Leisure Court Nursing Center

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary psychotropic drugs for four of five sampled residents (Residents 4, 7, 38, and 52) reviewed for unnecessary medication, two of 22 final sampled residents (Residents 9 and 10), and two nonsampled residents (Residents 80 and 83). * The facility failed to ensure Resident 38's orthostatic blood pressure was accurately monitored, as ordered by the physician, for the use of the quetiapine (antipsychotic) medication. In addition, the facility failed to ensure non-pharmacological interventions were implemented for the documented observed behaviors. * The facility failed to ensure Resident 52's orthostatic blood pressure was accurately monitored as ordered by the physician for the use of the quetiapine (antipsychotic) medication. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 22 final sampled residents (Resident 67) and two nonsampled residents (Residents 41 and 109) reviewed for respiratory care were provided with the appropriate respiratory care and services. * The facility failed to ensure Resident 41's nasal cannula tubing and storage bag were changed every seven days. * The facility failed to ensure Resident 67 was administered with the oxygen therapy as ordered by the physician; and failed to ensure Resident 67's nasal cannula tubing was dated and labeled. In addition, the facility failed to ensure a sign to show oxygen in use was posted outside the resident's room. * The facility failed to ensure a physician's order was obtained for Resident 109's use of oxygen administration. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with a cleanable surface. * The facility failed to ensure the food in the walk-in refrigerator was thrown out after the use by date. These failures had the potential to cause foodborne illnesses for the 97 residents who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the facility's infection prevention and control program in accordance with the facility's P&P.* The facility failed to maintain an accurate infection control surveillance program for January 2026 through May 2026 and failed to ensure the Surveillance Data was accurate to determine whether the residents' infection met McGeer's (a standardized surveillance definitions used to detect infections in long-term care facilities, ensuring consistent reporting and monitoring) criteria for true infection for Residents 2, 21, 37, 52, 71, 93, and 112.* The facility failed to ensure the water management plan was available which addressed and identified where Legionella (a type of bacteria found in water that causes Legionnaires' disease, a severe form of [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to accurately monitor and address the use of the antibiotics for two final sampled resident (Residents 2 and 52) and three nonsampled residents (Residents 21, 37, and 112) reviewed for antibiotic stewardship. * Residents 2, 21, 37, 52, and 112 who did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) were prescribed antimicrobial therapy. These failures resulted in continued use of unnecessary antibiotic therapy, increasing the risk of adverse drug reactions and the development of antibiotic resistant organisms. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents or their representatives were informed in advance of the proposed treatment regarding the use of psychotropic medications for one of five sampled residents (Resident 38) and one nonsampled resident (Resident 80) reviewed for unnecessary medications. * The facility failed to ensure the informed consents for quetiapine (antipsychotic) and buspirone (antianxiety) medications were renewed after six months for Resident 38. * The facility failed to ensure three of three informed consents for Resident 80's Restoril (hypnotic) medication were completed in a timely manner with the prescriber's signatures. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide a reasonable accommodation to meet the needs of one of 105 residents in the facility (Resident 111). * The facility failed to ensure Resident 111's call light was within the resident's reach. This failure had the potential to negatively impact the resident's psychosocial well-being and cause delays in receiving the needed care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident was assisted with the formulation of the advance directive (legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) for one of 22 final sampled residents (Resident 68) reviewed for advance directives. * Resident 68 who wished to formulate an advance directive was not provided assistance by the facility. This failure had the potential for the resident's decisions regarding the healthcare and treatment options not being honored.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the restraint free periods for one of 22 final sampled residents (Resident 7) reviewed. * The facility failed to ensure Resident 2's use of pommel cushion in wheelchair had a physician's order and informed consent obtained; and a care plan developed prior to the application of the restraint to the resident. These failures posed the risk of compromising the resident's independence and psychosocial well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the recommendations from the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level II determination was incorporated into the resident care for two of four final sampled residents (Residents 19 and 67) reviewed for PASRR. * The facility failed to coordinate the Level II PASRR recommendation into the assessment and care planning for Resident 19. * Resident 67's Level II PASRR Mental Health Evaluation was conducted on 6/5/25, with recommended specialized services. Resident 67 was readmitted to the facility on [DATE]; however, the facility failed to incorporate the Level II PASRR recommendations into Resident 67's plan of care. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the resident centered comprehensive care plan was developed for one of 22 final sampled residents (Resident 7). *The facility failed to ensure Resident 7's care plan was created for the use of pommel cushion in wheelchair. This failure posed the risk to not provide Resident 7 with the appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of 22 final sampled residents (Resident 2) was revised to reflect the resident's current care needs and interventions. * Resident 2's care plan for risk for renal failure was not revised to address the correct dialysis access site and the amount of fluid restriction as ordered by the physician. This failure posed the risk of not providing the resident with individualized and person-centered care.

Inspectors wroteBased on interview, medical record review, facility record review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for three of 22 final sampled residents (Residents 9, 10, and 19). * The facility failed to ensure the insulin (medication that regulates the amount of sugar level in the bloodstream) injection sites were rotated as ordered by the physician, for Residents 9 and 10. * The facility failed to ensure Resident 19's left forearm skin discoloration was monitored and care planned. These failures had the potential to result in ineffective treatment, worsening skin conditions, altered medication effectiveness, impaired insulin absorption, and tissue damage which could lead to negative resident outcomes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of a new pressure ulcer (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) for one of two final sampled residents (Resident 24) reviewed for pressure ulcers. * The facility failed to ensure Resident 24's alternating pressure pad (APP) mattress was connected to the device unit and properly working. This failure placed Resident 24 at risk of not benefiting from the therapy provided by the APP mattress and be at high risk of developing new pressure ulcers.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate treatment and services were provided to one of two final sampled residents (Resident 11) reviewed for positioning/mobility. * The facility failed to assess and check the skin of Resident 11 when the splint device was applied. In addition, the plan of care to address Resident 11's joint mobility failed to include the interventions for skin assessments when the splint device was applied to Resident 11's left hand. These failures had the potential to affect the resident's well-being while wearing the splint device.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of two final sampled residents (Residents 4 and 56) were evaluated for nutrition status, to receive the appropriate services needed to maintain acceptable parameters of nutritional status. * The facility failed to obtain Resident 4's weekly weights as per the physician's order and care plan. Resident 4 experienced a seven-pound weight loss in one month and the facility failed to ensure the resident was seen and evaluated by the RD as per the physician's order. * The facility failed to ensure Resident 56 was seen and evaluated by the RD for the weight loss of 7lbs in one week. These failures had the potential for further weight loss and for Residents 4 and 56 to not meet their nutritional needs.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate dialysis care was provided for one of 22 final sampled residents (Resident 47) reviewed for dialysis services. * The facility failed to ensure the emergency dialysis kit was kept at Resident 47's bedside. In addition, the facility failed to ensure Resident 47's AV shunt was assessed every shift and the blood pressure was not taken on the resident's left upper arm where the AV shunt located. These failures had the potential for the Resident 47 to not receive the necessary and/or immediate interventions to manage the dialysis access site and prevent possible medical complications.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure safe and effective pharmaceutical services for one of 22 final sampled residents (Resident 47) and one nonsampled resident (Resident 108). * Resident 47's Controlled Drug Record (CDR) failed to show documentation of an Ativan (medication to manage anxiety) 0.5 mg as wasted (disposed) by two licensed nurses when the medication was logged out of the CDR but not administered to Resident 47. * The facility failed to clarify Resident 108's physician order for famotidine (medication to treat heartburn) 40 mg and the medication's indication for use prior to the administration of the medication to Resident 108. These failures had the potential for inacurrate controlled medication accountability, drug diversion, or loss; [...]

Inspectors wroteBased on the observation, interview, facility document review, and facility P&P review, the facility failed to ensure safe medication labeling practices were followed for two of three medication carts inspected (Medication Carts A and B); failed to ensure the medications were not left unattended at the bedside for one nonsampled resident (Resident 109); and failed to ensure the medications were stored at the proper temperature range in accordance with the accepted standards of practice and/or manufacturer's instructions for one of one Central Supply storage area. * Two inhaler mouthpieces and an opened bottle of artificial tears eye drops were not properly labeled with sufficient information to clearly identify the specific resident for Residents 42, 65, and 75 stored inside Medication Carts A and B. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed for two nonsampled residents (Residents 29 and 95) reviewed for therapeutic diet. * The facility failed to ensure Residents 29 and 95 were served with the cappuccino mousse dessert as per the menu for the lunch meal on 6/15/26. This failure had the potential to not meet Resident 29 and 95'a nutritional needs and negatively impact the residents' nutritional health.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 22 final sampled residents (Resident 47) was accurate. * The facility failed to ensure Resident 47's information on the H&P and Physician Progress Note was accurate. This failure had the potential for the resident's care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to complete the MDS assessments accurately for one of 22 final sampled residents (Resident 11). * The facility failed to code Resident 11 for the application of the left hand splint. This failure posed the risk of Resident 11 not receiving the individualized plan of care based on the resident's specific needs.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure for a safe and secure environment for one of three sampled residents (Resident 1). * Resident 1 left the secured facility without the staff's knowledge, and was located two days later in an emergency department approximately 50 miles away. This failure put the resident at risk for injury while unsupervised in the community, without medications and medical care for an extended period of time.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to protect the resident's right to be free from physical abuse by another resident. * Resident 2 pushed Resident 1, causing Resident 1 to fall on the floor. This failure resulted in Resident 1 sustaining a left lateral superior pubic ramus and left inferior pubic fractures and/or psychosocial harm to the resident.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the P&P to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one of two sampled residents (Resident 1). * The facility failed to report an allegation of abuse in a timely manner when Resident 2 pushed Resident 1, causing Resident 1 to fall on the floor. This failure had the potential for abuse to go unreported and uninvestigated timely.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to provide the required skilled nursing services for one of four sampled resident (Resident 1). * The facility failed to timely notify the physician of Resident 1's abnormal radiology result. * The facility failed to manage Resident 1's pain after a fall. These failures had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the correct cutting board was used for raw poultry. * The facility failed to ensure the sanitizing solution used to sanitize food preparation surfaces was the proper concentration. * The facility failed to ensure kitchen equipment and utensils were clean . * The facility failed to ensure kitchen equipment and utensils were air dried . * The facility failed to ensure maintenance tools were stored in a sanitary manner . These failures had the potential to cause bloodborne illness in a medically vulnerable resident population of 94 who consumed food prepared from the kitchen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to assess if it was safe for one nonsampled resident (Resident 56) to self-administer the medications. * The facility failed to assess and develope a plan of care to address the self-administration of the medications when Resident 56 had a bottle of Flax Seed Oil (supplement) and Omegas + Tumeric (supplement) at the bedside. This failure had the potential for Resident 56 to administer the medications inaccurately and negatively affect the Resident 56's well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of 24 final sampled residents (Resident 106) received a Level II mental health evaluation, after a Level 1 Screening was positive for serious mental illness, for one of three final sampled residents, reviewed for PASRR. This failure posed the risk for Resident 106 not receiving specialized services beneficial to the resident's wellbeing.

Inspectors wroteBased on interview, medical records, and facility P&P review, the facility failed to ensure two of three final sampled residents (Residents 28 and 53) reviewed for PASRR were accurately screened. * The facility failed to ensure Residents 28 and 53 PASRR screenings were completed by the appropriate facility staff member. In addition, the facility failed to verify with DHCS when Resident 53's PASRR Level 1 screening was closed due to the facility staff not responding to two or more separate attempts of communication by DHCS. These failures posed the risk for Residents 28 and 53 not properly screened, and the risk to not receive adequate level of services, comprehensive assessment, intervention and evaluation for conditions related to Residents 28 and 53's mental disorder.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary services as ordered by the physician for one of one sampled resident reviewed for physician's consult (final sampled resident, Resident 82). * The facility failed to ensure the dermatology consult was provided to Resident 82 as ordered. This failure had the potential for the resident not to receive the necessary care and services.

Inspectors wroteBased on observation, medical record review, interview, and facility P&P review, the facility failed to provide the necessary restorative nursing services for one of three final sampled resident (Resident 53) reviewed for positioning and mobility. * The facility failed to ensure Resident 53 was applied carrot splint to both hands, and AFO to both feet for four hours as tolerated, per the physician's order. This failure had the potential for Resident 53's hand and foot contractures to worsen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 28) reviewed for elopement was free from accident hazards. * The facility failed to document Resident 28's wandering and/or exit-seeking behaviors and failed to conduct her elopement assessment accurately. Resident 28 was not assessed to be a high risk for elopement; however, the facility staff had observations of the resident verbalizing she wanted to go home or she wanted to leave the facility with her daughter, wandering around the facility, episodes of going outside the facility, and standing by the locked front door to wait for her daughter so she could leave the facility. In addition, the facility failed to provide Resident 28 with an ID bracelet as per the elopement assessment plan. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services related to the GT feeding were provided for one of three final sampled residents (Resident 62) reviewed for tube feeding. * The facility failed to ensure Resident 62's GT feeding rate was updated according to the physician's orders and failed to ensure Resident 62's GT feeding care plans were revised. These failures posed the risk for not providing the necessary GT care and interventions to Resident 62.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled resident (Resident 37) reviewed for dialysis care. * The facility failed to ensure Resident 37's vital signs and weight were monitored post-dialysis. This failure had the potential for delay in the provision of care to Resident 37 for complications of the dialysis treatment.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (nonsampled resident, Resident 13) reviewed for side rail use remained free from accident hazards due to the use of side rails. * The facility failed to obtain the physician's order and informed consent, review the risks and benefits, provide the least restrictive alternatives, and develop the plan of care for Resident 13's use of the side rails. This failure had the potential to place the resident at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to one final sampled resident (Resident 82) and one nonsampled resident (Resident 20). * The facility failed to ensure Resident 20's medications were administered as ordered by the physician and accurately documented in the MAR. * The facility failed to ensure the documentation for Resident 82's controlled medication administrations were accurate and complete. * The facility failed to ensure the narcotic sheets inventory were properly conducted showing the nurses' initials and signatures for Medication Cart B. Theses failures had the potential for the resident not to receive the necessary medications and posed the risk for diversion of the medications.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure two of 24 final sampled residents (Residents 37 and 53) were free from unnecessary drugs. * The facility failed ensure Resident 37 was not administered metoprolol (medication to treat high blood pressure) and clonidine (medication to treat high blood pressure) medications when Resident 37's blood pressure was below the parameter prescribed by the physician. * The facility failed to ensure Resident 53 was administered with metoprolol medication when Resident 53's blood pressure was below the parameter prescribed by the physician. These failures had the potential for the residents to develop the significant side effects such as hypotension and negatively affect the residents' health condition and well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure 7 of 11 final sampled residents (Residents 12, 13, 28, 37, 44, 53, and 73) reviewed for unnecessary medications were free from unnecessary psychotropic drugs. * The facility failed to ensure Resident 37's was accurately monitored related to the use of Remeron (antidepressant medication). Resident 37's meal intake documentation was inconsistent, showing either a % or a hashmark, and did not match the CNA's Documentation Survey Report. In addition, the monthly behavior summary of the episodes of Resident 37's meal intake less than 50% did not match the MAR nor the CNA's Documentation Survey Report. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 20) was free from the significant medication errors. * The facility failed to provide Resident 20's Zyprexa (antipsychotic medication) as ordered by the physician and accurately document the Zyprexa administration. This failure placed Resident 20 at risk for medical complications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of the medications for two of five Medication Cart (Medication Carts A and B) when: * The facility failed to ensure the orally administered medications were stored separate from externally used medications and supplies in Medication Cart A. * The facility failed to ensure Medication Cart B was not left unlocked and unattended by the licensed nurses while parked in the hallway. These failures had the potential to negatively impact the residents' well-being and opportunities for drug diversion or drug misuse.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff were competent in their position related duties when: 1. Two of 13 kitchen employees (Dietary Aides 2 and 3) were unable to correctly test the sanitizing solution used to sanitize the food preparation surfaces in the kitchen and sanitize the food preparation equipment washed in the manual ware washing sink. 2. One of 13 kitchen employees (Cook 1) did not know the correct cutting board to be use when preparing raw poultry. These failures posed the risk for exposure to unsafe food handling practices which could lead to food borne illness in the 94 vulnerable residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the nutritional needs were met for two of 82 nonsampled residents (Residents 11 and 70) who received a vegetarian diet preference when the lunch meal served provided nine grams of protein vs 28 grams of protein per the regular menu. This failure posed the threat of the nutritional needs; specifically the protein needs for Residents 11 and 70 to not be met which could lead to medical complications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure food brought to the facility from family members or visitors was stored, prepared and safe food handling practices were followed. This failure had the potential for unsafe food handling which could lead to food borne illness in the 94 residents receiving an oral diet who resided in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled resident reviewed for hospice services (Resident 49). * The facility failed to ensure Resident 49 received the hospice care visits three times a week by the Certified Home Health Aid and one to three visits a week from the Skilled Nurse. * The facility failed to assign a designated hospice coordinator for Resident 49. These failures posed the risk for delays in the communication between the hospice provider and the facility which may affect resident care.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices were implemented as evidenced by: * The employees and residents' personal belongings were in the laundry room's clean folding area. * The facility failed to clean the spoon container on the Medication Carts for two of five medication carts inspected (Medication Carts B and C). These failures had the potential for spread of infection.

Inspectors wroteBased on observation, interview, and facility document and facility's P&P review, the facility failed to ensure the essential equipment was maintained in proper working order when: * The ice machine manufacturer's guidelines for cleaning and sanitizing were not followed. * The microwave located on Station 1 was not maintained in a safe operating condition. * Two medication refrigerators and one specimen refrigerator were observed with ice buildup. These failures had the potential for equipment hazards or unsafe practices which could affect the residents' well-being in the facility.

Inspectors wrote3. On 1/21/25 at 0900 hours, during the initial tour of the facility, Resident 37 was observed in bed with bilateral grab rails elevated. Resident 37 stated she used the grab rails when turning and repositioning during incontinence care. Medical record review for Resident 37 was initiated on 1/30/25. Resident 37 was readmitted to the facility on [DATE]. Review of Resident 37's MDS dated [DATE], showed Resident 37 was cognitively intact, with impairment to the upper extremities, and required partial/moderate assistance for mobility. Review of Resident 37's Bedrail/ Grab bar use and Entrapment Risk Evaluation dated 1/3/25, showed the following: - The grab bars were requested by the resident, and the resident demonstrated the ability to use the grab bars; - The possible risks of entrapment were discussed, and verbalized understanding and agreement for continued use. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment for one of 24 final sampled residents (Resident 72) and one nonsampled resident (Resident 4). * Resident 72 resided in Room A and Resident 4 resided in Room B. Rooms A and B were observed with scratches and unpainted areas on the walls, adjacent to the residents' bed. This failure had the potential to negatively impact the residents' quality of life.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide a notice of transfer/discharge to the Ombudsman for one of two sampled residents (Resident 109) reviewed for closed records. This failure posed the risk for Resident 109 and Resident 109's representative not being aware of their appeal rights and potentially jeopardizing the appeal process in the event Resident 109 and/or Resident 109's representative felt the facility-initiated transfer or discharge from the facility was inappropriate or involuntary.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record was complete and accurately maintained for one of 24 final sampled residents (Resident 8). * Resident 8's POLST and Advance Directive Acknowledgement form failed to show documentation as to whether Resident 8 had formulated an advance directive. This failure had the potential for the resident's wishes specific to health care interventions not being honored.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) remained free from the accident hazards. * CNA 1 had provided ADL care to Resident 1 in bed by herself instead of two or more persons to assist as per the resident's MDS and plan of care. When CNA 1 turned the resident to the right side, the resident rolled and fell off the bed to the floor sustaining multiple bruises and a skin tear to the right cheek. This failure had the potential for Resident 1 to sustain serious injury.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop and implement the individualized resident-centered plans of care for one of two sampled residents (Resident 2). * Resident 2's care plan interventions were not implemented as recommended in PASRR Level II evaluation. * Resident 2's desire to be discharged to a lower level of care was not assessed by the IDT team and reflected in the plan of care. These failures posed the risk of not providing appropriate and individualized care to Resident 2 to maintain her highest practicable physical well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the ice machine was maintained in sanitary condition. * The facility failed to follow proper sanitation and food handling practices to prevent a potential outbreak of foodborne illnesses during the preparation of pureed foods. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain a copy of advance directive for one of 22 final sampled residents (Resident 44). This had the potential for the residents' advanced care planning decisions regarding the health care and treatment options not being honored.

Inspectors wroteBased on interview, medical record review, facility document review, and DHCS PASRR guidelines review, the facility failed to ensure PASRR Level II Mental Health Evaluation was conducted as required for two of 22 final sampled residents (Residents 44 and 60). This failure had the potential for the residents to not receive the specialized care and services appropriate for their condition.

Inspectors wroteBased on the observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 22 final sampled residents (Resident 36) and one nonsampled resident (Resident 35). * Resident 36's Floranex (probiotic supplement) was not administered as ordered by the physician. * Resident 35's florastor (probiotic supplement) and carbonyl iron (supplement) were not administered as ordered by the physician. These failures posed the risk for possible complications related to residents not receiving the prescribed medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 22 final sampled residents (Resident 45). * Resident 45 who had bilateral ½ sides in bed was not assessed for risk for entrapment. This failure posed the risk for injury from side rail use.

Inspectors wroteBased on the observation, interview, medical record review, and facility P&P review, the facility failed to maintain the accurate medical record for one nonsampled resident (Resident 35). * LVN 1 documented on the MAR for Resident 35's Florastor (supplement) and carbonyl iron (iron supplement) as given when they were not administered during the medication administration observation. In addition, LVN 1 documented both of Resident 35's medications as administered even when they were not available. These failures had the potential for the resident's care not being met as his medication administration was inaccurate.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment were implemented. * The facility failed to use the appropriate disinfectant to clean the porous foam on Resident 45's bilateral siderails. This posed the risk for not adequately cleaning and disinfecting the resident's equipment.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure regular inspection of all bed frames, mattresses, and side rails as part of the regular maintenance program to identify areas of possible entrapment. This had the potential to negatively impact the residents in the facility.