Lighthouse Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to notify the Power of Attorney (POA, a legal document that lets one person, act on their behalf) for health care decisions, during Changes of Condition (COC- a noticeable or measurable deviation in a person's physical, mental, or functional health status compared to their normal baseline), for one of 4 residents' (Resident 1). This failure violated the resident's instructions and the resident representative's rights provided by the state law and resulted in the resident's POA for healthcare decisions not aware of the residents changes in medical condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure, one of four sampled residents (Resident 1), did not develop pressure sores (injuries to the skin over bony areas), at the facility. The facility failed to: 1). Develop a baseline care plan (initial person-centered care plan within the first 48 hours of admission, that will provide instructions for care of the resident) with interventions to prevent Resident 1 from developing a skin breakdown. 2). Ensure the Certified Nurse Assistants (CNAs) conducted skin checks during showers and bed baths, as indicated in the facility's policy and procedure (P&P titled Skin Care Tips for CNAs. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to maintain a complete and accurate resident medical records, for one of four residents (Resident 1). This failure resulted in resident medical records not available and not accessible when needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received adequate supervision and assistance devices to prevent accidents. The facility failed to: 1). Implement Resident 1's care plan titled, At high risk for falls and injuries related to diagnosis of quadriplegia (paralysis from the neck down, including legs, and arms) and dementia (a progressive state of decline in mental abilities), which indicated to use a hoyer lift (a mechanical device used to lift and/or transfer a person from place to place) during transfers. 2). Ensure Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/3/2026, indicated the resident required the use of a hoyer lift for transfers. 3). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Unusual Occurrence (an unexpected event or accident that results in significant harm or requires significant additional measures) Reporting , which indicated the facility will report unusual occurrence by phone and in writing to the appropriate Stated or Federal agencies, within 24 hours, when one of three sampled residents (Resident 1), sustained fracture ( broken bone) on the left tibia/fibula (long bone in the lower leg), and distal fibula (lower end of the 2 long bones in the lower leg) on 6/8/2026. This failure delayed the investigation by the California Department of Public Health (CDPH) and placed Resident 1 and other residents at risk for potential neglect and abuse.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality, for one of three residents (Resident 1), by failing to: 1). Ensure Resident 1's pain level was reassessed and documented within one hour, after the pain medications were administered on 3/13/2026, 3/15/2026, 3/16/2026, 3/17/2026, 3/19/2026, 3/20/2026, 3/21/2026, 3/26/2026, 3/27/2026, 3/28/2026 and on 4/2/2026 and 4/3/2026.2). Clarify from Resident 1's physician, the orders of Tylenol (a pain-relieving medication), 500 milligrams ([mg], metric unit of measurement, used for medication dosage and/or amount) given for moderate pain and Tylenol 325 mg two (2) tablets (650 mg.) given for mild pain.3). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure (P&P) titled Change of Condition Notification, revised 5/1/2018, for one of two sampled residents (Resident 1) when Resident 1's order for oral antibiotics was not transcribed or carried out, and staff failed to document 72-hour monitoring and develop a care plan for Resident 1's change of condition (COC) identified on 3/5/2026. These deficient practices placed Resident 1 at risk for complications from missed antibiotics, including worsening of a potential infection. This also placed Resident 1 at risk for developing unidentified complications requiring nursing or medical intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen that affected 123 residents out of 125 sampled residents when: 1. One container that contained margarine, one opened bottle of whipped cream, one opened bottle of chocolate syrup, one box of dairy creamer, and one bag of parmesan cheese with no use by date (date the food item must be consumed by), were stored in the refrigerator. 2. The can opener was not maintained in a sanitary manner. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 123 of 125 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain good grooming and personal hygiene for two of 25 sampled residents (Resident 29 and 68) by failing to: 1. Ensure Resident 29 was bathed. 2. Keep Resident 68's fingernails clean and trimmed. These deficient practices had the potential to negatively impact Resident 29 and 68's quality of life and self-esteem. These deficient practices also had the potential to result in the development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Residents 89 and 29) received the necessary care and services to maintain normal bladder function. Resident 89 did not receive daily urinary catheter care and Resident 29's urinary catheter was not secured with a leg strap. These deficient practices had the potential to result in a urinary tract infection (UTI- an infection in the bladder/urinary tract), urethral injury and / or unnecessary discomfort for Resident 89 and Resident 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that its medication error rate was less than five percent (%). There were two medication errors out of 31 total opportunities which contributed to an overall medication error rate of 6.45% affecting two of five residents observed for medication administration (Resident 23 and Resident 60). Resident 23 and Resident 60 did not receive medications per Physician's Order, nor did the pharmacy have the medication available for Resident 23. The deficient practice of failing to administer medications in accordance with the physician's orders, including pharmacy not having the prescribed medication available, increased the risk that Residents 23 and 60 may have experienced medical complications possibly resulting in hospitalization.

Inspectors wroteBased on observation, interview, and record review, the licensed nursing staff failed to ensure a resident was free from significant medication errors when staff failed to ensure the following for one of six sampled residents (Resident 23): 1. Resident 23's blood pressure medication was administered as ordered when the licensed nursing staff crushed and administered isosorbide mononitrate (a blood pressure medication) oral tablet 30 milligrams (mg- a unit of measurement) extended-release (ER- a medication that is formulated so that the drug is released slowly over time) in place of the prescribed isosorbide mononitrate 30 mg immediate release (IR- medication that allows for immediate absorption) on 14 occasions. 2. The pharmacy supplied the facility the correct form and dose of isosorbide mononitrate oral 30 mg for Resident 23, as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's preference regarding personal care by assigning a male certified nursing assistant (CNA) to provide showers to one of eight sampled residents (Resident 86) when the resident requested to have female CNAs assigned on her shower days. This failure resulted in a violation of Resident 86's personal dignity and right to make decisions about her care.

Inspectors wroteBased on interview and record review, the facility failed to timely submit the referral for probate conservatorship (referral to the court to appoint a conservator [an appointed person to act or make decisions for a person who cannot make decisions for themselves]) for one of three sampled residents (Resident41), who did not have the capacity to make decisions. This deficient practice resulted in the delay in the process of obtaining a conservator, which resulted in the Interdisciplinary Team ([IDT], a coordinated group of experts from several different fields) overseeing Resident 41's care.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the residents prior to treatment with psychotropic (medications that affect brain activities associated with mental processed and behavior) medications for two of six sampled residents (Residents 77 and 86) by failing to: 1. Obtain informed consent from Resident 77, for the use Chlorpromazine (an antipsychotic medication [a medication that effects the mind, emotion, and behavior]). 2. Ensure Resident 86's informed consent for Risperidone (an antipsychotic medication), and Seroquel (an antipsychotic medication) was renewed every six months. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was kept within reach for two of 25 sampled residents (Resident 23 and Resident 34). This deficient practice removed Resident 23's and Resident 34's ability to exercise their right to request assistance from staff and created the potential for accidents and/or delays in care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Sets (MDS, a resident assessment tool) for three of 25 sampled residents (Residents 72, 76, and 83) accurately reflected the care and services they received. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding the above residents' health status and unique healthcare needs. This deficient practice also created the potential for Residents 72, 76, and 83 to not receive the interventions needed monitor the effectiveness of the care received.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan for five of 25 sampled residents (Resident 94, 101, 121, 83 and 77) by failing to: 1. Develop a care plan to address Resident 94's use of valproic acid (an anticonvulsant medication, a medication used to prevent or treat seizures and can be used to treat behavioral disorders). 2. Develop a care plan for Resident 101's wearable external heart defibrillator (a device that provides an electric shock to the heart to allow it to treat a potentially fatal abnormal heart rhythm). 3. Develop a care plan for the refusal for Restorative Nurse Aid services (nursing interventions that promote a person's ability to adapt and adjust to living as independently and safely as possible) for Resident 121, a resident diagnosed with an extremely painful bone disorder that severely affected his mobility. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise one of five sampled resident's (Resident 5) care plan and interventions after Resident 5 had an unwitnessed fall on 11/24/2025. This deficient practice had the potential to result in Resident 5 sustaining a major injury after another fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 76) had floor mats (cushioned floor pads designed to help prevent injury should a person fall) placed appropriately to prevent injury related to potential falls. This deficient practice placed Resident 76 at risk of experiencing injuries related to falls, such as bruises and/or broken bones.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change the nasal cannula (device used to deliver supplemental [extra] oxygen placed directly on a resident's nostrils) and humidifier (water used to increase the moisture while providing oxygen therapy) weekly and store an oxygen mask (mask placed over the nose and mouth and connected to a supply of oxygen) inside a plastic bag in accordance to the facility's policy and procedure for one of three sampled residents (Resident 29). This deficient practice had the potential to result in an increased the risk for Resident 29 to acquire a respiratory infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Registered Nurse (RN) 1, RN 2, and Licensed Vocational Nurse (LVN) 4 practiced the necessary competencies when providing care and services when the following occurred: 1. RN 1 did not correctly interpret or carry out Resident 115's physician order to change the resident's urinary catheter (thin tube inserted into the bladder) drainage bag (a medical device used to collect urine that is drained from the bladder). 2. RN 2 and LVN 4 did not know the facility policy and procedure (P&P) for replacing a resident's humidifier bottle (a device that adds moisture to the oxygen being delivered). These deficient practices placed the residents at risk for infection and illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services and routine medications for two of six sampled residents (Resident 23 and Resident 60). Resident 23 and Resident 60 did not receive medications per Physician's Order, nor did the pharmacy have the medication available for Resident 23. These deficient practices had the potential to cause adverse outcomes to the residents such as low blood pressure and cerebral hypoperfusion (inadequate blood flow to the brain) for Resident 23, and gastric upset for Resident 60.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of one sampled resident (Resident 5) with weighted utensils (eating tools designed to be heavier, providing added weight to help stabilize shaking hands and reduce hand tremors) in accordance with the physician's order. This deficient practice had the potential for Resident 5 to become discouraged in self-feeding due to difficulty handling regularly weighted utensils.

Inspectors wroteBased on observation, interview, and record review, infection control measures were not maintained for two of 25 sampled residents (Resident 13 and Resident 78) when Certified Nursing Assistant (CNA) 5 failed to implement enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] that employs targeted gown and glove use during high-contact resident care activities that are associated with a high risk of MDRO colonization, such as presence of a gastrostomy tube) and failed to perform hand hygiene (hand washing with soap or using alcohol-based hand rubs) while providing direct patient care. These deficient practices placed the residents at risk for infection and illness.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure one of 25 sampled residents (Resident 6) had a functioning call light. This deficient practice resulted in Resident 6's inability to call for staff assistnace or express his needs, and placed him at risk for delayed care and/or accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was offered and provided showers and baths, who required assistance with Activities of Daily Living (ADLs). This failure had the potential to cause skin irritation, infections and negatively affect the residents' psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 1) received treatment and care in accordance with professional standards of practice by failing to ensure Resident 1's Primary Care Provider (PCP) was notified of the resident's refusals of showers/baths and wound care treatment. This failure had the potential to place Resident 1 at risk for worsening skin conditions and complications from wound care noncompliance such as sepsis (a life-threatening blood infection), hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure weekly skin checks were documented timely for one out of five sampled residents (Resident 1). This failure had the potential to result in inaccurate information communicated between healthcare providers and a delay in the provision of care or interventions for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe transfer to a medical appointment for one resident of three sampled residents (Resident 1) by failing to:1. Ensure a transportation vehicle was parked in a designated parking space to transport Resident 1 to a dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) appointment. The medical transportation van was double parked (parked beside a row of vehicles already parked parallel to the curb) in the middle of a street.2. Ensure staff was in-serviced on safe resident transportation to medical appointments.3. Follow its policy and procedure (P&P) titled Accidents and Incidents, which indicated the facility will comply with current rules and regulations to prevent accidents.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents was free from physical abuse for one of four sampled residents (Resident 1). This deficient practice resulted in Resident 1 being hit with a wet floor sign cone ([12 inch wide and 36-inch height 36 between 5-10 pounds] a safety measure used to notify of a slippery surface) by Resident 2, and left Resident 1 feeling threatened (the sense that something bad might happen) and scared for his life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents ' environment remained free of accident hazards by keeping housekeeping cones (wet floor signs) unattended in residents ' rooms. This deficient practice resulted in Resident 1 being hit by Resident 2 with a wet floor sign-cone ([12 inch wide and 36-inch height 36, and between 5-10 pounds] a safety measure used to notify of a slippery surface) and had the potential to cause physical harm to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility staff failed to ensure one out of two sampled residents (Resident 1) was informed about her medical coverage during her stay at the facility by: 1. Not informing Resident 1 that she did not have a secondary coverage (insurance that pays after primary coverage, it will cover the remaining costs that the primary insurance did not cover) for the length of her stay at the facility. 2. Not assisting Resident 1 with the process of applying for a secondary coverage. These deficient practices resulted in Resident 1 to live at the facility without being informed she had no medical coverage and Resident 1 received a medical bill for the uncovered amount.

Inspectors wroteBased on interview and record review, the facility failed to ensure, one of three residents (Resident 1), received treatment and care in accordance with professional standards of practice by failing to ensure: 1. The license nurse notified the attending physician (MD) for Resident 1's blood sugar (BS) level of 55 milligrams/ deciliter ([mg/dl] unit of measurement, normal BS level 70 to 99 mg/dL) on 1/24/2024 at 11:30 a.m. 2. Administer Glucagon 1 mg. Intramuscular ([IM] injection of medicine into the muscles) on 1/24/2024 at 11:30 a.m. when Resident 1 had a blood sugar level of 55 mg/dl as indicated in Resident 1's physician order to administer Glucagon 1 mg. IM, if BS was less than 60 mg/dl. 3. Resident 1, who was diabetic and on multiple medications to lower blood sugar levels, was assessed when Resident 1 became nonverbally responsive on 1/24/2024 at 11:41 p.m. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled Communication Barriers, which indicated the facility will provide effective interpretation or arrange for a qualified interpreter to meet the needs of residents who had a hearing, visual, or speech disability, for one of one sampled resident (Resident 107). The facility failed to: 1. Provide Resident 107 with communication aides to enable Resident 107 communicate her needs to staff. 2. Ensure staff used communication tools such as a writing board or American Sign Language (ASL) when communicating with Resident 107. 3. Assess Resident 107's behaviors of agitation, frustration, and desire to leave the facility. 4. Assess the cause of Resident 107's poor oral intake starting on 6/8/2024. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP), who was responsible for the facility's Infection Prevention Control Program, completed ten hours of continuing education training on an annual basis. This deficient practice had the potential for the IP to be unaware and be unable to educate the facility's staff of updated information regarding Infection Prevention and Control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents and/or responsible party were informed in advance, of the risks and benefits of the use of physical restraints (manual method or device used to restrict freedom of movement or normal access to one's body) for five of 12 sampled residents (Resident 66, Resident 71, Resident 15, Resident 88, and Resident 16). These deficient practices resulted in the violation of Resident 66, 71, 15, 88, and 16's and/or responsible party's right to make an informed decision regarding the use of physical restraints.

Inspectors wrote5. During an observation on 6/10/2024 at 10:36 a.m., in Resident 93's room, Resident 93 was observed lying in bed. Resident 93's bed was observed against the wall, and bilateral siderails upper position. A review of Resident 93's admission Record, indicated Resident 93 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 93's diagnoses included chronic obstructive pulmonary disease ([COPD] a chronic lung disease that causes obstructed airflow from the lungs) and chronic kidney disease (loss of kidney function). A review of Resident 93's MDS, dated [DATE], the MDS indicated Resident 93's cognitive skills for daily decision making was intact. The MDS indicated Resident 93 required moderate assistance (helper does less than half the effort) from staff for toileting hygiene, shower, and personal hygiene. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement, and update the comprehensive care plan for 15 out of 25 residents (Resident 88, 10, 13, 66, 109, 11, 71, 15, 16, 17, 93, 40, 13, 36, and 112) by failing to: 1. Develop a comprehensive care plan for Resident 88's use of Buspirone (a medication used to treat mental illness) and to address the problematic behavior of auditory hallucinations (hearing voices to harm self or others), and Resident 17's use of Ativan (a medication used to treat anxiety [feeling of unease, excessive worry]). 2. Develop a comprehensive care plan for Resident 10's behavior of wandering into Resident 13's room. 3. Develop a comprehensive care plan for Resident 66's use of dentures. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for four of 14 residents (Resident 13, Resident 16, Resident 47, and Resident 98) by failing to: 1. Check Resident 98's soiled diaper in a timely manner per facility policy and professional standards. 2. Keep Residents 13, 16, and 47's nails clean and neat. These deficient practices had the potential to result in a negative impact on Resident's 98, 13, 16, and 47's quality of life and self-esteem, and had the potential for the development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the medical need, obtain a physician order, and informed consent for the use of bed side rails for nine of nine sampled residents (Resident 93, Resident 40, Resident 13, Resident 36, Resident 112, Resident 66, Resident 71, Resident 88, and Resident 16). These deficient practices had the potential to place Residents 93, 40, 13, 36, 112, 66, 71, 88, and 16 at risk for accidents, injury, and hazards such as entrapment and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed food production recipes and fortified diet (diet to increase caloric intake) guidelines during lunch service when: 1. Fortified diets (diet enriched to increase caloric content) were not prepared and served to 10 residents who were receiving a fortified diet. 2. 17 residents who were prescribed a pureed diet (foods that do not require chewing and are easily swallowed in which all foods should be smooth and pureed to the consistency of pudding) received pureed vegetables (carrots and green beans) that were lumpy, not smooth, and had chunks which required chewing before swallowing. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. One package of ready to eat ham was stored in the walk-in refrigerator with no thaw date. One large tray of breaded fish, two large packages of diced pork and six logs of ground beef were thawing in the walk-in refrigerator with no pulled out of the freezer or thaw date. One plastic storage bag with a breaded food item stored in the reach in freezer had no label or date. 2. The ice machine was not maintained in a clean manner and the inside compartment of the ice machine was observed with black residue. 3. Dietary Aide 1 did not follow cleaning and sanitizing procedures when there was raw ground beef in the food preparation sink, and when [NAME] 1 used the same sink to drain ready to eat cooked vegetables. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS, a standardized resident assessment care screening tool) were accurate for two of seven sampled residents (Resident 17 and 88) when the facility failed to: 1. Include the presence of hallucinations (an experience involving the apparent perception of something not present) for Resident 17. 2. Include a diagnosis of anxiety disorder per information in the medical record for Resident 88. Theses deficient practices had the potential to negatively affect Resident 17 and Resident 88's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals with a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) assessments were accurate, and that determination for the necessity of potential necessary services was completed for two of 25 sampled residents (Resident 109 and Resident 25). This deficient practice had the potential for Resident 109 and Resident 25 to not receive the required services and care needed for their diagnosed mental disorders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer (a wound that develops from prolonged pressure depriving the tissue from receiving oxygen) for one out of three residents (Resident 58). The deficient practice had the potential to cause serious infection, tissue injury, and extreme discomfort to Resident 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the environment free from hazardous maintenance tools and nails in the room for two out of eight residents (Resident 10 and Resident 51). The deficient practice had the potential to cause injury to Resident 10 and 51 by coming into direct contact with sharp objects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the Registered Dietician's (RD, a health professional who has special training in diet and nutrition) recommendations for one of 25 sampled residents (Resident 66), when staff were unaware of recommendations for Resident 66 to be initiated on a Restorative Nursing Aid (RNA, a certified nursing assistant primarily assigned to perform therapeutic exercises and activities to maintain or re- establish a resident's optimum physical function and abilities) feeding program (a medical and nutritional treatment regimen to aid those with nutritional concerns). This deficient practice increased the risk for Resident 66 to sustain further weight loss and not meet his nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled Behavior - Management, which indicated when a resident displayed new behavioral symptoms, staff would use effective verbal and non-verbal communication techniques to manage the behavior problems, prior to initiating psychotropic medications (medications used to treat anxiety) for one of one sampled residents (Resident 107), who was deaf and visually impaired. The facility failed to ensure: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one bottle of Gabapentin (a medication used to treat nerve pain) 250 milligrams (mg - a unit of measure for mass) per 5 milliliters (ml - a unit of measure for volume) was stored in the refrigerator in one of three inspected medication carts (Station 2 Medication Cart 2) for Resident 62. The deficient practice of failing to store medications per the manufacturers' requirements increased the risk that Resident 62 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodated residents' preferences and offer meal substitutes of the same nutritive values for one of six sampled residents (Resident 112). These deficient practices had the potential to alter Resident 112's nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was supervised while walking. Resident 1 was allowed to walk independently after being assessed by the physical therapist (PT, professionals who educate patients about exercises for muscle strength, coordination, and balance) as requiring moderate assistance (staff does half the work for the resident) while walking. This deficient practice resulted in an avoidable fall. Resident 1 fell at the front lobby and sustained a bump on the back side of her head, a right hip fracture (broken bone) that required admission and surgical intervention at the general acute care hospital (GACH) for six days.

Inspectors wroteBased on interview and record review, the facility failed to accurately obtain blood pressure readings to determine if two of four sampled residents (Resident 1 and Resident 2) have orthostatic hypotension (a form of low blood pressure that happens when standing after lying down or sitting). This deficient practice had the potential for Resident 1 and Resident 2 to experience delayed medical interventions, falls, and injuries due to not having their orthostatic blood pressures (taken while lying, sitting, and standing to determine orthostatic hypotension) taken appropriately to determine orthostatic hypotension.

Inspectors wroteBased on interview and record review, the facility failed to implement the care plan by providing a two staff assist when turning and repositioning one of 4 sampled residents (Resident 2). This deficient practice had the potential for Resident 2 to be at risk for a fall or injury.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to notify the physician of behavior changes for one out of four sampled residents (Resident 2). This deficient practice had the potential to result in harm for Resident 1 by not informing the physician of Resident 2's mental health decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its abuse prevention policy by failing to report the unusual occurrence of a resident-to-resident altercation to the State Survey Agency (SA) within 2 hours after the allegation occurred for one of four sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for elder abuse.

Inspectors wroteBased on interview and record review, the facility failed to report an incident of a resident-to-resident altercation between two of two sampled residents (Resident 1 and Resident 2) within two hours from the time the altercation occurred. The above failure had the potential to cause a delay in the notification of necessary agencies and the timeliness of their investigations, and the potential for additional altercations between Resident 2 and other facility residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure Physician Orders for Life-Sustaining Treatment ([POLST] a written medical order that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) for one of three sampled residents (Resident 1) was honored. The deficient practice resulted in Resident 1's end of life care wishes, not being followed, and had violated her preference and residents' rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control measures and the prevention of COVID-19 (a highly contagious infection that easily spreads from person to person) when: 1. Resident 1, who was COVID-19 positive (confirmed infected or sick), was not isolated from other residents (Resident 2 and Resident 3) from 12/5/2023 to 12/12/2023, while other rooms were empty. 2. Resident 2 and Resident 3, who were exposed to COVID-19 (close contacts) but negative (not confirmed infected or sick), were kept in the same room of a COVID-19 positive resident from 12/5/2023 to 12/12/2023, while other rooms were empty. 3. Resident 2 and Resident 3 were not wearing a face mask before or after eating in the room. 4. Resident 2 left her room without a mask. 5. [...]

Inspectors wroteBased an observation, interview, and record review, the facility failed to label three (3) insulin (a medication used to regulate blood sugar levels) pens with an open date in accordance with the facility's policy in two (2) of three (3) inspected medication carts for Resident 4, 20, and 100. This deficient practice increased the risk for Resident 4, 20, and 100 to potentially receive medication that may have become ineffective or toxic due to the failure of not labeling medication with an open date which may have potentially resulted in harmful side effects, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility's kitchen staff failed to demonstrate the correct calibration technique (process of validating the thermometer was working properly) for a food thermometer. This deficiency had the potential to result in food being held at unsafe temperatures, thus potentially compromising food safety and contaminating foods that facility residents consume.

Inspectors wroteBased on observations, interviews and record reviews, the facility's staff failed to store and prepare food under sanitary conditions in the kitchen, by failing to: a. Ensure the ice machine was clean. b. Remove the rubber object in the bottom shelf of the walk-in refrigerator. c. Monitor the temperature in the dry storage area and date the bags of hamburger buns and loaves of bread. These deficient practices had the potential to result in the transmission of infectious agents that can lead to food born illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for two of 45 sampled residents (Resident 17 and 62) when the facility did not: a. Use a dignity bag (blue nonwoven material that conceals fluid in the drainage bag to improve resident dignity) for Resident 62's Foley catheter drainage bag (device that holds the urine that drains from the resident's body). b. Serve Resident 17's meal at the same time with the roommates. These deficient practices had the potential to negatively affect Resident 17 and 62's 's self-esteem and self-worth and to cause psychosocial harm or decline to the residents and violates residents' right to be treated with dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation clarifying if a resident had an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) or not for one (1) out of the 23 sampled residents (Resident 95). This deficient practice had the potential to result in confusion in the care and services for Resident 95 and placed the resident at risk of receiving unwanted treatment and not receiving appropriate care based on her wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of two residents (Resident 105 and 100) were free from physical restraints (any manual method adjacent to the resident's body, that cannot be removed easily by the resident, and restricts the resident's freedom of movement) by failing to: a. Identify position change alarms (alerting devices emit an audible signal when the resident moves in certain ways) as physical restraints. b. Assess the residents (Resident 100 and 105) prior to use of position change alarm. c. Ensure documentation of a medical symptom that warrant the use of position change alarm. d. Ensure the alarms were not used for staff convenience. e. Ensure individualized care planning by the Interdisciplinary team (IDT) that addressed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the minimum data set ([MDS] a comprehensive standardized assessment and screening tool) assessment accurately reflected resident's medical status for three of three sampled Residents (Residents 81,100 and 94). This deficient practice had the potential to negatively affect Residents 81,100 and 94's plan of care and cause delay of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan to meet the preferences and goals, and address the residents' medical, physical, mental, and psychosocial needs for three of three sampled residents (Resident 1, 81, and 90 ). This deficient practice may potentially result in the facility not providing the residents' individual needs, services, and care to attain or maintain his or her highest practicable quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of seven sampled residents (Resident 22, 105, 94, 81, and 67) received treatment and necessary care in accordance with professional standards and in accordance with the plan of care (provides direction for type of nursing care to be rendered) by failing to: a. Comprehensively assess and report 126 bowel movements with a consistency of diarrhea/loose to the physician and manage Resident 67's diarrhea/loose bowel movements. As a result of this deficient practice Resident 67 experienced 126 diarrhea/loose bowel movements which led to Resident 67's suffered the discomfort of constantly having loose/diarrhea and needing to be changed frequently. Resident 67 was isolated to his room and did not want to go outside due to fear of having stool leak out of his adult brief. [...]

Inspectors wroteBased on interview and record review, the facility failed to manage and re-assess two of two sampled residents' (Resident 105 and 81) pain after the residents fell and sustained major injuries. a. Resident 105 fell and complained of pain six out of 10 ([moderate pain] 6/10) on a pain scale, the resident was medicated with no pain relief noted. There was no documented evidence the resident's pain was re-assessed after the pain medication was given. b. Resident 81 fell in the bathroom and complained of pain 5/10 on a pain scale to the left hip, the resident was given Tylenol 650 milligrams ([mg] unit of measurement). There was no documented evidence the resident's pain was re-assessed. This deficient practice resulted in Resident 105 and 81 experiencing necessary pain and lack of proper management of pain.

Inspectors wroteBased on observation, interview, and record review, the facility's staff failed to ensure the spreadsheet menu for a regular diet on 4/26/2022 was followed. This deficiency had the potential to result in residents receiving the wrong protein and caloric intake prescribed when not following the menu, which could result in undernutrition and further compromise the resident's medical status.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Ensure two of three residents (Residents 35 and 13) unvaccinated residents or partially vaccinated (received only one dose and needed another dose of the COVID-19 [a highly contagious viral infection] vaccine ) residents did not attend indoor communal dining during the COVID-19 outbreak (presence of least one confirmed COVID-19 resident) in the facility. b. Ensure Licensed Vocational Nurse (LVN) 2 wore personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) per recommended guidelines. These deficient practices had the potential to expedite the transmission of Covid-19 to the residents and staff of the facility; and thereby the community.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 105) had the right to be informed of, and participate in their care by not: 1. Obtaining informed consent (process in which residents were given important information, including possible risks and benefits, about a medical procedure or treatment) for Resident 105 prior to administering her with Remeron (medication used to treat depression [mental health disorder characterized by persistent sadness or loss of interest in daily life]) on 3/26/2022. 2. Updating and implementing the facility policy for treating residents without a decision-making capacity and without a representative to include the following, as per all facilities letter (AFL 20-83.1): i. Defined process for verbal and written notice ii. [...]

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to provide personal privacy for one of three residents (Resident 71) by not closing the privacy curtain or door while cleaning the private area of the resident. This deficient practice violated the resident's right to personal privacy.

Inspectors wroteBased on interview and record review, the facility failed to follow up with the status of the Pre-admission Screening and Resident Review ([PASRR] a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) Level II (a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has a Mental Disorder (MD), Intellectual Disability (ID) or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs) required evaluation and integrate the level of care into a plan of care for one (1) of one (1) sample resident (Resident 61). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the range of motion ([ROM] movement of the joints) decline of one (1) of three (3) sampled residents (Resident 22) when: a. The facility failed to provide RNA services for Resident 22 upon return to the facility on 1/3/2022. b. The Rehabilitation (services help people return to daily life and live in a normal or near-normal way) department did not re-attempt to reassess Resident 22 after she refused the initial attempt to screen for needed services upon re-admission to the facility on 1/3/2022. c. The Director of Rehabilitation (DOR) did not notify nursing services or the interdisciplinary team (IDT) team that Resident 22 refused the joint mobility assessment (JMA) on 1/4/2022. d. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, evaluate, and implement accident risks and hazard interventions for one of two sampled residents (Resident 94), who was identified as a high risk for falls and assessed on the Minimum Data Set ([MDS] resident assessment and care-screening tool) as having moderate visual impairment and requiring supervision, by failing to: 1. Provide supervision to prevent Resident 94 from having three fall incidents on 12/17/2021, 1/20/2022, and on 2/8/2022. 2. Comprehensively assess and follow up after each of Resident 94's fall incidents. 3. Ensure Resident 94's room was free from trip hazards. These deficient practices resulted in Resident 94 tripping and falling three times on 12/17/2021, 1/20/2022, and 2/8/2022. [...]

Inspectors wroteBased on observation, interview and record review, the facility's staff failed to ensure a Gradual Dose Reduction ([GDR] an attempt to decrease or discontinue) for a psychotropic (acting on the mind) medication was done after no more than three months, after starting on a psychotropic medication, unless clinically contraindicated for one of one sampled residents (Resident 100). This deficient practice had the potential to result in Resident 100 receiving unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility's staff failed to properly dispose of one of three sampled residents (Resident 56) tube feeding bag which was labeled with the resident's medical information. This failure had the potential outcome of residents' personal medical information being released to the public without the resident's knowledge or consent.