in Resident 1 sustaining a right humeral head fracture (a break in the bone near the shoulder). This deficient practice also had the potential to result in further falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' personal belongings were inventoried, tracked, and safeguarded upon receipt, in accordance with facility policy for one of three sampled residents (Resident 1). This deficient practice resulted in the facility's inability to account for Resident 1's radio headset.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was promptly notified and appropriate follow-up occurred for one out of three sampled residents (Resident 1) when licensed nursing staff was made aware of Resident 1's report of new onset pain and noted limited range of motion in Resident 1's left knee on 10/12/2025 (three days after Resident 1 exhibited a fall) but did not confirm receipt of physician notification on 1/24/2026 after Resident 1 complained of pain accompanied by a popping noise in her left knee. These failures had the potential to result in delayed diagnosis, delayed treatment, missed opportunity for diagnostic testing and specialty consultation, and delayed care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of three sampled resident's (Resident 1) pain was effectively assessed, reassessed, and managed when facility staff failed to ensure:Resident 1's complaint of pain and subsequent refusal of a therapy session were communicated to nursing staff for further assessment and intervention on 1/27/2026. A numerical pain reassessment was documented following the administration of pain medication to evaluate effectiveness throughout the month of January 2026. Resident 1's pain was reassessed and addressed after physical therapy sessions on 10/21/2025 and 10/22/2025, despite continued reports of pain that affected the resident's participation. Resident 1's complaint of new-onset of 10/10 pain was treated with ordered pain medication, including Tramadol (pain medication), on 10/28/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an At Risk for Fall Care Plan for one out of three sampled residents (Resident 1) when the facility failed to ensure Resident 1 was wearing appropriate footwear before Resident 1 fell on [DATE]. This failure placed Resident 1 at an increased risk for fall and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff did not use a blanket to tie one of three residents (Resident 1) to the bed, to prevent from falling. This failure had the potential to restrain the resident without a physician's order. This failure placed Resident 1 at risk of injury. This failure had the potential to negatively affect the resident's psychosocial and physical well-being when the resident could not move freely.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Ambulation (walking) which indicated to stand on the weakest side and a little behind during ambulation for one of two sampled residents (Resident 6). This deficient practice resulted in Resident 6 losing her balance and falling to the floor while ambulating to the restroom resulting in a laceration (cut) above the right eyebrow. Resident 6 was transferred to the general acute care hospital (GACH) and required sutures (thread used to sew up wounds to hold the tissue together for healing).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide range of motion ([ROM] full movement potential of a joint) services to one of six sampled residents (Resident 6) with position and mobility (ability to move) concerns after experiencing femoral neck fractures (break in the bone just beneath the rounded bone of the hip) to both hips on 6/6/2025 by failing to: 1. Clarify Resident 6's weight-bearing tolerance ([WB tolerance] amount of weight allowed to put on an injured or surgically repaired limb) and ROM parameters (extent of movement at a joint) to both legs after Resident 6's orthopedic physician's (branch of medicine dealing with the correction or prevention of deformities, disorders, or injuries of the bones and associated soft tissue) appointment on 9/17/2025.2. Provide ROM exercises to both of Resident 6's legs from 9/17/2025 to 12/4/2025.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to prevent a fall for four of 10 sampled residents (Resident 139, Resident 155, Resident 102, and Resident 164) when: 1. Certified Nursing Assistant (CNA) 4 failed to provide two-person assistance prior to providing care to Resident 139.2. CNA 4 failed to place the low-air-loss mattress (LALM, a specialized air mattress that constantly releases air to alternate pressure to shift weight) into static mode (no alternation in pressure), prior to providing care to Resident 139.3. Staff failed to apply a helmet to Resident 155 as ordered by her physician.4. Staff failed to ensure Resident 102 was adequately supervised while in possession of sharpened pencils.5. Smoking precautions were not implemented for Resident 164. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents, menu ticket and diet type report, containing protected health information ([PHI]- any health information that can be used to identify a specific individual which must remain confidential to prevent harmful consequences) were shredded prior to disposing in the waste container for 295 out of 295 residents. The facility also failed to ensure the privacy curtain was drawn for two of 35 sampled residents (Resident 178 and Resident 188). These deficient practices had the potential to violate 295 of 295 residents' rights for privacy and confidentiality of personal and medical records. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and monitor changes in condition, implement ordered and care-planned interventions, ensure timely administration of medications, and maintain accurate medical records for five of five sampled residents (Residents 18, 36, 130, 155, and 191). These deficient practices resulted in poor quality of care and had the potential to result in delayed identification and treatment of changes in skin condition, worsening of existing skin conditions, unnecessary discomfort, and adverse health outcomes for Residents 18, 36, 130, 155, and 191.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician's orders were followed for two of five sampled residents (Resident 18 and Resident 36). This deficient practice placed Residents 18 and 36 at risk for complications due to not receiving their medications, supplements, and not being monitored for signs and symptoms of COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove and separate from current residents' medications 14 discontinued orders for controlled substances (drugs that are regulated by the government because they can be abused or cause addiction) as required by the facility's policy and procedures (P&P), titled, Discontinued Medications and Controlled Medication Storage, affecting nine residents (Residents 24, 29, 45, 59, 63, 127, 237, 257, and 288) in three of five inspected medication carts ([Medcart] (West Station Medcart 1, [NAME] Station Medcart 2, and South Station Medcart 1). This deficient practices increased the risk that Residents 24, 29, 59, 63, 127, 237, 257, and 288, may have received controlled medications without physician orders, more often than prescribed possibly resulting in serious health complications, hospitalization. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and demonstrated competency skills when: a. [NAME] 2 did not follow the recipe when preparing puree (foods that are smooth and pudding like consistency) stir fry vegetables. b. [NAME] 1 did not prepare soft-bite size chopped (foods that can be mashed or broken down with pressure from fork, spoon or chopstick and bite-sized pieces no larger than 1.5 cm [cm., unit of measurement]) stir-fry vegetables in the right size. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved appearance and temperature for lunch when: 1. Cinnamon apricot was at 64.9 degrees Fahrenheit ( F, a degree of temperature), country baked beans 103.1 F, roast beef melt on soft roll 104 F, lettuce and tomatoes 92.3 F for regular diet (diet with no restrictions) and soft bite sandwich at 113 F, beans at 110 F, onion soup 106.7 F and milk 47.3 F for soft bite-sized diet (food that are soft and chopped to 1.5 centimeters [cm, a unit of measurement]). 2. Plate presentation for double portion servings and extra food was overflowing and tortilla was touching the beans. 3. The soft bite sized stir-fried vegetables were mushy and mashed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in a form designed to meet individual needs for 38 of 295 residents on puree/IDDSI level 4 diet and 96 of 295 residents on soft bite-sized/IDDSI level 6 diet when: a. Residents on puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level four (4) received thick puree fried rice and thick Chinese roasted chicken and watery puree salad. b. Resident on IDDSI Level 6 Soft (foods that can be mashed or broken down with pressure from fork, spoon or chopstick and bite-sized pieces no larger than 1.5 cm [cm., unit of measurement]) in size for oral processing) and bite-sized stir-fried vegetables were not chopped into pieces no larger than 1.5 centimeters x 1.5 cm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety practices and sanitary food storage and food preparation practices when: 1. The refrigerator temperature log indicated temperature at 42 degrees Fahrenheit ( F, a scale of temperature) on 12/10/2025 and freezer temperature log indicated temperature of 10 F on 12/3/2025 and 12/10/2025. 2. Three (3) dented canned foods were stored alongside non-dented canned foods in the dry storage area. 3. The Dietary Supervisor's (DS) was wearing a spiral elastic bracelet touched the plates used in tray line (an area where foods were assembled from the steamtable to resident's plate). 4. Dietary Aide (DA) 1 wore a gold ring with rock while preparing and serving food in the tray line. 5. Ice machine gasket was torn. 6. Two (2) plastic food storage containers on the kitchen shelf had tape and sticker residues. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required room size measurement of 80 square feet ([sq. ft.])- a unit of measurement) of room space per resident in rooms with multiple residents. This deficient practice could potentially not provide residents with privacy and could potentially affect residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure translator services or a communication board were provided to two of three sampled residents (Resident 155 and Resident 159). This deficient practice prevented staff from being able to respect Resident 155's and 159's preference to communicate in their respective preferred languages, and to be aware of the care and treatments they were receiving. Cross reference: F-tag F941Findings: 1. During a review of Resident 155's admission Record, the admission Record indicated Resident 155 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 104) was able to exercise her choice to smoke. This deficient practice resulted in a missed or delayed smoking opportunity causing frustration for Resident 104, and had the potential to cause emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident shower rooms and restrooms were maintained in clean, sanitary, and homelike conditions when the grout in the showers and restrooms of Cottages 4, 5, 6, and 7 were observed to have a visible black to brown-colored substance and brown staining, and mosquitoes and gnats were observed along the shower walls, for two of eight sampled residents (Residents 48 and 74). This deficient practice resulted in the reports of discomfort and disgust by Residents 48 and 74, and had the potential to increase the risk of infection, discomfort and diminished quality of life for the residents residing in Cottages 4, 5, 6, and 7.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse for two out of eight sampled residents (Resident 110 and Resident 45) when the facility failed to ensure one-to-one supervision (a type of supervision that includes a nurse or qualified personnel to be present with a patient at all times to prevent harm) was rendered for Resident 45 who had documented episodes of impulsive, physically aggressive behaviors. This deficient practice resulted in Resident 45 punching Resident 110 on the right side of his nose while he slept at approximately 2:55 a.m. on 12/5/2025.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete an accurate Minimum Data Set (MDS, a resident assessment tool) assessment addressing the oral and/dental status for one of six sampled residents (Resident 72). This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 72's missing natural teeth and had the potential to negatively affect resident care plan and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized resident centered care plan addressing a language barrier and broken, missing teeth for two of 12 sampled residents (Resident 32 and Resident 13) This deficient practice had the potential for Residents 32 and 13 to not receive the care required for the residents to reach their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement dietary recommendations for one of three sampled residents (Resident 7) with nutrition concerns by failing to perform weekly weights and accurately document Resident 7's intake for lunch on 12/16/2025. This deficient practice had the potential to result in continued, unmonitored weight loss. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 11/12/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was less than five percent (%). Six medication errors out of a total of twenty-five opportunities contributed to an overall medication error rate of twenty-four percent (%), for one of seven sampled residents (Resident 53) observed for medication administration (med pass) on one of three nursing stations (East Station at Medication Cart 2) reviewed. The medication errors noted were as follows:1. Failure to assess Resident 53's heart rate (HR - how fast the heart beats, measured by taking the pulse, which is the throbbing of the arteries as blood is pushed through them) prior to administering the following medications: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven residents (Resident 53) was free of a significant medication errors. The facility failed to administer carvedilol (medication used to treat hypertension [HTN- high blood pressure]), furosemide (a diuretic medication that helps the body get rid of extra fluid by making the kidneys produce more urine), sacubitril-valsartan (medication used mainly for heart failure [when the heart is not pumping blood as well as it should]), and spironolactone (medication that helps the body get rid of extra fluid without losing too much potassium [a mineral in the blood that helps the heart beat normally, the muscles move, and the nerves work]) in accordance with physician's orders, with a parameter to check the heart rate (HR - how fast the heart beats, measured by taking the pulse, which is the throbbing of [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff transcribed the verbal order for Ativan (used to treat anxiety) for one of one sampled resident (Resident 64), who was on Hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility). This deficient practice placed Resident 64 at risk for not receiving the prescribed dose.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP - infection control measures required to reduce the risk of infection transmission to residents by limiting the spread of infectious organisms during high-contact care) for two of five sampled residents (Resident 300 and Resident 28). This deficient practice placed Resident 300 and Resident 28 at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a privacy curtain to assure full visual privacy for one of 35 sampled residents (Resident 188). This deficient practice had the potential for Resident 188 to be exposed during care. During a review of Resident 188's admission Record, the admission Record indicated Resident 188 was initially admitted to the facility on [DATE]. Resident 188's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), Type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) of multiple muscle sites including both ankles and knees. [...]

Inspectors wroteBased on observation and interview, the facility did not provide a working call light to one of eight sampled residents (Resident 240). This deficient practice had the potential to cause a delay or the inability in obtaining necessary care and services for Resident 240.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were aware of and/or trained on the location and/or use of the communication board and language translation line for residents with language barriers. This deficient practice had the potential to impede effective communication between staff and patients with limited English proficiency or communication barriers, which could result in unmet resident needs, delays in care, and compromised resident safety. Cross reference: F-tag F558Findings: 1. During an interview on 12/17/2025 at 10:25 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was not aware of any available translator services and stated she had never been trained to use translator services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident bedrooms accommodated no more than four residents in one out of 98 rooms (Room S4). This deficient practice could adversely affect the adequacy of space, nursing care, comfort, and privacy to the residents and their visitors residing in Room S4.

Inspectors wroteBased on interview and record review, the licensed nurse failed to document the monitoring of signs and symptoms of infection and the amount of urine output, for one of three residents (Resident 1), on the Medication Administration Record on two different shifts in the month of February 2025. This deficient practice had the potential to result in lack of communication between staff and delay and interrupt the provision of care needed to maintain the residents' highest practicable, physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan was developed or implemented for one out of three sampled residents (Resident 1) for oxygen administration (medical treatment that delivers oxygen at a concentration higher than room air). This deficient practice resulted in no care plan being created for Resident 1's oxygen administration, which could potentially cause a delay in care and negatively affect the delivery of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen safely for one out of three sampled residents (Resident 1) by failing to ensure: 1. Resident 1's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was dated with an open date; and2. Resident 1 received oxygen according to doctor's order. These deficient practices had the potential to cause Resident 1 to have lung damage and increased the risk for Resident 1 to develop a respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure non-pharmacological interventions (NPIs- treatments that do not involve medications) were documented prior to the administration of Ativan (antianxiety medication used to treat anxiety which is the feeling of fear, dread, and uneasiness) for one of six sampled Residents (Resident 5). This deficient practice had the potential to result in Resident 5's cause of anxiety induced behaviors being unaddressed being managed only with medication.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's order for one of three sampled residents (Resident 5), who had an order for one-to-one monitoring ([1:1] assigning a dedicated staff member to continuously observe and monitor a single resident to ensure their safety and well-being). This failure placed the resident at risk of not receiving the care and services necessary to maintain the residents' highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan intervention to document wandering behavior (a person wandering moving from one place to place without a clear or immediate purpose) for one of seven sampled residents (Resident 1). This deficient practice resulted in Resident 1 leaving the facility unnoticed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 1) did not elope (leave the facility unsupervised) by failing to:1. Conduct regular inspection of the facility's exterior gate.2. Document Resident 1's wandering behavior episode as indicated in the care plan. This deficient practice resulted in Resident 1 leaving the facility unnoticed on 7/14/2025.

Inspectors wroteBased on interview and record review, the facility failed to notify one of seven sampled residents' (Resident 6) Responsible Party (RP) 1 of Resident 6's abuse allegation with another resident. This deficient practice resulted in RP 1 being unaware of Resident 6's wellbeing and of the facility's interventions to keep Resident 6 safe.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled resident's (Resident 6) right to be free from physical abuse by another resident (Resident 7). This deficient practice had the potential for Resident 6 experiencing further abuse from Resident 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was treated with dignity and respect by Certified Nursing Assistant (CNA) 1 during care. This deficient practice resulted in Resident 3 feeling unvalued or respected and had the potential to negatively affect the resident's sense of self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to revise one of three sampled residents (Resident 2) comprehensive care plan and interventions after a new order from the neurologist (a medical doctor who specializes in the diagnoses, treatment of disorders affecting the brain, and nervous system) which indicated the resident should avoid smoking due to medical risks. This deficient practice had the potential to result in Resident 2's ineffective care, treatment and services which could lead to increased risk in the resident's medical condition due to continued smoking.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of three sampled residents (Resident 2) by failing to: 1. Ensure implementation of physician's orders for dental and podiatry services for Resident 2. 2. Clarify a neurologists' (a medical doctor who specializes in the diagnoses, treatment of disorders affecting the brain, and nervous system) order for drug testing for Resident 2. This deficient practice resulted in Resident 2 not receiving services and treatments as ordered by the physician and had the potential to place the resident at risk for unmanaged health concerns.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 17 sampled residents (Resident 1) who was confused with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), anxiety (a feeling of fear, dread, and uneasiness), hypertension (high blood pressure), and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), did not elope (leave the facility unsupervised) from the facility on 6/8/2025 by failing to: 1). Ensure Resident 1 ' s window was secured with a screw (an equipment used to secure the window) to prevent the resident from eloping on 6/8/2025. 2). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the physician's orders for one of six sampled residents (Resident 9), who had orders to administer Hydrocortisone cream (a medication used to reduce pain, itching, and swelling because of the body's immune response) for dermatitis (skin inflammation, causing redness, itching, blistering or scaling) and for a Dermatologist (physician who specializes in treating the skin) consultation. This failure had the potential to lead to worsening of Resident 9's skin condition and placed the resident at risk for discomfort and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment free of accident and hazards for two of the four sampled residents (Resident 1 and Resident 2), by failing to ensure: 1. Housekeeping (HK) did not leave Residents 1 and 2, who were cognitively impaired and at risk for falls, in the resident ' s room while the floor was wet, and the room was being deep cleaned. 2. HK did not leave a bottle of Clorox spray (powerful bleach-based cleaner) unattended in Resident 1 and 2 ' s room. These failures had the potential to cause Resident 1and Resident 2 to fall, be exposed to harsh cleaning agents which could result in injuries, hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to implement the comprehensive person-centered care plan to 1 of 3 residents, Resident 1, who requested for a female Certified Nursing Assistant (CNA) to provide care. This failure resulted in the resident ' s feelings of fear and anxiety of being abused.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan to include safety interventions for one of five sampled Residents (Resident 4) who was at high risk for fall and sustained falls at the facility on 4/3/2025 and 4/11/2025. This deficient practice had the potential to place Resident 4 at risk for further falls and injuries including fractures (broken bones).

Inspectors wroteBased on interview and record review, the facility failed to report injury of unknown origin (injuries not observed by any person or the source of the injury could not be explained by the resident) to the California Department of Public Health (CDPH), for one of seven sampled residents (Resident 7), who had bruise on right and left lower side of face and swollen left side of cheek. This failure resulted in a delay of investigation by the CDPH and placed Resident 7 at risk for further injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate skin care, adequate skin reassessment as indicated in the resident's care plan, were provided to one of seven sampled residents (Resident 6), who had generalized body dermatitis (condition of the skin in which it becomes red, swollen, itchy and sore, sometimes with small blisters and rashes) since 12/13/2024. This failure resulted in the resident ' s delayed, non-healing skin condition and had the potential to affect in maintaining the resident ' s highest practicable, physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from accident hazards by failing to consult with the Psychiatrist (a medical doctor who specializes in mental health) prior to going out on pass (OOP, temporary leave from the facility), according to its Policy and Procedure (P&P). This failure had the potential to negatively affect Resident 1 psychosocial well-being and cause harm or danger for the resident and others while OOP.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received medications as ordered by the physician by failing to: 1. Provide Resident 1's medications to the resident's Responsible Party (RP) to be given while the resident was Out on Pass (OOP, temporary leave from the facility), according to its Policy and Procedure (P&P). 2. Accurately document medication administration in Resident 1's Medical Records. These failures had the potential to result in worsening of Resident 1's symptoms or condition and lead to medication errors.

Inspectors wroteBased on interview and record review, the facility failed to notify, one of eight sampled residents (Resident 1) doctor, when the resident refused to receive dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) on 12/13/2024 and missed scheduled dialysis on 12/16/2024 and 12/20/2024. This failure resulted in the doctor not aware and not providing further orders for Resident 1 ' s treatment. This failure placed Resident 1 ' s health and safety at risk for medical complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to complete and send pre (before)-dialysis (a treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to) evaluation to the dialysis center, for one of eight sampled residents (Resident 1). This failure had the potential to cause lack of communication between the facility and the dialysis provider.

Inspectors wroteBased on interview and record review, the facility failed to document in the medical record, the assessment and interventions conducted to one of eight sampled residents (Resident 2), who complained of itchy scalp. This deficient practice had the potential to result in lack of communication among staff involved in the resident's care and the facility's failing to reassess the effectiveness of Resident 2 ' s scalp treatment.

Inspectors wroteBased on interview and record review, the facility failed to effectively notify both designated emergency contacts listed on a resident ' s admission Record for one out of three sampled residents (Resident 1) when the following occurred: 1) The licensed nurses did not attempt to contact Family Member (FM) 2 listed on Resident 1 ' s admission Record when Resident 1 exhibited a change of condition on 10/17/2024. 2) The licensed nurses did not contact Resident 1 ' s Responsible Party (RP- Family Member [FM] 1) on 10/17/2024 to obtain informed consent for a newly prescribed medication (hydroxyzine hydrochloride - a medication used to help control anxiety and tension caused by nervous and emotional conditions) for the management of Resident 1 ' s anxiety and aggressive behavior. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident slept on a pillow with a pillowcase for one out three sampled residents (Resident 1). This deficient practice had the potential to make Resident 1 feel less dignified and feel uncomfortable sleeping or resting in his own bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations for resident needs for five of 15 sampled residents (Residents 91, 196, 80, 156, and 255) by failing to ensure the call light (a device that residents use to request assistance from staff) was within reach at the bedside. This deficient practice had the potential to negatively impact the psychosocial well-being of Residents 91, 196, 80, 156, and 255 or result in delayed provision of care and services.

Inspectors wroteBased on observation, interview, and record review the facility did not provide a home like environment for two residents out of eight sampled residents (Resident 211 and 225) by not ensuring, 1. Resident 211 had a bedside table during mealtimes. 2. Resident 225 had a bedside table to use when coloring, and during mealtimes. These deficient practices did not provide dignity to Residents 211 and 225 and it did not provide comfort during mealtimes and activities.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan with interventions for three out of nine sampled residents (Residents 148, 15, and 274), by failing to: 1. Ensure an individualized care plan for oxygen administration and respiratory therapy was developed for Resident 148 and Resident 15. 2. Ensure an individualized care plan was developed addressing Resident 274's hand tremors. These deficient practices had the potential to negatively affect the delivery of oxygen therapy and interventions for Residents 148 and 15 and potentially delayed the care for Resident 274.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure low-air-loss mattresses ([LALM] a mattress that provides airflow to help keep skin dry, as well as to relieve pressure, and used to treat and prevent pressure ulcers [injuries to the skin and underlying tissue]) were inflated properly for five of 13 sampled residents (Resident 117, 133, 155, 206, and Resident 255) when: 1. Resident 155's LALM was inflated based on a weight of 350 pounds (Lbs., unit of weight). Resident 155 weighed 222.4 Lbs. on 9/15/2024. 2. Resident 206's LALM was inflated based on a weight of 320 Lbs. Resident 206 weighed 147.8 Lbs. on 9/4/2024. 3. Resident 255's LALM was inflated based on a weight of 350 Lbs. Resident 255 weighed 106.2 Lbs. on 9/4/2024. 4. Resident 133's LALM was inflated based on a weight of 200 Lbs. Resident 133 weighed 135 Lbs. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure quality Restorative Nursing Aide (RNA) services were provided, as ordered, for three out of eight sampled residents (Residents 132, 166 and 223) by failing to: 1. Ensure enough Certified Nursing Assistants (CNAs) were staffed to ensure RNAs would not be utilized to perform both CNA and RNA duties. 2. Ensure RNA documentation tasks were made accessible in the electronic medical record (EMR) to allow RNAs to review and document RNA services that were ordered. 3. Ensure RNA orders were performed, as ordered by the physician. These failures had the potential to cause a decline in the mobility and range of motion for Residents 166, 132, and 223.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and record the urine output from the indwelling catheter (a thin, hollow tube that is inserted into the bladder to drain urine) for two of two sampled residents (Residents 71 and 246). This deficient practice had the potential to cause undetected fluid overload (a condition where the body has too much water), or fluid deficit (occurs when the body loses more fluids than it takes in), and an undetected malfunction of the indwelling urinary catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 15 and Resident 148) received respiratory care consistent with professional standards of practice by failing to: 1. Ensure Resident 15 received oxygen as ordered. 2. Ensure the nasal cannula (a device used to deliver supplemental oxygen through the nose) tubing, oral suction device (a small plastic tube attached to a suction machine to remove saliva or mucus from the mouth), nebulizer (a device that turns the liquid medicine into a mist which is then inhaled) mask, and respiratory set-up bags (plastic bags used to store oxygen supplies) were changed after seven days. 3. Ensure there was signage indicating oxygen was in use outside of Resident 15 and 148's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 50) was administered medications in accordance with physician orders to meet the medical needs of the resident by failing to administer Resident 50's medications scheduled for 8 AM administration with a meal as ordered or too close to the next scheduled dose for: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%). Four medication errors out of 27 total opportunities contributed to an overall medication error rate of 14.81 % for one of five residents (Resident 50) observed during medication administration (MedPass). The facility failed to ensure Resident 50 was administered medications as order with meals, for metformin (used for diabetes [high blood sugar] to lower blood glucose/sugar) and naproxen (used for pain) and within an hour of the prescribed administration time for lactulose (prevent or relieve constipation) and lidocaine patch (for pain relief). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from significant medication error by administering carvedilol (medicine to treat high blood pressure) outside the parameter (specific instructions that you could measure) as ordered by the physician for one of 11 sampled residents (Resident 30). This deficient practice had the potential to cause complications of hypotension (low blood pressure, dizziness and fainting leading to falls) and low heart rate (leading to lose consciousness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three medication storage rooms, Advance Care (AC) Unit had a medication room thermometer, and failed to ensure THE refrigerator and room temperatures was properly monitored and maintained as indicated in the facility's policy and procedures (P&P), titled, Medication Storage in the Facility: Storage of Medications. This deficient practice had the potential to result in the loss of strength and integrity of stored medications, and the potential for residents on the AC Unit, requiring medications from the one of three medication storage rooms observed to receive deteriorated or ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff: a. Failed to follow puree diet recipes (texture-modified diet where all the foods have a soft pudding-like consistency). b. Failed to demonstrate and verbalized the process of testing Quaternary ammonium compounds ([Quat], group of chemicals used to disinfect and sanitize) sanitizer concentration. These deficient practices had a potential to result in inaccurate food texture, ineffective therapeutic diets, difficulty swallowing, chewing, eating and foodborne illnesses (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for 281 of 284 facility residents receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not the meet nutritional needs of residents receiving puree diets (diet consisting with soft, pudding like consistency foods) when the seasoned brown rice was runny and the fruit cup was watery. This deficient practice placed 23 of 284 facility residents receiving a puree diet at risk of difficulty in eating, chewing, swallowing and decrease food and nutrient intake resulting to unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when, the seasoned brown rice was too sticky, the rice grains were not separated, and the broccoli tasted bland without the sesame taste. This deficient practice placed 260 of 284 facility residents at risk of unplanned weight loss, a consequence of poor food intake, from food the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Four (4) of seven (7) racks in the walk-in refrigerator had cracks, chips, and rust. b. Walk-in freezer floor had dried ice cream drippings, two (2) axes on the floor, a bowl, and the walk-in freezer had ice buildup and torn door gaskets. c. Baking pans had burnt particles. d. Clear storage containers had blue tapes and tape residues and was not air dried prior to stacking. e. Chopping boards in the clean area had scratches and were sticky to touch. f. Three (3) dented cans were stored with non-dented cans. g. Internal parts of the ice machine in the kitchen had black dirt particles. h. Low temperature dishmachine by the preparation area was at 110 degrees Fahrenheit ([°F] a degree of temperature). i. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not maintaining the trash area free from trash, plastic, plastic cups, black garbage bags with trash on the floor and completely covering the dumpster (a large trash metal container designed to be emptied into a truck). This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to all 284 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection control practices were followed for four of eight sampled residents (Residents 62, 246, 132 and 155) by failing to: 1. Ensure Resident 62's oxygen nasal cannula (device used to deliver supplemental oxygen placed directly on the resident's nostrils) and nebulizer mask (nebulizer a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) were properly stored in plastic bag and dated as indicated in the facility's policy and procedure (P&P). 2. Ensure Resident 246's indwelling catheter (a tube that allows urine to drain from the bladder into a bag) drainage bag was not touching the floor. 3. Ensure Resident 155's oxygen tubing, nasal cannula, and humidifier were changed every seven (7) days and dated. 4. [...]

Inspectors wroteDuring an observation, interview, and record review the facility failed to meet the required room size measurement of 80 square feet ([sq. ft.]- a unit of measurement) of room space per resident in rooms with multiple residents. This deficient practice could potentially not provide residents privacy and could potentially affect residents' health and safety.

Inspectors wroteBased on interview and record review, the facility failed to verify the code status (a resident's instructions to a medical team about the type of treatment they want to receive in the event of a cardiac [heart] or respiratory [breathing] arrest) of a resident prior to initiating cardiopulmonary resuscitation (CPR- a lifesaving technique used in emergencies when a resident's breathing or heartbeat has stopped) for one out of one sampled resident (Resident 285). This deficient practice resulted in the administration of CPR and the utilization of an ambu bag (a medical tool which forces air into the lungs of patients who have either ceased breathing completely) for greater than ten minutes before paramedics took over and continued CPR. This deficient practice did not allow Resident 285 to pass comfortably during her last minutes of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the resident's responsible party (RP 1) when there was a room change for one of 11 sampled residents (Resident 101). This deficient practice violated RP 1's right to be promptly informed of changes.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure one of seven sampled residents (Resident 115) was free from an unnecessary restraint, as evidenced by: 1. Failing to ensure an appropriate assessment for less restrictive measures were done prior to placing Resident 115's bed against the wall. This deficient practice had the potential to inhibit Resident 115's freedom of movement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the comprehensive care plan intervention for one of 11 sampled resident (Resident 216), after Resident 216 kept wandering into other resident's rooms. This deficient practice had the potential to increase the likelihood of Resident 216 getting injured and harmed from another resident and was a violation of the other residents' privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used a communication board and/or interpreter services for one of seven sampled residents (Resident 262) who did not speak the predominant (most spoken or used language) language of the facility. This deficient practice had the potential to negatively affect Resident 262's physical, mental, and psychosocial needs by preventing the resident from communicating with staff and potentially causing missed or delayed care and treatments.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of eight sampled resident's (Resident 117) blood sugar level was checked prior to administering Glipizide (blood sugar lowering medication). This deficient practice resulted had the potential for adverse reactions for Resident 117, including blood sugar levels that were too high or too low, and could possibly lead to complications including nerve damage, eye disease, kidney disease, heart and blood vessel disease, coma, and hypoglycemia (low blood sugar).

Inspectors wroteBased on interview and record review, the facility failed to ensure an order for Ativan (a medication used for anxiety- a feeling of fear, dread, or uneasiness) was limited to a 14-day duration for one of 11 sampled residents (Resident 140). This deficient practice had the potential to result in unnecessary or prolonged use of Ativan that could lead to Residents 140 experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to the medication therapy and may cause impairment or decline in mental, physical condition, functional, and/or psychosocial status of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident bedrooms accommodated no more than four residents in one out of 88 rooms (Room A). This deficient practice could adversely affect the adequacy of space, nursing care, comfort, and privacy to the residents and their visitors residing in Room A.

Inspectors wroteBased on interview and record review, the facility failed to obtain lithium (a chemical compound found in certain mood stabilizing drugs) blood levels for three months for one out of seven sampled residents (Resident 4), as ordered by the physician. This deficient practice resulted in Resident 4 ' s lithium blood levels to remain unmonitored for three months, which increased the potential for Resident 4 ' s lithium medication to remain subtherapeutic (ineffective). This also increased the potential for Resident 4's behavior disorders to be left untreated, increased the likelihood of Resident 4 to be involved in resident-to-resident altercations, exhibit increased agitation and aggression, and had the potential to lead to undetected lithium toxicity (occurs when too much lithium is found in the blood).

Inspectors wroteBased on interview and record review, the facility failed to document the findings related to a change of condition (COC) for three of four sampled residents (Resident 1, Resident 2, and Resident 4). This deficient practice had the potential to result in serious harm such as another episode of aggression towards others, and a delay of necessary treatments.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from significant medication error by administering carvedilol (medicine to treat high blood pressure) outside the parameter (specific instructions that you could measure) as ordered by the physician for one of four sample residents (Resident 5). This deficient practice had the potential to cause complications of hypotension (low blood pressure, dizziness and fainting leading to falls) and low heart rate (leading to lose consciousness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA 4) did not grab Resident 8 ' s left arm and push the resident to the floor, after Resident 8 refused to have his blood pressure checked by CNA 4. This deficient practice caused Resident 8 to sustain a left hip fracture (broken bone), admitted to a General Acute Care Hospital (GACH), and a had a hemiarthroplasty (surgical procedure that replaces half of the hip joint with an artificial surface) of the left hip and is still in the hospital awaiting discharge to another facility. Cross Reference F610.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to report an allegation of resident-to-resident sexual abuse, for one of two sampled residents (Resident 1), after being made aware of the allegation on 7/30/2024 at 12:53 PM. This deficient practice had the potential to cause a delay in the notification of necessary State and local agencies and the timeliness of their investigations. The failure also increased the potential for additional resident-to-resident sexual abuse incidents to occur.

Inspectors wroteBased on observation, interview and record review, facility staff failed to follow their policy and procedure (P&P) titled Abuse Reporting and Investigations , dated 1/2024, following an allegation of resident-to-resident sexual abuse, for one of two sampled residents (Resident 1), after being made aware of the allegation on 7/30/2024 at 12:53 PM; and thoroughly investigate a fall with injury for one of three sampled residents (Resident 8), who was actually physically assulted by Certified Nursing Assistant (CNA) 4 on 7/28/2024. This failure increased the potential for additional resident-to-resident sexual abuse incidents to occur as the alleged perpetrator remained in the room directly across the hall from Resident 1 until the day after the allegation was made, and also caused Resident 1 to report feeling unsafe in her room and unable to sleep. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that quality of care was maintained for two of 11 sampled residents (Resident 4 and Resident 6) when the following occurred: a. Facility staff failed to provide teaching to Resident 6's Responsible Party (RP) 1 about Resident 6's physician orders to immobilize and not put weight on Resident 6's right hip, prior to Resident 6 leaving the facility with RP 1 for the day. b. Facility staff failed to follow their facility protocol prior to allowing Resident 6 to leave the facility with a visitor. 2. Facility staff failed to provide Resident 4 with a splint (a strip of rigid material used for supporting and immobilizing a broken bone), as ordered by the physician, for her ulnar fracture (a broken bone in the forearm). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall mats and non-skid footwear were implemented, as indicated in the care plan, for one of two sampled residents (Resident 4). This deficient practice had to the potential to result in an avoidable repeat fall incident, and a worsening of Resident 4's existing ulnar fracture (a broken bone in the forearm) or the occurrence of a new injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely update of the care plan when three residents (RES6, RES7, and RES8) were exposed to Candida Auris. This failure resulted in staff not knowing the appropriate interventions to implement to provide care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate contact isolation precautions (action to prevent the spread of germs) for three residents (RES6, RES7, and RES8) known to have been in contact with Candida Auris (type of yeast that causes illness). This failure had the potential to result in Candida Auris being spread to other residents in the Special Care Unit.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Follow its policy and procedure (P&P), titled, Abuse-Prevention, Screening, and Training Program, dated 7/2018, which indicated facility did not condone any form of resident abuse or neglect for one of three residents (Resident 12). As a result, this violation delayed the investigation by the State agency and placed Resident 12 and other residents at risk of abuse.

Inspectors wroteBased on interview, and record review, the facility failed to ensure adequate number of staffs were present to supervise the 12 of 12 residents who were in the patio. This deficient practice resulted in Resident 1 physically assaulting Resident 2, and Resident 1 sustaining laceration on his forehead that required treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, one of 12 residents (Resident 11), was provided dignity and privacy, by failing to put on resident's clothing, provide privacy curtains and bed linens while on bed. This deficient practice had the potential to negatively affect Resident 11's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the unusual occurrence of employee to resident altercation to the State Survey Agency within 24 hours after the allegation occurred for one of twelve residents (Resident 12). This deficient practice placed the resident at risk for further abuse, feelings of intimidation and neglect.

Inspectors wroteBased on interview and record review, the facility failed to report within two (2) hours, resident to resident allegation of physical abuse (Resident 8 hitting Resident 7 on the head and face) to the Department of Public Health, Licensing and Certification unit (CDPH), for one of three sampled residents, Resident 7. This failure resulted in the delay of investigation by the Department of Public Health, and had the potential for the abuse to continue, and cause resident further physical and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to prevent one of three sampled residents (Resident 1) from leaving the facility when the Dietary Aide (DA) allowed Resident 1 to exit a locked door without the DA identifying the resident first. As a result of this deficient practice, Resident 1 left the facility and had the potential to be harmed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Walk-in freezer pipe had ice buildup and freezer floors with food and dirt debris. b. Mixer attachments were found with dry food debris and food residue. c. Clean area for tray drying were cross-contaminated (transfer of harmful bacteria from one place to another) by wet food residue. d. Dry storage area for coffee and other food items by the tray line area (area for food assembly) was dusty and personal items such as bags were stored. e. Microwave had food debris. f. Clean pots and pans were not air dried and stacked wet. Food Service worker was using towel to wipe off the wet pots and pans. g. Scoops were stored with the handle not facing in one direction. h. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse (nonhazardous disposable materials) properly by: a. Not covering the dumpster (a large trash container designed to be emptied into a truck) while waiting for trash to be picked up by the garbage truck. b. Not maintaining the garbage storage area free from debris and free of foul odors. This deficient practice attracted flies to the dumpster area, and flies were observed in the kitchen placing two eighty-seven (287) of 287 facility residents receiving food from the kitchen at potential risk of cross-contamination (a transfer of harmful bacteria from one place to another).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that three of six sampled residents' belongings were appropriately stored and accounted for per facility policy (Resident 60, 100, and 242). This deficiency had the potential for avoidable theft and loss of the residents' personal property, and to negatively affect the residents' psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device was within reach for four of 48 residents residing on the East and [NAME] Unit of the facility (Resident 5, Resident 262, Resident 226, and Resident 237). This had the potential to result in a delay in or in an inability for the residents to obtain necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its Policy and Procedure (P&P) to report allegations of abuse to the State Agency within two hours for four of eight sampled residents (Resident 107, Resident 159, Resident 165, and Resident 288) when: a. Resident 107 reported that Resident 159 hit her in the face with a water pitcher. b. Resident 165 reported that Resident 288 pushed her out of her wheelchair. This deficient practice had the potential to result in a delay for the State Agency to investigate the allegation of abuse and continued abuse for Residents 107 and 165. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent further potential abuse or mistreatment of 2 of 45 residents (Resident 107 and 100) residing in the unit when the following occurred: a. Facility staff failed to investigate an alleged physical altercation where Resident 159 hit Resident 107's face with a water pitcher. b. Facility staff failed to document a change of condition for, or update the care plan for, Resident 41 following an alleged physical altercation where Resident 41 hit Resident 100's head with a metal pipe. These deficient practices had the potential to result in unidentified abuse in the facility, and the potential for avoidable further abuse of facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the care plan as necessary for three of five sampled residents (Resident 52, Resident 131, and Resident 175,) by failing to: a. Monitor the intake and output ([I&O] recording the amount of fluid that goes into the body and comes out of the body) of Resident 52 who was receiving hemodialysis treatment (a treatment that helps the body remove extra fluid and waste products from the blood when kidneys are unable to due to disease) per the resident's care plan. b. Update Resident 131's care plan to reflect the need for ongoing education due to non-compliance with abiding by the Food Brought in by Visitors policy. c. Develop a care plan for Resident 175 who had a known history of wandering into another resident's room (Resident 256) and invading her privacy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Treatment Nurse (TN) 1 provided skin treatments for one of one sampled resident (Resident 241), and Licensed Vocational Nurse (LVN) 12 administered the correct tube feeding flush rate for one of one sampled resident (Resident 205) to maintain the resident's hydration status. These deficient practices placed Resident 241 at risk for further skin complications that could possibly delay skin healing process and placed Resident 205 at risk for inadequate hydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance. In addition, food was not delivered at appetizing temperatures and portions were not correct. This deficient practice placed two hundred sixty-seven (267) of two hundred eight seven (287) facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide lunch at the facility's established mealtime in the facility's East Wing where 64 residents resided. This failure resulted in three of 64 residents (Resident 223, 192, and 121) receiving lunch at least 30 minutes late, causing Resident 223, 192, and 121 to feel hungry.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for 287 of 287 residents by failing to: a. Accurately and timely test the water for legionella (bacteria that could be present in water which can cause illness) and other water-borne pathogens (bacteria) with a test kit that was not past its expiration date. b. Ensure staff did not remove their N95 respirator (type of mask that provides protection from small particles in the air) during care for five sampled residents (Resident 146, 179, 205, 233, 243) during a COVID-19 outbreak (infectious disease that affects a person's organs and tissues that aid in breathing). c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a safe, clean, comfortable, and home-like environment for 14 of 48 sampled resident rooms located on the East and [NAME] Unit of the facility. Room A and Room B was observed with dry stool on the toilet seat and dry stool on Room A's bathroom floor, curtains in Room C, Room D, and Room E were not properly hung and were ripped at the bottom, the soap dispenser in Room E was empty, the bathroom in Room A and Room E was not well lit, and the glass sliding door rail was observed sticking out in Room A. These findings had the potential to result in an accident and had the potential to negatively impact the psychosocial wellbeing of the residents.

Inspectors wroteBased on interview and record review, weekend visitation was restricted for one of 36 sampled residents (Resident 242). This deficiency caused avoidable physical and psychosocial harm for Resident 242, who verbalized feelings of depression, frustration, and hopelessness related to his inability to see his family.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 241 and Resident 265) were free from the use of restraints for staff convenience. Residents 241 and 265 beds were positioned against the wall enabling the residents to get of the bed from the right side. This deficient practice had the potential to cause harm to Resident 241 and 265 and inhibited Resident 241's and 265's freedom of getting out the bed from either side of the bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 241 and 265), who were assessed as being dependent on staff for positioning, were repositioned daily. This deficient practice had the potential to negatively affect Resident 241 and Resident 265's physical comfort, skin integrity, and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for two out of eight sampled residents (Resident 165 and Resident 159) when Resident 165 alleged Resident 159 hit her left arm while both residents waited to be released for a smoke break in Hallway A. This failure had the potential to result in undetected resident to resident altercations, abuse, or episodes of mistreatment in Hallway A.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store one unopened Novolog FlexPen (a medication used to treat high blood sugar) in the refrigerator per the manufacturer's requirements affecting Resident 68 in one of five inspected medication carts (East Station Medication Cart 1). The deficient practice of failing to store medications per the manufacturers' requirements increased the risk that Resident 68 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of 28 sampled residents (Resident 226) with assistive devices (special eating equipment and utensils) while eating. This failure had the potential to lead to Resident 226's decreased independence with eating, which could lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident rooms measured at least 80 square feet per resident in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space when providing safe care and privacy to the residents housed in Rooms 1-A, 3-A, 4-A, 6-A, 7-A, and 8-A; 4-B, 5-B; and 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure staff donned (put on) and doffed (take off) personal protective equipment (PPE) correctly when cleaning Cottage C that housed Coronavirus Disease 2019 (COVID-19, infectious disease that affects a person's organs and tissues that aid in breathing) positive residents. 2. Provide separate restrooms in two cottages, Cottage A and Cottage B, that housed COVID positive residents (Residents 6, 7, 10, and 11) and non-COVID residents (Residents 4, 5, 8, 9, 12, 13, 14, and 15). 3. Provide adequate handwashing areas for staff. 4. Provide hand sanitizer to staff that was not past its expiration date. These failures had the potential to increase the spread the COVID-19 virus to uninfected residents, which could lead to illness requiring medical interventions.