Long Beach Care Center, Inc

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), who was conserved (when a resident has a court appointed conservator who has legal authority to make certain decisions on the resident's behalf because the resident has been found unable to make those decisions independently), was allowed to return to the facility after he was arrested on 7/6/2026, taken to jail, released to self and subsequently admitted to a General Acute Care hospital on 7/7/2026. On 7/9/2026, Resident 1 was deemed medically and psychiatrically stable for discharge back to the facility but was refused admission. The facility failed to provide a written Notice of Proposed Transfer/Discharge to Resident 1, and/or his Conservator (a legal guardian appointed by the court to manage health or financial affairs of an individual). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse when Resident 2 punched Resident 1 with his fist. This deficient practice resulted in Resident 1 sustaining a 1.0-centimeter ([cm] unit of measurement) V-shaped avulsion (injury in which tissue is forcibly torn away or detached) to his right lower lip, an open area to his right inner lip, and abrasion to his right upper lip. Resident 1 required immediate first aid for 14 days and transfer to a General Acute Care Hospital (GACH) for evaluation.

Inspectors wroteBased on interview and record review, the facility failed to involve one of three sampled residents (Resident 3) in Interdisciplinary Team (IDT-team of health care professionals that work together toward and prioritize the resident 's needs) care conferences. This deficient practice violated Resident 3's rights to be informed and the right to participate in resident's plan of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident's (Resident 3)'s consultation reports were in Resident 3's medical records. This deficient practice had the potential to result in a delay in care and services and depict an inaccurate and incomplete record of care and services received by Resident 3.

Inspectors wroteBased on interviews and record reviews, the facility failed ensure one of two Residents (Resident 1) was not able to throw a pitcher of water and a container of urine on Resident 2, after Resident 1 kicked Resident 2 out of the bed and onto the floor. This deficient practice resulted in Resident 1 drenching Resident 2 in water and urine, after he had kicked Resident 2 out of the bed onto the floor. Resident 2 also sustained a left maxillofacial (jaws and the face) contusion (bruise).

Inspectors wroteBased on interview and record review the facility failed to implement its facility policy to ensure the environment was free from accident hazards when one of two sampled residents' (Resident 3) bathroom floor was wet on 10/19/2025. The deficient practice resulted in Resident 3 slipping and falling onto the wet bathroom floor causing her to land on her right arm and shoulder. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) was not subjected to abuse when Resident 1, who had aggressive behaviors and required one-to-one monitoring (a care approach where a dedicated staff member is assigned to closely observe and attend to the needs of a specific resident. This level of monitoring is crucial in managing residents with aggressive tendencies or other complex needs, ensuring that any potential incidents can be promptly addressed), was not assigned staff to monitor him. This deficient practice resulted in Resident 1 punching Resident 2 on the left side of his chest and had the potential for Resident 2's continued abuse and other residents to be assaulted by Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan for one of four sampled residents (Resident 1) whose interventions included one-to-one-monitoring (a care approach where a dedicated staff member is assigned to closely observe and attend to the needs of a specific resident. This level of monitoring is crucial in managing residents with aggressive tendencies or other complex needs, ensuring that any potential incidents can be promptly addressed) was implemented. This deficient practice resulted in Resident 1 not being provided one-to-one-monitoring, Resident 2 being left unsupervised and punching Resident 2 on the left side of his chest. This deficient practice had the potential for continued assault to Resident 2 as well as other residents who resided in the facility.

Inspectors wroteBased on interview and record review, the facility staff failed to ensure the physician for one of four sampled residents (Resident 1) was notified when Resident 1's dose of Heparin (medication to prevent the development of clots [masses of blood that form when blood cells stick together]) was missed and when Resident 1 was not transferred to a General Acute Care Hospital (GACH), per the physician's order. These deficient practices resulted in Resident 1's physician being unaware that Resident 1 did not receive a dose of Heparin, delayed evaluation, treatment and delayed transfer to the GACH. These deficient practices had the potential for development of and/or increase in the size of a deep vein thrombosis ([DVT] a blood clot in a vein, usually in the leg).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) was free from physical abuse when Resident 3 entered Resident 2's room and hit Resident 2 repeatedly with a plastic water pitcher and her fists. This deficient practice resulted in Resident 2 feeling afraid while using his arms in self-defense against Resident 3'a attack on him and sustaining a 1.0 centimeter ([cm]-unit of measurement) x 0.5 cm abrasion (a break in the skin when the skin rubs off) to the right side of his forehead, along with multiple areas of redness to Resident 2's right forehead and right forearm, requiring immediate first aid for seven days.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse to the California Department of Public Health (CDPH) for one of four sample residents (Resident 3) when Resident 3 was heard by facility staff accusing Resident 1 of raping her. This deficient practice resulted in CDPH being unaware of the allegation of sexual abuse and the inability to investigate the allegation timely. This deficient practice had the potential for information to be lost and/or forgotten and placed Resident 3 at risk for continued abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate one of four sampled residents' (Resident 3) allegation of sexual abuse when Resident 3 yelled and screamed at Resident 2 that he (Resident 2) raped her. This deficient practice resulted in the facility's inability to determine if the allegation had actually occurred and had the potential for other uninvestigated allegations of abuse to be uninvestigated.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 administered Heparin (a medication used to prevent the formation of blood clots [masses of blood that form when blood cells stick together]) as ordered by the physician for deep vein thrombosis ([DVT] a blood clot in a vein, usually in the leg) prophylaxis (treatment to prevent disease or infection from occurring or spreading) for one of four sampled residents (Resident 1). This deficient practice contributed to Resident 1 experiencing swelling and heaviness in her left lower extremity (leg), her subsequent transfer to a General Acute Care Hospital (GACH), where she was assessed and diagnosed with an extensive acute deep vein DVT of the left lower extremity.

Inspectors wroteBased on interview and record review, the facility staff failed ensure a Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for one of four sampled residents (Resident 1) was not falsified, when Licensed Vocational Nurse (LVN) 1 documented he administered a dose of Heparin (a medication to prevent the formation of clots [masses of blood that form when blood cells stick together]) to Resident 1 on 11/10/2025 at 2 p.m., when he had not given it to her and then on 11/17/2025 documented another incorrect entry also indicating he had administered the Heparin dose to Resident 1. This deficient practice resulted in the inaccurate depiction of Resident 1's medication management and had the potential for non-continuity of care based on the inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to update the facility assessment tool for 137 out of 137 residents when:1. The facility failed to include the Infection Prevention Nurse (IPN) as part of the required staff for daily facility operations; and2. The facility failed to assess the cultural and ethnic makeup of the facility's resident population. These deficient practices had the potential to result in delays of care and services and deter the facility to offer more culturally competent resident-centered care.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure three of six sampled residents' (Resident 7, 9 and 114) were free from unnecessary psychotropic medications (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, or feelings, or behavior) by:a. Failing to ensure nonpharmacological interventions (therapies and measures that do not involve taking medication like distraction, music therapy, and activities) were attempted prior to administering Ativan (medication for anxiety [mental health condition characterized by excessive fear and worry]) as needed for inability to relax for Resident 7.b. Failing to ensure Resident 9 was monitored for adverse effects for Mirtazapine (medication for depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) use.c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions for 3 of 3 residents (Residents 16, 156, and 124) by failing to: Develop and implement a care plan to improve, maintain, or prevent a decline in range of motion (ROM, full movement potential of a joint) for Resident 16 who was identified as having ROM limitations in both arms and both legs. Develop and implement a comprehensive person-centered care plan for Resident 124's use of Lorazepam (Ativan, medication used to treat anxiety [a common mental health condition characterized by excessive worry, fear, and nervousness]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for two of seven sampled residents (Residents 5 and 16) with ROM concerns by failing to: Objectively measure Resident 5's ROM in both hands during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 6/27/2025. Provide ROM services to Resident 16 who was identified as having ROM limitations in both arms and both legs. [...]

Inspectors wroteBased on interview, and record review, the facility failed to Identify and to intervene in two of three sampled residents (Resident 114 and Resident 156)'s history of trauma (a strong emotional reaction to something upsetting or harmful that happened). and triggers (a sound, smell, place, or even a memory-that suddenly reminds someone of a scary or upsetting experience from the past. It can make them feel afraid, sad, or upset, even if they are safe now) which may cause re-traumatization as evidenced by:A. Failing to assess and identify the triggers of Resident 114's trauma related to a war he was in. B. Failed to do an assessment and identify the triggers of Resident 156's trauma related to family health status. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure employee files were maintained and kept up to date when performance evaluations (a process used by organizations to assess how well employees are performing in their roles) were not completed for three out of six sampled employees. This failure had the potential to adversely impact the quality of care of residents when staff performance is not current.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure:1.18 residents on pureed diet (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding) received pureed sweet potato texture in form that meet their needs and in accordance with the international Dysphagia Diet Initiative-level 4 (IDDSI-a framework made up of levels and describes food textures and drink thickness) level Four (pureed foods and extremely thick drinks) when the texture of the pureed sweet potatoes was lumpy, not smooth and had large pieces of potato present requiring chewing before swallowing. This failure had the potential to result in meal dissatisfaction and increased choking risk for residents on pureed diet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:1. Three boxes of juice were in use and connected to a juice dispensing machine with no date and label; one box with 24 ice cream cups stored in the reach in freezer (a vertical storage unit commonly found in commercial kitchens) with date 2/2025 expired; raw shelled eggs and raw liquid eggs stored on same shelf and next to milk and a box of raw bacon stored next to a medium container of cooked macaroni.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Residents 5, 66, and 124) had complete and accurate medical records by failing to:Ensure Resident 5's Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) splinting (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) orders for both hands and both knees were accurately written to indicate the recommended splint wear time and schedule (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Binding Arbitration agreements (a binding agreement by the parties to submit to a private process where disputing parties agree that one or several other individuals can decide about the dispute after receiving evidence and hearing arguments) provided a selection of a venue that is convenient to both parties for three of three sampled residents (Resident 29, 104, and 156). This deficient practice violated the rights of Resident 29, Resident 104 and Resident 156.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled resident's (Resident 7) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for psychotropics (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was obtained prior to administration of medications. This deficient practice violated Resident 7 and the responsible party's rights to receive all information, in advance, of risks and benefits of proposed care, treatment, treatment alterative, and choose the alterative of choice which includes information for administration of psychotropic drugs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of eight sampled residents (Resident 124). This deficient practice had the potential for Resident 124's needs not being met.

Inspectors wroteBased on interview and record review the facility failed to honor the choices of one of eight sampled residents (Resident 160) regarding care and cleaning of his wheelchair. This deficient practice resulted in Resident 160's wheelchair being removed from his room against his wishes, was not readily available when he wanted to use it and did not honor his resident's rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Advance Directive ([AD], a legal document that outlines a person's healthcare preferences and appoints a healthcare agent to make medical decisions on their behalf if they become unable to do so) was accurate and completed as per the facility's policy and procedure (P/P) for one of two sampled residents (Residents 156). This deficient practice violated the resident's rights to be fully informed of the option to formulate an AD and had the potential to cause conflict with the residents' wishes regarding health care in the event resident became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four residents (Resident 13) written notice of transfer was provided to the State Long-term Care Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities). This deficient practice resulted in violation of resident rights because the ombudsman could not advocate for the residents and investigate potential violations.

Inspectors wroteBased on interview and record reviews, the facility failed to update one of the two sampled residents' (Resident 9) care plans. This deficient practice had the potential to result in delays of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for the assessment and application of splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for one of seven sampled residents (Resident 4) by failing to:Ensure the Director of Rehab (DOR) who was a Physical Therapist (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) performed an assessment to determine the appropriateness and fit of Resident 4's right wrist/hand splint and right elbow splint. Ensure the DOR monitored and established Resident 4's right wrist/hand and right elbow splint wear time tolerance (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 45) was sitting upright when eating lunch. This deficient practice placed Resident 45 at risk for choking and aspiration (inhaling small particles of food or drops of liquid into the lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for two of two residents (Resident 114 and Resident 7):1. Ensure Resident 114's buspirone (a medication used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) was available in stock to be administered within 60 minutes of scheduled time of administration in accordance with physician orders and as per facility's policy and procedure (P&P) titled, Medication Administration, undated, affecting one of six sampled residents during medication administration. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications requiring refrigeration were stored in accordance with manufacturer specifications and per facility's policy and procedure (P&P) titled, Medications Storage, undated, at a temperature range of 36 Fahrenheit [( F) is a unit of temperature] to 46 F or 2 Celsius [( C) is a unit of temperature] to 8 C, affecting one of two facility's medication room refrigerators (Station B Medication Room Refrigerator). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up with status of unfitting dentures (a removable plate or frame holding one or more artificial teeth) for one of three sampled residents (Resident 63). This Failure had the potential to result in Resident 63 having discomfort while eating or chewing foods that could lead to unintended weight loss and low self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the lunch menu and spreadsheet (food portions and serving guide) was followed on 9/2/2025 for one of one residents (Resident 30) on a renal diet (a diet intended for residents with decreased kidney function. This diet regulates the dietary intake of sodium, potassium and protein to lighten the work of the diseased kidney) received the baked sweet potato instead of the mashed potato and received brown gravy instead of no gravy per the menu and renal diet guidelines. This deficient practice had the potential to result in meal dissatisfaction, and inadequate nutritional status when the menu is not followed to reflect the needs of the residents. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled resident's (Resident 7) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for Valproic Acid ([psychotropics]drug that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was renewed after 6 months. This deficient practice violated Resident 7 and the responsible party's rights to receive all information, in advance, of risks and benefits of proposed care, treatment, treatment alterative, and choose the alterative of choice which includes information for administration of psychotropic drugs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide 1 (RNA 1) wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while providing Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) exercises to one of seven sampled residents (Resident 5) who was on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection among the residents and staff members.

Inspectors wroteBased on observation, interview and record review the facility failed to protect one of three sampled residents' (Resident 1) right to be free from physical abuse. This failure resulted in Resident 2 punching Resident 1 on the left side of Resident 1's eye on 8/10/2025. Resident 1 had swelling on the left side of his forehead near the left eye.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled resident (Resident 2) who resided at the facility and was transferred to General Acute care hospital (GACH) on 8/10/2025 was readmitted to the facility. This deficient practice resulted in Resident 2 being denied readmission by the facility. Resident 1 did not return to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan with goals and interventions for one of six sampled residents (Resident 1) when Resident 1 was punched by Resident 2 on the left side of Resident 1's left eye on 8/10/2025. This deficient practice placed Resident 1 at risk for insufficient provision of care and services and had the potential for continued abuse.

Inspectors wroteIntake#2582955Based on interviews and record review, the facility failed to ensure the required Minimum Data Set (MDS-a resident assessment tool) data including resident assessments, was electronically transmitted to the Centers for Medicare and Medicaid Services (CMS- a federal and state program that provides and administers health insurance for those that qualify) System for all residing residents since August 2024. This failure resulted in the absence of federally mandated resident assessment data, which is essential for care planning, quality measure reporting, and reimbursement accuracy. The lack of submission affected all residents in Medicare/Medicaid-certified beds during this period, placing them at risk for inadequate care planning and inaccurate quality tracking.

Inspectors wroteBased on interview and record review, the facility failed to schedule and follow up on the ordered neurology (specialty care related to the diagnosis and treatment of the nervous system) consultation for one of three sampled residents (Resident 1). This failure resulted in a delay for the delivery of care and services for Resident 1.

Inspectors wroteBased on observation interview and record review the facility failed to protect the resident right to be free from physical abuse for one of three sampled residents (Resident 1) when Resident 2 punched Resident 1 on the left upper cheek. The facility failed to: 1. Intervene when Certified Nursing Assistant (CNA 1) and Licensed Vocational Nurse (LVN) 1 witnessed and heard Resident 1 and Resident 2 having an argument in a loud voice on 2/25/2025, at 6am. 2. Supervise Resident 1 and Resident 2 who were in the patio on 2/25/25. 3. Follow Resident 1's Care Plan titled Resident 1 has episode of aggressive behavior, believes someone is going to hurt him dated 12/29/24, with interventions to remove any resident in the immediate area if Resident 1 became aggressive. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) was treated with respect and dignity by failing to honor resident ' s refusal to come back to bed for provision of personal care. This failure had the potential to violate resident ' s rights and led to Resident 1 having increased agitation and restlessness.

Inspectors wroteBased on, interview and record review, the facility failed to ensure the resident, who had impairment (loss of function or ability) on both sides of upper extremity (shoulder, elbow, wrist, and hand) and lower extremity (hip, knee, ankle, and foot), did not sustained injury to left leg during transfer from a wheelchair to a bed for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 4 asked another staff member to assist her with transferring Resident 1 from a wheelchair to bed per care plan titled, Needs Assistance with Activities of Daily Living (ADL-basic tasks that residents need to do to care for themselves such as eating, dressing and toileting ) dated 1/26/2024 and revised on10/14/2024, which indicated Resident 1 required a total assistance of two to three persons for transfers. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Certified Nursing Assistance (CNA)1 closed the privacy curtain while performing Activities of Daily Living(ADL ' s - daily task in life) for 2 out of 3 sample Residents (Resident 4) and (Resident 5). This deficient practice placed Resident 4 and Resident 5 visually exposed to other staff and residents .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident, who was assessed as a high-risk for wandering, did not elope (when a resident leaves a facility without supervision nor authorization) from the facility for one of three sampled residents (Resident 1). The facility failed to: 1. Supervise Resident 1 by conducting observations of Resident 1's whereabouts and monitor the resident every shift for episodes of wandering or attempting to elope from the facility as indicted in the resident's untitled Care Plan dated 8/20/2024. 2. Ensure staff responded to the entrance/exit door alarm as Resident 1 was leaving the facility through. 3. Ensure staff followed the facility Procedure and Policy (P&P) titled Wandering Unsafe Resident and have a detailed monitoring plan in place to always know the whereabouts of Resident 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Label and date food stored and thawing in the refrigerator and freezer according to facility policy. This deficient practice placed the facility residents at risk for foodborne illness. 2. Ensure the chemical in the dishwasher used for sanitizing, was at the proper level of 50 ppm (parts per million). When the kitchen staff tested the sanitizer in the dishwasher, the test strip indicated the chemical level was 0 ppm. This deficient practice of insufficient chemical sanitizer in the dishwasher had the potential to lead to use of contaminated dishes and utensils for 140 of 142 residents in the facility residents and can cause foodborne illness -an infection or irritation of the gastrointestinal (GI) tract caused by food or beverages that contain harmful bacteria, parasites, viruses, or chemicals). Findings 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to keep Refrigerator #1 in working condition when Refrigerator #1 was observed to have a pool of water sitting at the bottom of the refrigerator. This deficient practice had the potential to result in rapid growth of bacteria that can cause foodborne illness (food poisoning). Findings During an observation on 7/16/2024 at 8:58 a.m. of Refrigerator #1, it was observed that ham, chicken, and bacon were being defrosted. Observed a standing water at the bottom under the container of defrosting chicken. During an interview on 7/16/2024 at 8:58 a.m. with [NAME] 1, [NAME] 1 stated water will drip from the top of the refrigerator and collect at the bottom of the refrigerator. [NAME] 1 stated that it has been going on for the last two weeks. [NAME] 1 stated that maintenance was notified and checked Refrigerator #1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three out of 16 sampled residents (Resident 10, Resident 33, and Resident 61) were treated with dignity and respect by failing to: 1. Acknowledge the call lights for Resident 10 and Resident 33 when they needed assistance. This deficient practice had the potential to cause a safety risk of residents getting out of bed and falling due to their call lights not being answered and had a potential of not meeting the needs of Resident 10 and Resident 33 resulting in feelings of not being important and low self-esteem. 2. Ensure Certified Nurse Assistant (CNA) 3 fed Resident 61 lunch while sitting at eye level. This deficient practice had the potential for Resident 61 to feel as though they were not treated with dignity and respect.

Inspectors wroteBased on interview and record review, the facility failed to ensure an investigation was conducted following a resident-to-resident altercation between Residents 18 and 61. This deficient practice resulted in the facility not identifying other potential residents who may have had resident-to-resident altercations not being identified and had a potential for further resident-to-resident altercations to occur between Resident 18 and 61.

Inspectors wroteBased on interview and record review, the facility failed to follow through with the Preadmission Screening and Resident Review ([PASRR] a tool to ensure possible individuals with mental illnesses or intellectual disabilities are appropriately placed in nursing homes for long term care) recommendation to obtain a PASRR Level II (helps determine placement and specialized services) evaluation for three of three sampled residents (Resident 4, 60 and 61). This failure had the potential to result in inappropriate placement and unidentified specialized services for Resident 4, 60 and 61.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized person-centered plan of care with interventions to meet the residents' needs for one of two sampled residents (Resident 152). The facility failed to: Ensure Resident 152's, care plan interventions to include call light within reach and implemented by CNA 5 prior to leaving the residents' room. CNA 5 was not aware Resident 159 was visually impaired. This deficient practice had the potential to put Resident 152 at risk for injury, delays the provision of care and is a violation of residents' rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information was posted and readily available to residents and visitors. This deficient practice resulted in residents and visitors not being able to access accurate daily numbers of clinical staff taking care of residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to track and record the administration of controlled substances (a medication/ drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) in real time for four out of 54 (Resident 34, Resident 82, Resident 115, and Resident 149) sampled Residents. This deficient practice had the potential to cause medication errors (any preventable event that may cause or lead to inappropriate medication use or patient harm) and the potential for drug diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dietary staff (Cook 1 and [NAME] 2) were competent in safe and effective food preparation. This deficient practice resulted in [NAME] 1 and 2 not having the knowledge and competency to prepare a fortified meal (add vitamins and minerals that are not naturally present in food). Findings During an observation on 7/17/2024 at 11:39 a.m. with [NAME] 2 during tray line (meal preparation when trays are moved along an assembly line), [NAME] 2 was observed adding extra tomato sauce for a fortified meal. During an interview on 7/17/2024 at 11:40 a.m. and a subsequent interview at 3:24 p.m. with [NAME] 2, [NAME] 2 stated when a meal needs to be fortified, extra sauce or gravy was added. [NAME] 2 stated the purpose of fortified meal was to make the food easier to swallow for the residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to appropriately assess one of one sampled resident (Resident 152) who was visually impaired. This deficient practice resulted to inaccurate assessment of Resident 152's vision leading to a potential delay in care and needed vision services.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the comprehensive resident centered care plan for one of three sampled residents (Resident 88). The facility failed to ensure Resident 88's care plan interventions were specific to include the need for direct line of sight (unobstructive view) monitoring for Resident 88. This deficient practice placed Resident 88 at high risk for harm due to falls or accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sample residents (Resident 129) who was receiving enteral (nutrition delivering into the body with the aid of a feeding tube) feedings received appropriate care and services to prevent complications of enteral feedings. The facility failed to ensure the licensed nursing staff appropriately assessed Resident 129 to be positioned with the head of bed (HOB- head of resident's bed elevated) at 35-45 degrees. This deficient practice resulted in potential harm resulting from aspiration (when fluid accidentally enters windpipe into the lungs) for Resident 129.

Inspectors wroteBased on interview and record review, the facility failed to ensure: a. physician gave informed consent (the process in which a health care provider educated a patient about the risks, benefits, and alternatives of a given procedure or intervention) before the administration of any psychotropic (capable of affecting the mind, emotions, and behavior) medication for one of eight sampled residents (Resident 14). b. Resident 4's Responsible Party (RP)and the Licensed Nurse who received the medication order and verified that medical doctor obtained informed consent (decision made freely by the resident or RP, after he/she had knowledge and understanding of the risks and benefits, available options about the various treatment alternatives) for the administration of Lorazepam (psychotherapeutic drug). c. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship program policy for one of one sampled resident (Resident 129) when an antibiotic (a substance used to kill bacteria and to treat infections) did not meet McGreer Criteria (criteria used to determine appropriate use of antibiotics). This deficient practice had the potential to increase antibiotic resistance and the resident to be provided antibiotics without justification.

Inspectors wroteBased on observation, interview and record review, the facility failed to mitigate the spread of legionella bacteria (a bacteria found in aquatic environment that can spread in droplets small enough for people to breathe in that cause lung infection with symptoms that include cough, shortness of breath, fever, muscle aches, headaches, diarrhea, nausea and confusion)in the facility when one of eight sampled residents was transferred to a General Acute Care Hospital (GACH) and tested positive for legionella bacteria on approximately 3/5/2024. a. the facility failed to ensure the facility's water supply used for drinking water, ice making (ice cubes), beverages and hygienic purposes (resident showers and personal hygiene) have been tested for the presence of legionella bacteria. b. the facility failed to ensure residents were not consuming the untested water for drinking and ice cubes. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was safely assisted by a Certified Nursing Assistant (CNA 2) when Resident 1 was turned and repositioned during incontinence care (cleaning the skin with mild soapy water, rinsing well, and patting the skin dry after an episode of uncontrolled urine and bowel movement). This deficient practice resulted in Resident 1 falling from her bed, hitting her head and knee on the floor and had the potential for Resident 1 to sustain injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures by: 1. Failing to handle and dispose trash bags in an appropriate receptacle by leaving them on the floor of Resident 1 ' s room. 2. Failing to ensure an unvaccinated employee ' s N95 mask ( high filtering face piece respirator that protects the wearer from inhaling airborne particles) fit test was up to date during a Covid-19( contagious and infectious respiratory disease) outbreak This failure had the potential to result in spread of infection and risk of cross contamination( physical movement or transfer of harmful bacteria from one person, object or place to another).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed in the kitchen when: The foods were not identified, not labeled with opened dates, there was no received dates, foods were stored for use past its printed best by dates, the shelves and floors of the refrigerator and dry storage areas contained food debris and dust, and the chemicals were kept next to foods. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide two of 12 residents (19, 100), and or their responsible parties with written information on how to formulate an Advanced Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). This deficient practice had the potential for violating Resident 19 and 100 choices about their medical care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and timeframe to meet four of 27 resident (22, 25, 80, 209) medical, nursing, and mental, and psychosocial needs as identified in the comprehensive assessment by: Resident 22, who was performing self cauterization (the insertion and removal of a catheter several times per day to empty urine in bladder) did not have a plan of care to reduce the risks for infections. [...]

Inspectors wroteBased on interview, and record review the facility failed to inform four of 4 residents (9, 53, 95, 100) by notifying and inviting the residents, their family members or responsible parties to an Interdisciplinary Team ([IDT] a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the patient, whenever possible the patient and the patient's family should be part of the team) meetings to participate in the development, review or revisions of the plan of care. This failure had the potential to cause inappropriate care and services by not receiving any pertinent or necessary information from Resident 9, 53, 95, and 100, their responsible parties and/or family members to assist with developing and revising comprehensive person centered plan of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide quality of care and treatments based on the comprehensive assessment and plan of care for four of 5 residents (14, 44, 80, 90), which put them at risk for further decline by: Resident 14, complained of itchiness and rash (temporary outbreak of red, bumpy, scaly, or itchy patches of skin, possibly with blisters or welts) to the staff but the change of condition was not reported to the charge nurse. Resident 44, who had a fracture (broken bone), pain during ambulation (walking), and used a controlled ankle motion (cam) boot was not rescheduled for a cancelled orthopedic (the branch of medicine that deals with the musculoskeletal system) appointment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed food production recipes and the fortified diet (diet enhanced to increase caloric intake) spreadsheet when preparing lunch using pre-made frozen meatballs. The facility failed to serve fortified diets for the first three meal carts during the 5/11/21 lunch service as ordered. This deficient practice of not following recipes during food production had the potential to affect overall nutrient intakes for residents who consumed pre-made meatballs and not providing fortified diets as instructed had the potential to result in undesirable weight loss for residents who required a fortified diet.

Inspectors wroteBased on observation, interview, and record review, the staff failed to have a systematic timeline and documenting the inspection for checking the laundry room dryer lint screens in for increased buildup of lint in order to reduce the risks of fire hazard. This deficient practice had the potential of exposing all the residents, staff, and visitors to an unsafe and hazardous environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functioning call light (a communication system that calls directly to a staff member or to a centralized location where staff are working, such as a nurses' station) for two of 2 resident (52, 104). Resident 52, who needed the assistance of staff for activities of daily living ([ADLs] self-care activities performed daily such as bathing, eating, and getting in and out of a bed or chair) had was not equipped with a call light. Resident 104, who needed the assistance of staff for ADLs was not equipped with a functioning call light. Resident 104's call cord was broken. This deficient practice had the potential to result in a delay in meeting Residents 52, and 104's during emergencies, and when needing assistance with ADLs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide complete personal privacy for one of 3 residents (102) who had a behavior of undressing self. Resident 102, who needed assistance with activities of daily living ([ADL] a term used to collectively describe fundamental skills that are required to independently care for oneself), needed incontinent briefs (diaper) due to incontinence (no control) of bowel and bladder functions, and who had a behavior of undressing self was exposed to the general population walking in the hallway. This deficient practice resulted in the violation of Resident 102's personal privacy.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 5 residents (66) was made aware of a facility's bed-hold policy by documenting the acknowledgment of the rights before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility. This deficient practice had the potential for Resident 66 to be at risk for not understanding their rights for bed hold policy during all transfers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 3 residents (53) received assessment and assistive devices if needed, to improve hearing. Resident 53, who was assessed as having minimal difficulties with hearing, and cerumen ( (ear wax) but the physician orders/treatment for a follow-up with for re-evaluation of the hearing abilities was not followed up. This deficient practice prevented Resident 53 from gaining access to an appointments and possible treatment to be reassessed for hearing and to be fitted with hearing aids if needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of 27 residents (109) received the services for range of motion ([ROM] the full movement potential of a joint) and when refused the physician and responsible party were both notified. Resident 109, who refused rehabilitation department to assess the mobility status when there was no weight bearing (NWB) of the left lower extremity, the risks were identified and the physician and responsible party were both notified. The deficient practice could potentially cause the ROM to decline further leading to increased pain for Resident 109.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 1 resident (19) was provided with a safe and secure bed that was equipped with functioning wheel locks to avoid accidents when leaning or standing along the bedside. This deficient practice had the potential for the bed to move and cause Resident 19 to stumble and fall resulting in bodily harm or injury.

Inspectors wroteBased on interview and record review, the facility failed to implement and reevaluate the plan of care that was ordered by the physician for one of three sampled residents (Resident 22). Resident 22, who preferred to self-catheterize by using an in and out catheter method; Resident 22 not provided with services and treatments to prevent urinary tract infections and to restore incontinence to the extent possible. This deficient practice of delaying treatment from an Infectious Disease consult [ID](A physician that specialized in infections) prevent the reevaluation of recurring urinary tract infections. Resident 22 has had multiple recurrent Urinary Tract Infections (An infection in any part of the urinary system [kidney, bladder or urethra) and an E. Coli infection (A type bacteria that lives in the intestines) was identified on 5/3/2021, 4/03/2021 and 2/2/2021. [...]