Landmark Medical Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for three of five sampled residents (Residents 3, 6 and 8) when on 5/20/26 Resident 4 punched Resident 3 in the right eye area suddenly and without warning while Resident 3 was passing through the hallway. Also, during that same day after Resident 4 punched Resident 3 on 5/20/26, while staff escorted Resident 4 to Resident 4's room, Resident 4 punched Resident 4's roommate (Resident 8) on the left side of the head while Resident 8 was lying in bed. On 5/27/26 Resident 7 hit Resident 6's face while returning from smoke break. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) received adequate supervision and was not left unattended by facility staff following a resident altercation with Resident 1, in accordance with the facility's Policy and Procedure (P&P) titled Policy for Timely and Accurate 1:1 Monitoring and every 15 Minutes Monitoring Documentation in Point Click Care (PCC- electronic health record), by failing to: 1. Enter the physician's order for 1:1 monitoring for Resident 2 for two (2) hours, followed by every 15 minutes monitoring for 2 hours, in PCC.2. Provide a 1:1 Sitter (a trained staff member assigned to directly observe a single resident continuously within direct line of sight) after Resident 2 assaulted Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services to prevent resident-to-resident abuse (intentional bodily injury that includes slapping, pinching, choking, kicking, shoving, grabbing, and punching) for two of five sampled residents (Resident 3 and Resident 5), according to the facility's policy and procedure (P&P) titled, Residents Right to Human Care, and the facility's five-day Follow-up Investigation Report (FUIR - mandatory follow-up report long-term care facilities must submit to the State Survey Agency within five working days of an abuse/neglect incident, detailing investigation results, corrective actions taken, and if the allegation was verified) dated 12/1/2025 by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision every hour for two of six sampled residents (Resident 3 and Resident 6) in accordance with the facility's policy and procedure (P&P) titled, Policy for Hourly Monitoring, by failing to ensure Certified Nurse Assistant (CNA) 1, CNA 2, CNA 3, and CNA 6 had visually seen and identified Resident 3 and Resident 6 between the hours of 12 am and 4 am on 10/18/2025, 10/19/2025, and 10/20/2025. This failure resulted in Resident 3 and Resident 6 not being visually checked during hourly monitoring on 10/18/2025 at 12 am and from 2 am to 4 am, on 10/19/2025 at 1 am, and from 3 am to 4 am, and on 10/20/2025 from 12 am to 4 am, and had the potential to result in Resident 3 and Resident 6 harming themselves, harming each other, and being susceptible to abuse. Cross Reference: F842Findings: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate documentation of the Follow Up Question Report (FUQR - used by facility to document hourly visual monitoring of residents) for two of six sampled residents (Resident 3 and Resident 6) according to the facility's policy and procedure (P&P) titled, Policy for Hourly Monitoring of Residents, by failing to ensure CNA 1, CNA 2, CNA 3, and CNA 6 did not falsify (change something in order to deceive people) Resident 3's and Resident 6's FUQR. CNA 1, CNA 2, CNA 3, and CNA 6 documented on Resident 3's and Resident 6's FUQR they had visually seen and identified Resident 3 and Resident 6 between the hours of 12 am and 4 am on 10/18/2025, 10/19/2025, and 10/20/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Residents 1), who had a history of major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life) was properly and adequately monitored in accordance with the facility's policies and procedures (P&P). This failure potentially resulted in Resident 1 gaining the opportunity to hang himself to attempt suicide (the act of intentionally causing one's own death) while inside Resident 1's room (Area 2) and resulted in Resident 1 to be resuscitated (to revive from apparent death or from unconsciousness) and transferred to the General Acute Care Hospital (GACH) where Resident 1 was declared brain dead two days later. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure an environment free from physical abuse for two of six sampled residents (Resident 38 and 52) when: A. Resident 38 was punched (hit with a closed fist) by Resident 7 while unsupervised in the dining room on 8/13/2025. B. Resident 52 was hit by Resident 44 on the left side of the face on 8/12/2025. This deficient practice resulted in physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) to Residents 38 and 52 and mild pain (may be annoying and noticeable, but it doesn't keep you from performing normal activity) on Resident 52's left cheek. Additionally, there was potential for psychosocial harm to both residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop or implement individualized person-centered care plans (CP) for four of four sampled residents (Resident 1, Resident 7, Resident 13, and Resident 47) by failing to ensure:A. CPs titled, Compliance with Activities of Daily Living [ADL, term used in healthcare that refers to self-care activities] and Oral/Dental Care, were implemented for Resident 13. On 8/18/2025, Resident 13 was observed with a dry crust around the lips and build up and discoloration on Resident 13's upper and lower teeth. B. A CP was developed that addressed smoking for Resident 7. C. A CP was developed for Resident 1 and Resident 47 that addressed the resident's diagnoses of Post Traumatic Stress Disorder (PTSD- a mental health condition that can develop after experiencing or witnessing a traumatic event). [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure two of two sampled residents (Residents 1 and Resident 47) received Post Traumatic Stress Disorder (PTSD- a mental health condition that can develop after experiencing or witnessing a traumatic event) care that addressed their individual experiences, necessary to minimize the risk of re-traumatization. This deficiency could have potentially resulted in emotional distress, exacerbation of PTSD symptoms, and an increased risk of behavioral or psychological harm to Residents 1 and Resident 47. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store food items in a manner that prevented food borne illness (condition caused by consuming contaminated food or beverages), in one of one kitchen (Kitchen 1), by:A. Failing to remove five of 47 apples and one of 16 onions that had spoiled (food that has deteriorated in quality and becomes unfit and/or unsafe for consumption). B. Failing to ensure employees kept personal belongings out of Kitchen 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 79) was informed and provided information regarding housing alternatives after discharge. This deficient practice violated Resident 79's rights to be informed of Resident 79's treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a radio to one of one sampled resident (Resident 44) in a timely manner. This failure had the potential to lead to psychosocial decline, increased depression, and anxiety for Resident 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure eyeglasses were made available for one of one sampled resident (Resident 1) as indicated in the optometry consultation, dated 10/18/2024, and the care plan (CP) for impaired visual function. This deficient practice had the potential to result in worsening of Resident 1's vision and a psychosocial decline to Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately document a one to one (1:1- continuous observation) monitoring for two hours after an altercation (physical aggression) for one of eight sampled residents (Resident 1). This failure resulted in inadequate documentation of Resident 1's one to one monitoring as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide immediate cardiopulmonary resuscitation (CPR - emergency lifesaving procedure, consisting of a combination of chest compressions, mouth- to-mouth, or mechanical breathing [using a device to help someone breathe], performed when the heart stops beating or beats ineffectively to restore breathing) to one of two sampled residents (Resident 1), who was a full code (when the resident's heart stops beating and/or the resident stops breathing, the resident or their representative's wishes to perform all lifesaving procedures to keep the resident alive, a full code is the default status for all patients unless they have explicitly discussed other wishes with their medical provider). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LPT 1) made hourly visual checks for five of five sampled residents (Resident 1, 2, 3, 4, and 6) during the night shift (11 pm to 7 am) as indicated in the facility's Policy and Procedures (P&P). This deficient practice had the potential to result in unmet needs, untimely assistance from staff, and distress to Residents 1, 2, 3, 4, and 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nurse Assistant 1 (CNA 1) and Licensed Psychiatric Technician 1 (LPT 1) demonstrated competency during a medical emergency for one of one sampled resident (Resident 1) who was found on the floor unresponsive on [DATE]. Additionally, the facility failed to provide 37 of 74 CPR certificates for direct care staff. This deficient practice had the potential to result in a delay in treatment and delivery of cardiopulmonary resuscitation (CPR - emergency lifesaving procedure, consisting of a combination of chest compressions, mouth- to-mouth, or mechanical breathing [using a device to help someone breaths], performed when the heart stops beating or beats ineffectively and/or to restore breathing) to Resident 1 and had the potential to affect all other residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from abuse for two of two sampled residents (Residents 1 and 4) as indicated in the facility's policy and procedure (P&P) titled, Elder/Dependent Adult Abuse, by failing to: a. Protect Resident 1 from being kissed on the neck by Resident 2. b. Protect Resident 4 from being spit on and intimidated by Resident 3. These failures resulted in Resident 1 to feel disgusted and for Resident 4 to feel afraid. These failures had the potential to negatively impact the health and well-being of Residents 1 and 4.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for one of two sampled residents (Resident 1) to the California Department of Public Health (the Department), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours, in accordance with the facility's policy and procedure (P&P), titled Elder/Dependent Adult Abuse, revised 3/22/2024. This failure resulted in the delay of notification to the Department and had the potential for Resident 1 to be subjected to further sexual abuse while at the facility. (Cross Reference F610)

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and document the investigation of an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P), titled Elder/Dependent Adult Abuse, revised 3/22/2024. This failure had the potential to result in Resident 1 to experience sexual abuse while in the care of the facility. (Cross Reference F609)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) in according to the facility's policies and procedure (P&P), by failing to ensure Resident 1 did not experience unwanted anal (opening of digestive tract where waste leaves the body) digital penetration (fingers to penetrate [force] someone body) from Resident 2. This deficient practice resulted in Resident 1 experiencing physical and emotional abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 3), were free from abuse (deliberately aggressive or violent behavior with the intention to cause harm) in accordance with the facility's policy and procedure (P&P) titled Physical Assault and the facility's lesson plan titled, Elder and Dependent Adult Abuse, Prevention and Policy when, a. On 8/16/2024, Resident 2 inappropriately touched Resident 1's vaginal area (female private area). b. On 8/16/2024, Resident 4 pushed Resident 3 on the back. This deficient practice resulted in Resident 1 feeling uncomfortable and Resident 3 feeling scared and unsafe at the facility. Additionally, the deficient practice had the potential to result in psychosocial declines to Residents 1 and 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for two of four sampled residents (Residents 1 and 2) by failing to: a. Protect Resident 1 from being pushed by Resident 2. b. Protect Resident 2 from being pushed by Resident 1. As a result, on August 11, 2024, Residents 1 and 2 were involved in an altercation. Resident 2 pushed Resident 1 and Resident 1 pushed Resident 2 back, resulting in both residents falling to the floor. This failure resulted in Resident 1 to experience pain and to sustain an abrasion (a superficial rub or wearing off the skin) to Resident 1's right forearm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system in place to ensure safeguarding of all prescribed medications including controlled medications (medications with a high potential for abuse) for 17 of 17 Resident (Residents 18, 20, 25, 27, 28, 34, 37, 45, 51, 55, 57, 71, 84, 97, 148, 150, and 151) by failing to: 1. Maintain accountability records for all controlled substances/medications that were disposed of or destroyed with the unused supply between 1/1/2024 through 8/8/2024 and ensure each resident's individual controlled drug record (CDR, any Schedule 2 through Schedule 5 controlled drugs [potential for abuse and/or addiction] received or supplied by a pharmacy) for each controlled medication was used for accurate accountability of controlled medications for 6 of 6 sampled Residents (Residents 34, 71,97, 148, 150 and 151). [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide documented evidence for five of 18 sampled residents (Residents 24, 48, 89, 9, & 59) and/or their legal representative (RP) were informed and/or provided written information regarding Advance Directives (AD, legal document, which specifies the health-related actions in accordance with the resident's wishes, that is executed when the resident is no longer able to make decisions for himself/herself due to illness or incapacity). These failures had the potential to result in violation of the residents' right to formulate ADs and the potential for the residents to receive inappropriate or medically unnecessary care and/or treatment.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to prevent physical abuse (willful infliction of injury that includes, but is not limited to, hitting, slapping, punching, biting, and kicking) for three of six sampled residents (Residents 73, 87, & 57), who were involved in resident-to-resident altercations, when, A. For Resident 73, Resident 87 hit Resident 73's face on 7/29/2024. B. Resident 87, who was on 1:1 monitoring (continuous observation), got hit on the face when Resident 73 hit Resident 87 back with a closed fist on 7/29/2024. C. For Resident 57, the facility failed to provide an abuse-free environment on 8/6/2024. These failures had the potential to result in a decline in the residents' physical and/or psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized person-centered care plan (CP) for two of two sampled residents (Resident 44 and Resident 10) as indicated in the facility's policy and procedures (P&P) when, a. Resident 10's High Risk for Falls CP was not updated or addressed falls that occurred on 12/21/2023, 1/4/2024, 1/15/2024, 4/17/2024, 4/24/2024 and 7/7/2024. b. Resident 44 did not have an individualized CP that addressed Resident 44 being a high risk for falls and Resident 44 being legally blind. These failures had the potential to result in unmet individual needs for Residents 10 and Resident 44 and the potential to affect the resident's physical well-being. Additionally, there was a potential for Resident 10 and 44 to receive inaccurate or inconsistent provision of treatments and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of one sampled resident (Resident 84) who was assessed as high risk for fall, by failing to: 1. Ensure facility staff provided supervision/monitoring to Resident 84 to prevent recurrent (repeated) falls. 2. Ensure Resident 84's care plan (CP) for falls, titled, High Risk for Falls, dated 1/21/2024 had specific interventions to address Resident 84's recurrent falls. 3. Ensure Resident 84's CP was revised with new interventions after the resident's recurrent falls. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the facility had a Registered Nurse (RN) at least 8 consecutive hours a day for 7 days a week for one of 10 sampled dates in July 2024 (7/28/2024). This failure had the potential to cause a decline in the residents' physical and/or psychosocial well-being related to insufficient supervision, monitoring, and coordination of care and services by an RN.

Inspectors wroteBased on interviews and record review, the facility failed to ensure three of five sampled residents (Residents 41, 23, and 66) did not receive unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) by failing to: A. [...]

Inspectors wroteBased on observations and interviews the facility failed to ensure two of two medication storage rooms had thermometers or thermostats and failed to ensure temperatures and humidity was properly monitored and maintained as indicated in the facility's policy and procedures (P&P), titled, Medication Storage in the Facility, and Storage of Medication. This deficient practice had the potential to result in the loss of strength and integrity of stored medications, and the potential for residents requiring medications from the two medication storage rooms to receive deteriorated or ineffective medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the minimum food holding temperature on the kitchen steam table was maintained at required temperature. This failure had the potential to affect the palatability (taste) of food and placed the residents at risk for food borne illness (illness from ingesting contaminated food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the representative of one of one sampled resident (Resident 44) when Resident 44's physicians recommended cataract (clouding of the normally clear lens of the eye) surgery for Resident 44. This deficient practice resulted in a delay of informing Resident 44's representative of the needed eye treatment and/or services for Resident 44 and prevented Resident 44's representative from being included in decision making regarding Resident 44's plan of care. This deficient practice had the potential to negatively affect Resident 44's quality of life from Resident 44's untreated cataract.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and homelike environment for one of two sampled residents (Resident 48) when Resident 48's room bed light's pull-cord switch (pull chain) was not in working condition. This deficient practice had the potential to result in compromised safety to Resident 48 and made the resident feel depressed.

Inspectors wroteBased on interview and record review, the facility failed to notify the Ombudsman (an official, public advocate, helps to resolve issues between parties through various types of informal mediation) regarding one of two sampled resident's (Resident 96) transfer/discharge. This failure had the potential to result in violation of Resident 96's rights regarding appropriate discharge and/or transfer and the potential for the Ombudsman to not be able to advocate for Resident 96.

Inspectors wroteBased on interview and record review, the facility failed to revise the Comprehensive Care Plan (CP) for falls following recurrent/repeated fall incidents for one of one sampled resident (Resident 84). This failure had the potential to result in an avoidable fall and injury to Resident 84.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents' (Resident 49) did not continue to experience progressive weight loss by failing to reassess Resident 49, provide meal intake encouragement for Resident 49 to consure 80 to 100% of Resident 49's meal, provide Nutrition Education Group every Saturday, and provide a banana for lunch and dinner in Resident 49's meal tray in accordance with the physician's order (PO), Resident 49's care plans (CP), and the facility's policy and procedures (P&P). These failures resulted in continued weight loss to Resident 49. Resident 49 lost 13.2 pounds (lbs. unit of weight) in six consecutive months from 3/2024 to 8/2024.

Inspectors wroteBased on interview and record review, the facility failed to ensure a medication regimen review (MRR- a thorough evaluation of a resident's medication regimen to promote positive outcomes and minimize adverse consequences and potential risks associated with medication) was completed by a licensed pharmacist monthly and failed to ensure the licensed pharmacist identified medication irregularities (refers to use of medication that is inconsistent with accepted standards of practice, not supported by medical evidence, and/or interferes with achieving the intended outcomes) for one of five sampled residents (Resident 23) on psychotropic medications (drugs that affect brain activities associated with mental processes and behavior). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices and ensure one of one sampled resident's (Resident 8) closet, was maintained orderly and failed to ensure Resident 8's pile of clean clothes did not spill out (overflow) of Resident 8's closet and did touch the floor. This deficient practice had the potential to result in infection to Resident 8 and for Resident 8's clothes to become a breeding ground for dust mites and other allergens (a substance that could trigger an allergic reaction [a damaging immune response by the body to a substance]) that could potentially impact the health of Resident 8.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled resident's (Resident 44) responsible party (RP) was provided education regarding the benefits and potential risks associated with the COVID-19 (a respiratory viral infection that affects primarily the lungs and result in cough and difficulty breathing) vaccine prior to administration of the vaccine to Resident 44. This deficient practice had the potential to result in Resident 44's RP not to make an informed decision due to the facility not providing education regarding the benefits, risks, and potential side effects associated with the vaccine, or the opportunity to accept or refuse the vaccine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a residents' right to remain free from physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) for three of eight sampled residents (Residents 1, 3, and 5) by failing to: a. Protect Resident 1 from being pushed by Resident 2. On 5/31/2024, Resident 2 pushed Resident 1 on Resident 1's left arm. b. Protect Resident 3 from being punched by Resident 4. On 6/1/2024, Resident 4 punched Resident 3 on Resident 3's right cheek. c. Protect Resident 5 from being punched by Resident 6. On 6/4/2024, Resident 6 punched Resident 5 repeatedly on Resident 5's face and forehead. This failure had the potential to result in Residents 1, 3, and 5 feeling afraid and not safe while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse for one of four sampled residents (Resident 7) on 2/11/2023 and on 5/8/2023, to the California Department of Public Health (the Department), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours, in accordance with the facility's policy and procedure (P&P), titled Elder/Dependent Adult Abuse, revised 1/19/2018. This failure resulted in the delay of notification to the Department and had the potential for Resident 7 to be subjected to further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (PP) titled, Q:15 (every 15) Minute Monitoring, and provide supervision every 15 minutes per the physician's order to prevent elopement (leaving the facility without notice) from the locked (equipped with secured locks or other functioning security devices) facility for one of four sampled residents (Resident 1) who was assessed as at risk for elopement by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 and CNA 2 monitored and kept Resident 1 in a clear and direct line of sight (within someone's view) every 15 minutes. 2. Ensure CNA 1 and CNA 2 accurately monitored and documented Resident 1's whereabouts every 15 minutes. As a result of these failures, on 5/19/2024 at 10:15 am, Resident 1 entered the facility's unlocked Recreation Room without CNA 1 and CNA 2's supervision. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure Certified Nurse Assistant (CNA) 1 and CNA 2 accurately documented the resident's location every 15 minutes for one of four sampled residents (Resident 1). This deficient practice resulted in inconsistencies and inaccurate in Resident 1's medical record. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a medical doctor's (MD) order for one of nine sampled residents (Resident 7) when Resident 7 had an active MD order for a Buddy Splint (bandaging a damaged or fractured finger together with a healthy, uninjured finger for support) for the left fourth and fifth finger for a nondisplaced fracture (bone is cracked but not broken all the way) of the left fifth finger. This failure had the potential to result in delayed healing for Resident 7's left fifth finger.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a Registered Nurse (RN), who worked eight (8) hours a day from Monday to Friday and ensure the Director of Nursing (DON) was not used as a Supervisor or Charge Nurse in this 95 bed skilled nursing facility. This deficient practice had the potential for the residents not to have adequate supervision and appropriate intervention which can only be provided by a Registered Nurse.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility's policy and procedure on Posting of Direct Care Service Hours Per Patient Day (DHPPD) by failing to: 1. Post accurate staffing information of actual hours worked by the staff directly responsible for resident care per shift, every day, and failed to post the nurse staffing information for two of two units (West and East units). 2. Complete information in the Census and DHPPD for 39 of 90 days (2 days in January, 2022, and 28 days in February, 2022, and 9 days in March 2022). These deficient practices could misled the residents and visitors and may result in inappropriate nursing care.

Inspectors wroteb. A review of Resident 58's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included benign prostatic hyperplasia (BPH- prostate gland enlargement; an enlarged prostate gland can cause uncomfortable urinary symptoms such as blocking the flow of urine out of the bladder). A review of Resident 58's Physician's Order Summary Report, dated 10/7/2021, indicated the physician prescribed Tamsulosin HCL capsule ,0.8 milligrams (mg- a unit of measurement) by mouth one time a day. A review of Resident 58's consultant pharmacist's Medication Regimen Review Report dated 12/2/2021 indicated the consultant pharmacist made a recommendation to the attending physician to give the medication at bedtime to minimize the risk for falls. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store and/or prepare food under sanitary conditions by failing to: a. Ensure two opened plastic bottles containing red liquid in the walk- in refrigerator and one bin of dried green peas in the dry storage area were labeled and dated. This deficient food handling practices had the potential for the facility to serve expired food to the residents that could lead to illness. b. Ensure one of two red buckets containing a chemical sanitizing disinfectant solution (Bucket 2) meets acceptable parameters for Quaternary (QAC, sanitizer used for food service areas) disinfection. This deficient practice had the potential to not fully sanitize equipment and utensil that can lead to contamination and infection.

Inspectors wroteBased on interview and record review, the facility failed to provide nursing care and treatment in accordance with the physician's order and the facility's policies and procedures for one of 19 sampled residents (Resident 67) by failing to: 1. Ensure Resident 67 received insulin (medication to lower the blood sugar) injection per the physician's order. 2. Rotate Resident 67's insulin injection sites in accordance with the facility's policy and procedure. These deficiency practices resulted in Resident 67 did not received one insulin injection as the physician order and had potential for Resident 67's insulin absorption decrease due to staff did not rotate the resident's insulin injection sites.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 5), who was incontinent (any void that occurs involuntarily) of bladder received services and assistance to maintain continence and/or restore continence to the extent possible. This deficient practice had the potential for Resident 5 to decline in bladder continence.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 35) received adequate monitoring for the use of a Geodon (antipsychotic medication used to treat mental disorder) as ordered by the physician and as indicated in the facility's policy. This failure had the potential for the resident to receive unnecessary medication and develop side effects resulting from the medication.

Inspectors wroteBased on interview and record review, facility's staff failed to ensure the content of the Medication Administration Record (MAR) was accurately completed for 1 of 19 sampled residents (Resident 67). Quality Assurance Nurse 1 (QAN 1) signed and dated Resident 67's MAR to indicate she administered the insulin (medication to lower blood sugar) and checked the resident's blood glucose/blood sugar (accucheck) on 3/3/22, at 6: 45 AM when she was not working at the facility on 3/3/22 at 6: 45 AM. This failure resulted in Resident 67's MAR was altered with inaccurate information.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement precautions to promote health and safety of residents and prevent possible cross-contamination for one of two licensed nurses (Licensed Vocational Nurse 2 [LVN2] ). LVN 2 was observed with long and acrylic (nail enhancements made by combining a liquid acrylic product with a powdered acrylic product) nails while preparing medications for residents in the East Nursing Station. This deficient practice had the potential to result in the transmission of healthcare associated infection to residents receiving care from LVN 2.