Lassen Nursing & Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' right to be free from verbal abuse for four of four sampled residents when the Activities Assistant (AA), yelled at Residents during a smoke break activity. (Residents 1, 2, 3 and 4)This resulted in embarrassment, fear, humiliation and made the Residents felt like children. This caused Resident 1 emotional distress and had the potential to negatively impact the other Resident's emotional and psychosocial well-being. During a review of the facility's policy and procedure titled, Abuse Prevention Program indicated, the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility is committed to protecting our residents from abuse by anyone, including, but not necessarily limited to: [...]

Inspectors wroteThe facility failed to store, prepare, and serve food in a safe and sanitary manner when:1. Meat was not thawed appropriately.2. Water from thawing meat splashed onto ready to eat vegetables causing possible cross contamination (transfer of harmful bacteria, viruses, or allergens from one surface, food, or object to another between raw meat thawing and cooked vegetables).3. Staff did not wash hands after handing dirty items on the dirty side of the dish machine and before touching clean items such as eating utensils, water pitchers, and food storage tubs. Staff did not wash hands upon entering the kitchen and before starting kitchen tasks.4. Cooking pans were in poor condition.5. The can opener blade and holder was not clean.6. Cutting boards were in poor condition.7. The standing mixer was not clean.8. The knife holder was not clean.9. [...]

Inspectors wroteBased on interview and facility policy and procedure (P&P) review, the facility failed to ensure call lights were answered timely for 8 of 19 sampled residents (Residents 73, 98, 3, 85, 74, 57, 6, 93) and four of seven confidentially interviewed residents. This failure resulted in dependent residents (residents not able to help themselves to the bathroom, out of bed, or out of their wheelchairs) not receiving the assistance they needed.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure Food and Nutrition Services (FNS) staff had the appropriate competencies and skills sets to carry out the functions of the FNS department when:1. Two staff did not know manual dishwashing procedures;2. One staff did not follow the recipe for pureed food;3. One staff used expired test strips for testing sanitizer strength; and4. Two staff did not follow proper hand hygiene procedures (Cross Reference F812). The failure to ensure FNS staff competency and skills sets resulted in 4 of 10 FNS staff not appropriately carrying out tasks related to their jog duties which had the potential to lead to contamination of food and food service equipment, and decreased quality of food for a census of 90.

Inspectors wroteBased on observation and interview, the facility failed to provide alternate entrees of equal nutritive value to the entree served. This failure had the potential to result in decreased nutrient intake leading to food related medical issues for 11 out of 11 residents who requested an egg salad sandwich alternate entree for a lunch meal out of a census of 90.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide basic safety measures for three of 19 residents (Resident 1, 64, and 93) when call lights were not easily accessible as they were not placed within the resident's reach. This failure placed residents at risk for avoidable complications, including incontinent issues and falls, associated with the inability to urgently communicate with staff for needs and safety issues, which could result in physical and emotional decline and reduced quality of life.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure professional standards of quality were met when one of the Registered Dietitians (RD) was not onsite to complete timely and comprehensive nutrition assessments. This failure had the potential to result in delayed nutrition care for residents leading to an increased risk for nutritionally related clinical decline.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two Residents (26, 30) received assistance with their meal in a timely manner. This failure had the potential to result in decreased quality food and/or decreased intake of food leading to weight loss for 2 of 13 residents who received their lunch during the assisted dining.

Inspectors wroteBased on interview and record review, the facility failed to comprehensively assess and implement appropriate interventions to restore bladder continence following indwelling urinary catheter (a tube inserted into the bladder to remove urine), removal for one of 19 sampled residents (Resident 74). This failure placed Resident 74 at risk for missed opportunities to restore or improve bladder continence, avoidable complications associated with prolonged incontinence (loss of bladder control), and reduced quality of life.

Inspectors wroteBased on interview and document review, the facility failed to ensure:1. One of one Dietary Managers received frequently scheduled consultations from a qualified dietitian; and2. One of one Dietary Managers was qualified for his position when DM did not meet a State requirement for a Dietary Manager. Failure to ensure one of one Dietary Managers received frequent consultation from the dietitian and training qualifications were met for the Dietary Manager, had the potential to result in substandard Food and Nutrition Services operations serving a census of 90.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four Residents (27 and 35) received their prescribed nutritional supplements. This failure placed Residents 27 and 35 at increased risk for malnutrition and weight loss.

Inspectors wroteBased on observation and interview, the facility failed to maintain equipment located in the kitchen when there was not a system to track maintenance requests, and:1. One of seven food storage coolers was leaking;2. There was a leak from plumbing in relation to the ice machine;The failure to have a system for tracking maintenance requests and maintain leaks from two of over 13 pieces of equipment had the potential to result in delayed maintenance of equipment; attract and provide harborage for pests leading to contamination of food and equipment; and pose an electrical safety risk for a census of 90.

Inspectors wroteBased on interview and record review, the facility failed to prevent verbal and physical abuse for three of five sampled residents (Residents 1, 2, and 5) when:Resident 2 hit Resident 1 in the arm twiceResident 3 pulled Resident 2's hair and spit on Resident 4Nursing Assistant (NA 2) sprayed Resident 5 in the face with the shower nozzle, tossed her in bed and verbally threatened her. These failures had the potential to result in psychological, behavioral, and psychosocial outcomes causing fear, anxiety, and adverse outcomes. During a review of the facility's policy and procedure titled, Abuse Prevention Program indicated, the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility is committed to protecting our residents from abuse by anyone, including, but not necessarily limited to: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to report to the California Department of Public Health (CDPH), the Ombudsman (State advocacy program for residents), and to local Law Enforcement a verbal and physical abuse allegation for two of three sampled residents when Resident 3 told the facility Administrator (FA) that Certified Nursing Assistant (CNA) A was harsh, brutal and mean to her roommates (Residents 1 and 2). This failure to report an abuse allegation prevented local and state agencies from providing prompt oversight to ensure the residents in the facility were safe and protected from abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure that significant medication error was avoided for one of three sampled residents (Resident 1) when, an order written by the Family Nurse Practitioner (FNP) to restart Resident 1's Eliquis (a blood thinner) was not carried out and went unrecognized by the FNP and Licensed Nurses (LN), for 42 days. This failure contributed to Resident 1 developing a Deep Vein Thrombosis (DVT, blood clot) in his right leg which required a surgical procedure and hospitalization to remove the blood clot and had the potential to cause serious pain, emotional distress, prolonged health declines, and life-threatening conditions.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure that one of three residents sampled (Resident 1) received care consistent with professional standards when the physician's order to change her urostomy bag (a waterproof pouch worn on the outside of the abdomen to collect urine) was not followed. This failure had the potential to cause infection.

Inspectors wroteBased on interviews and record reviews, the facility did not notify the Pharmacy Consultant (PC) to complete medication reviews for three out of three sampled residents (Resident 1, 2, and 3) who experienced weight loss. This resulted in unmet pharmacy service needs and had the potential to contribute to further weight loss.

Inspectors wroteBased on observations, interviews, and reviews, the facility failed to consistently provide three out of three sampled residents (Residents 1, 2, and 3) with Physician ordered therapeutic (customized meal plan to manage a medical condition) diets when: 1. Residents 1 and 2 were not consistently provided with a meal that was fortified (added calories); and 2. Resident 3 was not consistently served a fortified meal that included double portions of protein (examples of protein are meats, eggs, and dairy). These failures had the potential to contribute to weight loss.

Inspectors wroteBased on interview and record review the facility and the Registered Dietician (RD) did not maintain an adequate food and nutrition department for three out of three sampled residents (Resident 1, 2, and 3) with weight loss when: 1. A timely nutrition assessment was not performed for Residents 1, 2, and 3 after a weight loss triggered a change of condition. 2. The RD did not attend weight variance interdisciplinary team (IDT, a group of department heads and staff that provided resident care, to discuss resident care goals and identified concerns) meetings and did not document a progress note that indicated the IDT meeting notes had been reviewed. 3. RD did not communicate to the facility the recommendations made for residents with weight loss or collaborate with the dietary department. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to treat one out of three sampled residents (Resident 1) with dignity and respect when Resident 1 wanted to return to her room during lunch and the Licensed Nurse (LN) assessed (examined) Resident 1 at the lunch table in front of three other residents. This violated Resident 1's right to maintain the privacy of her medical conditions by allowing other residents to watch and listen as the LN examined her.

Inspectors wroteBased on interviews and record reviews the facility failed to perform a Minimum Data Set (MDS, a resident assessment tool), assessment for one out of three sampled residents (Resident 1) when a significant change of condition was identified. This had the potential for a delay in the review and revision of the care plan (documented resident goals that included instructions for care).

Inspectors wroteBased on the interview and record review, the facility did not monitor and evaluate the effectiveness of an intervention (instruction for obtaining goals) for one out of three sampled residents (Resident 1) when the staff did not document the amount of Boost (a nutritional drink/supplement) that was consumed. This failure prevented the facility from monitoring and evaluating the intervention's effectiveness, potentially leading to weight loss.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to honor food preferences for one out of three sampled residents (Resident 1) when food portions were too large, and Resident 1 stated she was tired of chocolate. This had the potential to contribute to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records were accurate and complete for three out of five residents (Residents 1, 2, and 3) when: 1. Resident 1's code status (the residents' wishes regarding life-sustaining treatment, specifically if the resident stopped breathing or the heart stopped beating) was inaccurately documented throughout Resident 1's medical records. 2. The Resident's Clothing and Possessions form, (inventory sheet, described personal belongings brought into the facility) was not signed by Residents 2, 3, or the resident's responsible party (RP, decision maker). 3. Resident 3's wedding ring and wristwatch were not added to the inventory sheet. These failures had the potential to cause a delay in life sustaining care and personal belongings to not be identified if lost or stolen.

Inspectors wroteBased on interview and record review the facility failed to protect one out of three resident's (Resident 2) from misappropriation (taken without permission) of resident property when Resident 2's wedding ring was stolen. This violated Resident 2's rights and had the potential to cause psychosocial harm.

Inspectors wroteBased on interview and record review the facility failed to report a reasonable suspicion of a crime to the California Department of Public Health (CDPH, responsible for protecting the public's health) for two out of three sampled residents (Residents 2 and 3) when the facility suspected Certified Nurse Assistant (CNA) D had stolen two wedding rings. This failure had the potential for further abuse and could negatively affect residents' mental and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to maintain an effective training program when facility staff did not attend mandatory in-services (training classes), and the facility failed to provide additional opportunities to make-up the missed in-services. This had the potential for residents not to attain or maintain their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide palatable (tasted good) meals to five out of five sampled residents (Residents 1, 2, 5, 6, and 7) when they stated, the food was bad, had a weird flavored spice that could be tasted on all the food, and the food was cold. This caused residents to have feelings of anger and had the potential to cause unintended weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow safe infection control practices for three out of four sampled residents (Residents 1, 2, and 3) when: 1. Facility staff did not wear personal protective equipment (PPE, gloves, gowns, or masks that were worn to reduce the spread of infection) while performing resident care with Resident 1 and did not perform hand hygiene (washing hands with soap and water or use alcohol-based hand sanitizer) after providing care for Resident 1 or before touching Resident 2; and 2. Enhanced barrier precaution (EBP, use of PPE to reduce the spread of infection for residents who have wounds or foley catheters, a tube inserted into the bladder and was attached to a bag) signage and PPE was not present outside of Resident 3's room and facility staff touched Resident 3's foley catheter tube without use of PPE. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to answer call lights in a timely manner when five out of five sampled residents (Residents 1, 2, 5, 6, and 7) stated experiencing long call light wait times. This failure caused residents to have feelings of anger, worthlessness, and had the potential to negatively impact resident health status.

Inspectors wroteBased on interview and record review, the facility failed to adhere to professional standards of practice for one out of three sampled residents (Resident 4) when: 1. The facility did not implement the Urologist's (a physician that specialized in the urinary system) order for daily suprapubic catheter (a catheter tube inserted through the lower abdomen into the bladder to drain urine) flushes (sterile water was inserted through the catheter tube into the bladder to remove debris or blockage). 2. Treatment nurse did not document a provided treatment or an assessment following a reported suprapubic catheter complication. These failures had the potential to cause a decline in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that there was sufficient, qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for nine of 22 sampled residents (Residents 43, 62, 52, 17, 42, 19, 65, 12, and 285), and three of five confidentially interviewed residents, when their call lights were not answered timely and resulted in falls, being left in stool and urine because they were not taken to the bathroom. This failure had the potential to result in skin breakdown, infection, increased pain, increased accidents and injuries, and a decline in physical health status and have a negative impact on the resident's mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide meals that were served at a palatable temperature when 10 of 22 sampled residents (Residents 12, 67, 28, 19, 65, 43, 62, 52, 17, and 41), and five of five confidentially interviewed residents, stated the food was cold and bland. This failure had the potential for the residents to experience a loss of appetite, decreased nutrient intake, and result in unintentional weight loss and adverse clinical outcomes.

Inspectors wroteBased on observation and interview, the facility did not ensure that the kitchen was clean when; 1. An electrical pest control device had a dark substance on the surface. 2. The floor and wall near food preparation areas was covered with black debris and patches of a gray substance. 3. There was grime on the door and doorknob of the food storage room. 4. There were black stains on the ceiling from the air that was blowing out of the vents in two storage rooms. This had the potential of contaminating food that was prepared in these areas and result in germs getting into the residents' food and make them physically sick.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. Licensed Vocational Nurse (LVN) 6 did not perform hand hygiene (cleaning and disinfecting hands) while doing medication pass (when a nurse goes from resident to resident to give them their prescribed medication). 2. Resident 285's water tumbler's (a water drinking cup that did not have a straw) lid/drinking hole was covered with brown and white spots, dust, and black particles. These failures placed residents receiving medication and Resident 286 at an increased risk of healthcare-associated infections (infections caused by facility practices).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity and respect were maintained for two of 22 sampled residents (Resident 39 and 285) when: 1. Certified Nursing Assistant (CNA) A sat behind Resident 39 while assisting her with the lunch meal. 2. Resident 285 received breakfast sixteen minutes after the other resident at her table. These failures resulted in Resident 285 feeling forgotten, and had the potential to result in loss of self-esteem and self-worth for both Resident 39 and 285.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment when: 1. The walls in two of 22 sampled resident's (Resident 285 and 76) rooms were unpainted and scratched up. 2. A Hoyer lift (a mobile assistive device that allows residents to be transferred between bed and a chair, by the use of electrical or hydraulic power using a sling to hold the resident), that was used by residents was soiled with dried thick brown and white matter. This deficient practice had the potential to create a poor quality of life that may lead to depression due to the unkept living conditions.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse to The California Department of Public Health (CDPH), when Resident 25 alleged that she heard Resident 20 rape Resident 36, and the facility had not reported this allegation to CDPH. Failing to report allegations of abuse to CDPH created the potential for ongoing undetected resident abuse.

Inspectors wroteBased on observation, interview, and record review, the facility had a 10 percent (%) medication error rate, when three medication errors out of 30 opportunities were observed during a medication pass. These failures resulted in medications not given in accordance with the prescriber's orders which may result in residents not receiving the full therapeutic effects of their medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure an open multi-dose vial (contains more than one dose of medication) Tubersol (a solution that aids in the detection of infection with Mycobacterium tuberculosis-TB, a potentially deadly lung infection) 5TU/0.1mL (Tuberculin units / milliliters, a measurement of the solution for injection) was dated when the vial was opened. This deficient practice had the potential for the TB skin test solution to be outdated and ineffective and therefore, lose the inability to correctly detect TB in a resident or staff member and spread a potentially deadly infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of 22 sampled residents (Resident 27) and five of five confidentially interviewed residents, were offered snacks between meals and at bedtime, without the residents having to ask. This failure had the potential to result in undesired weight loss, hunger, discomfort, and the humiliation of having to ask staff for food.

Inspectors wroteBased on interview, observation, and record review, this requirement was not met when the facility failed to follow physician's orders to cover the insertion site during showers for one of seven sampled residents (Resident 1), who had a nephrostomy tube (a surgically placed tube that drains urine from the kidney into a collection bag when the bladder no longer functions properly). This had the potential to increase the risk of infection, illness, and rehospitalizations.

Inspectors wroteBased in interview and record review the facility failed to ensure direct care staff to meet the needsfor six of nine residents (Residents 2, 3 4 9, 5, and 7) when activities of daily living (toileting showers and hydration) were delayed. This resulted in residents to unrelieved pain, to feel closed in, and forgotten.

Inspectors wroteBased in interview and record review the facility failed to ensure sufficient staffing to meet the needsfor six of nine residents (Residents 2,3,4,9,5, and 7) when activities of daily living (toileting showers and hydration) were delayed. This resulted in residents to unrelived pain, to feel closed in, and forgotten.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to address and manage the pain for one of three sampled residents (Resident 1) to support Resident 1's highest practicable level of physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and care plan, when: 1. Resident 1 was having constant pain and did not have routine pain medication. 2. The nursing staff was giving Resident 1 the wrong pain medication for the wrong pain level. This failure resulted in Resident 1 not being properly medicated when she was in severe pain.

Inspectors wroteBased on interview and record review, the facility failed to provide nursing staff with necessary competencies and skill sets to meet the care and services for residents' need for two of nine residents (Resident 1 and Resident 2) when a change of condition was not identified and reported to the physician. These failures resulted increased pain and discomfort for Resident 1 and Resident 2 to have low blood sugars.

Inspectors wroteBased on interview and record review, the facility failed to ensure a timely Urology consultation (evaluation by a physician who specializes in diseases of genitourinary system) as determined to be necessary and ordered by the MD (Medical Doctor) for one of nine sampled residents (Resident 1) to attain or maintain Resident 1 ' s highest practicable physical, mental, and psychosocial wellbeing in accordance with Resident 1 ' s comprehensive assessment and plan of care. This failure resulted in delayed treatment, increased pain and discomfort, and a six-month delay in scheduling/obtaining a Urology consult for Resident 1 who has suffering from multiple Urinary Tract Infection (UTI- bacterial infection in the urine) from 2/2024 to 4/2024, and pain caused by her nephrostomy.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medical Director (MD) addressed and documented in one of the three sampled residents ' records (Resident 1) that the identified irregularity had been reviewed and acted upon. This failure resulted in Resident 1 suffering from a much worse pain because she was not proper medicated.

Inspectors wroteBased on interview and record review the facility failed to ensure for one of four residents (Resident 2) did not receive an unnecessary medication when a diabetic medication was unavailable, the other two diabetic medications were increased and were not adjusted once the medication was available. This resulted in low blood sugars for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the ordering physician of laboratory results for one of 3 sampled Resident (Resident 1), when: 1. Resident 1 ' s urinalysis (UA, a urine specimen that determines if there is a bacterial infection in the urine, as urinary tract infection - UTI) was obtained on 4/13/2024, two days after the physician placed the order on 4/11/2024. 2. The facility failed to notify the physician when the Urine Culture & Sensitivity (Culture- a lab test to check for bacteria or other germs in a urine sample; Sensitivity- determines the effectiveness of antibiotics against microorganisms) was reported on 4/15/2024. These failures resulted in delayed treatment, increased Resident 1 ' s pain and discomfort.

Inspectors wroteBased on interview and record review the facility failed to fully inform resident's representatives (RP) of the residents' dental health status and allow participation in decision making for care to be provided for 3 of 5 residents (Resident 1, 2, and 3) and their RP's, when RP 1, 2, and 3 were not notified of oral issues and changes of conditions identified by the Registered Dental Hygienist of Alternative Practice (RDHAP), and the potential need for a dentist consult. 1. RDHAP's evaluation indicated Resident 1 demonstrated several missing teeth, visible cavitation (permanently damaged area of hard part of tooth with decay that become tiny openings), retained roots, and general demineralization (outermost layer of tooth starts to weaken and deteriorate), and RP 1 was not notified. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately evaluate and record assessments reflective of the resident's dental status for 4 of 5 residents (Residents 1, 2, 3, and 4), when the Minimum Data Set (MDS, a standardized assessment tool used to evaluate problems for care planning and interventions), indicated that: 1. Resident 1 did not have cavities (permanently damaged area of hard part of tooth with decay that become tiny openings),or broken natural teeth. 2. Resident 2 , did not have cavities (permanently damaged area of hard part of tooth with decay that become tiny openings),or broken natural teeth. 3. Resident 3 did not have cavities (permanently damaged area of hard part of tooth with decay that become tiny openings),or broken natural teeth. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to pursue routine or emergency dental services with a Dentist to inspect, diagnose, obtain diagnostic testing, and provide treatment when 3 of 5 residents sampled for dental care (Residents 1, 2, 3), were evaluated by the Registered Dental Hygienist of Alternative Practice (RDHAP), who identified dental problems and there was no follow up with a Dentist. 1. Resident 1 was identified to have cavities (permanently damaged area of hard part of tooth with decay that become tiny openings) and retained roots and was not referred to a dentist. 2. Resident 2 was identified to have retained roots and fractured teeth and was not referred to a dentist. 3. Resident 3 was identified to have white spot lesions and cavities and was not referred to a dentist. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an alleged verbal abuse incident to the California Department of Public Health (CDPH) State Survey Agency within two hours for one of three sampled residents (Resident 1). Resident 1 alleged Licensed Vocational Nurse (LVN) 1 yelled at her and called her a liar in front of everyone in the dining room. Resident 1 ' s allegation of verbal abuse was made on 11/28/2023 and the first report CDPH the State Survey Agency received from the facility was on 12/1/2023. This failure had the potential to delay the investigation and affect the psychosocial well-being of Resident 1 and subject other residents to verbal abuse.

Inspectors wroteBased on interview and nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours per day/ 7 days a week. This failure had the potential to adversely affect resident's quality of care and quality of life with regards to overall health and well-being.

Inspectors wroteBased on observations, interviews, record reviews, and 6 confidentially interviewed residents, the facility failed to ensure meals and snacks met resident needs when food was not palatable, (was bland, had no flavor), and was not at the correct temperatures, (hot food was not hot, cold drinks were not cold), and meals were not served on time. This failure had the potential to result in decreased resident meal intakes, loss of appetites, weight loss and negatively impact their nutritional status, health status and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a home like environment for one of eight sampled residents (Resident 29) when comfortable sound levels were not maintained. This failure resulted in Resident 29 losing sleep at night and caused frustration with uncontrolled noise that interfered with Resident 29's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 70), who experienced a significant change in condition, was comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process within 14 days of the change in condition. This failure had the potential for staff to not be fully informed of Resident 70's health status in order to determine the need for further assessment and interventions that could potentially delay care and negatively impact her health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a care plan for one of eight sampled residents (Resident 70), following a significant change in condition with a new order for comfort care (the goal of care to keep the resident comfortable by managing pain and symptoms, and relieving anxiety, to improve the quality of life while allowing death to occur naturally), measures. This failure had the potential for staff not to be aware of Resident 70's end of life choices and comfort wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 326), was administered and inhaler according to manufacturer's specifications when; the Director of Staff Development (DSD) administered Advair Diskus (a medication inhaled through the mouth into the lungs), without explaining the procedure to Resident 326, without ensuring her mouth was rinsed with water after the inhalation, and tilted the inhaler upwards, instead of keeping flat. This failure had the potential to cause the medication to be ineffective and result in a mouth infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide physician ordered therapeutic diets (a modified diet for nutrients, calories and textures), for two out of six sampled residents, (Resident 16 and 47), when they had not recieved fortified (added nutrients) pudding with their meals. This failure had the potential to negatively impact the necessary essential nutrition required and desired weight goals for these residents and have a negative affect on their health status. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, revised 10/1/17, the P&P indicated, resident diets would be determined, with the resident's informed choices, preferences, treatment goals, and wishes. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure professional food safety and sanitation practices were in place when: 1. A table located in the dry storage area that had various boxes of food items stored on the top was visibly dirty with loose food debris. 2. Foods were stored in the dry storage area and in the refrigerator without being labeled and having use by dates. 3. Two unopened containers of half and half (a mixture of cream and milk), were expired and placed behind newer containers of half and half. 4. The floor under the kitchen's washing station was slimy and visibly dirty. 5. The grill was not cleaned after breakfast and contained food particles. 6. [...]