Long Beach Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified when one sampled resident (Resident 1), who was diagnosed with hypertension ([HTN] high blood pressure) refused to take his 9 a.m., medications, which included high blood pressure medications. This deficient practice resulted in Resident 1's physician being unaware of Resident 1's refusal to take his medications and the inability of the physician to instruct staff on care options. This deficient practice had the potential for Residen t1's blood pressure to remain elevated and for him to suffer consequences related to prolonged elevated blood pressure readings.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 did not taunt one of four sampled residents (Resident 1) by telling him to hit me Go ahead and hit me so we can send you out, following an altercation between Resident 1 and LVN 1. Following the altercation LVN 1 continued to be assigned to care for Resident 1. This deficient practice resulted in Resident 1 continuing to receive care from the LVN 1 who verbally abused him and had the potential to cause Resident 1 emotional distress, increased agitation, psychosocial harm, and loss of trust in facility staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of verbal abuse was immediately reported to the Administrator (ADM) when staff witnessed Licensed Vocational Nurse (LVN) 1 tell one of four sampled residents (Resident 1) to hit me Go ahead and hit me so we can send you out. This deficient practice resulted in the facility's inability to conduct a timely investigation and a delay in reporting the allegation to the California Department of Public Health (CDPH). This deficient practice had the potential for LVN 1 to continue verbally abusing Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 3 remained awake and available to respond to resident care needs during the 11 p.m. to 7 a.m., shift on 7/29/2026 or one sampled resident (Resident 1). This deficient practice resulted in CNA 1 being unaware and unavailable to assist with resident care needs and/or emergencies. This deficient practice had the potential for delayed and/or missed care/emergency response.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for two of three sampled residents (Resident 1 and Resident 14): 1. Medications prepared for Resident 1 by Licensed Vocational Nurse (LVN) 1 were not administered to Resident 1 by LVN 3. 2. Resident 14's discontinued medication, Gabapentin (a medication that calms overactive nerves in the body) was removed from the Medication Cart immediately after it was discontinued. These deficient practices resulted in LVN 3 administering medications to Resident 1 that she did not prepare, without verifying the order to ensure the correct medication and dosage was given, as well as the discontinued Gabapentin remaining in the Medication Cart and being administered to Resident 14. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Director of Rehabilitation ([DOR] oversees the rehabilitation department operations, not required to be a licensed Occupational Therapist [OT] a licensed healthcare professional who evaluates and treats individuals to improve their ability to perform everyday activities safely and independently] and is a Certified Occupational Therapy Assistant [COTA] trained to provide OT services only under the supervision of a licensed OT and cannot independently perform evaluations, assessments, determine the need for assistive devices, or initiate occupational therapy treatment plans) referred one of three sampled residents (Resident 14), who was non weight bearing (no weight placed on the affected leg, foot, or joint), to the OT when Resident 14 requested a drop arm commode (toileting assistive device with arms that lower or [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1), who was diagnosed with scabies (highly contagious microscopic bug that burrows (digs) into the top layer of the human skin to live and lay eggs causing intense itching) received the prescribed ivermectin (medication to kill scabies) and permethrin (medication to kill scabies) in a timely manner. This deficient practice resulted in Resident 1 to not feel listened to and caused Resident 1 to suffer from burning and itching due to active scabies mites burrowing into Resident 1's skin.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a personal protective equipment (PPE- gown, gloves and masks) trash receptacle had a cover for one of three sampled (Resident 1) who was on contact precautions (infection control strategy to help prevent the spread of infectious agents) for scabies (highly contagious microscopic bug that burrows (digs) into the top layer of the human skin to live and lay eggs causing intense itching). This deficient practice had the potential to spread scabies through cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff assisted residents at eye level during mealtimes for three of four sampled residents (Residents 85, Resident 70 and Resident 119. These failures had the potential for Residents 85, Resident 70, and Resident 119 to not be treated with dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a change of condition (COC) and notify the physician timely when two of five sampled residents (Residents 75 and 15) had a significant change of condition in physical status when:1. staff reported Resident 75's repeated refusals to walk during Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment and a decline in walking distance.2. staff reported Resident 15's repeated refusals to put on left ankle foot orthoses ankle foot orthosis (AFO, an orthotic device designed to correct or address problems with the ankle and foot) during RNA treatment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to maintain or prevent further decline in joint range of motion (ROM, full movement potential in a joint) in two of 31 sampled residents (Residents 5 and 15) when the facility failed to:1a. Objectively measure Resident 5's ROM impairments in the left shoulder, elbow, wrist and hand during an Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation dated 9/14/2025.1b. Document the application and removal of Resident 5's left elbow extension (straighten the elbow) splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and left resting hand splint (splint to help keep the hand open).2a. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from physical abuse for one of three sampled residents (Resident 160) when Resident 110 kicked Resident 160 on 6/27/2026. This failure resulted in Resident 110 kicking Resident 160 and had the potential for Resident 160 to feel unsafe and unprotected.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Notice of Proposed Transfer/Discharge form was provided to the Office of the State Long-Term Ombudsman (public advocate for residents in long-term care facilities) at the time of transfer to the General Acute Care Hospital (GACH) for one of three sampled residents (Resident 12). This deficient practice had the potential of Resident 12 being denied additional protection from being inappropriately discharged and access to an advocate who could inform them of their options and rights.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one sampled residents (Resident 9), change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) was documented when Resident 9's Dilantin (medication used to control and prevent seizures) (phenytoin) level is 10 to 20 microgram/milliliter (mcg/mL-measures mass and volume) dropped to less than 2. This deficient practice had the potential to result in a delay of care and services for Resident 9.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool) for one of three sampled residents (Resident 92) was accurate by failing to code Resident 92's fall on 3/24/2026. The MDS assessment conducted on 5/6/2026 indicated the resident did not have any falls. This failure had the potential to negatively affect Resident 92's plan of care and placed Resident 92 at risk for future falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure a preadmission screening resident review (PASARR A screening to ensure a person is appropriately placed and receives needed services before entering a nursing facility) Level II was completed for two of three sampled residents (Resident 10 and Resident 16). This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident 10 and Resident 16.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one sampled residents (Resident 9), had a care plan created, initiated, and implemented for the use of Dilantin(medication used to control seizures). This deficient practice had the potential to result in the side effects not being identified and addressed.

Inspectors wroteBased on interview, and record review, the facility failed to revise the care plans for two of four sampled residents (Resident 102 and 161) by:Failing to revise the at risk for falls care plan dated 3/27/26 for Resident 102 who was found lying on the floor on 4/22/26. Failing to revise the care plan for Resident 161 to reflect the current plan of care for Resident 161's ruptured blister on the left hip that started on 5/26/26. These deficient practices had the potential for Residents 102 and 161 to not receive the appropriate care and/or services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four sampled residents' (Resident 32 and Resident 113) fingernails were trimmed and free from accumulation of unknown substances underneath their fingernails. This failure resulted in Resident 32 and Resident 113's fingernails to have irregular edges, accumulation of dark brown substance under the fingernails, and had the potential to cause infection and impaired skin integrity.

Inspectors wroteBased on interview and record review, the facility failed to clarify and follow physician orders for one of three sampled residents (Resident 134) by failing to:Clarify frequency (number of times) for administration of Resident 134's Nicotine patch (medicated adhesive patch that you stick to your skin to help you quit smoking). Clarify frequency for administration of Resident 134's Diclofenac (medication used to treat pain). Check Resident 134's blood sugar three times daily per doctor's orders. These deficient practices had the potential to cause medication errors and/or inadequate treatment for Resident 134 and placed Resident 134 at risk for increased pain, hypoglycemia, and hyperglycemia.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure incontinence care (the help provided to manage the accidental leaking of urine and stool) was provided in a timely manner for one of two sampled residents (Resident 63), who was left soiled for an extended period. Resident 63 asked the staff to have his incontinence briefs (diaper) changed at 7:10 a.m. on 7/6/2026 and was changed and cleaned on 7/6/2026 at 11:00 a.m. This failure had the potential to result in psychosocial distress, frustration, discomfort and increased risk of skin impairment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 17) who received hemodialysis (a medical procedure to remove fluid and waste products from the body) had an emergency kit (medical supplies used to stop uncontrolled bleeding from a hemodialysis site if it got accidentally dislodged) at resident's bedside. This failure had the potential for delayed intervention during accidental dislodgment and bleeding on Resident 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Administer one of five residents' (Resident 73's) multivitamin with minerals in accordance with physician's orders.2. Ensure Resident 77's medications, namely diclofenac gel (a medication used to treat inflammation and pain), aformoterol (a medication used to treat breathing difficulty due to chronic obstructive pulmonary disease [COPD - a chronic lung disease causing difficulty in breathing]) and levalbuterol (a medication used to treat breathing difficulty due to asthma [a chronic lung disease causing inflammation and muscle tightness around airways]) were available in stock, affecting one of five residents.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and secure storage and labeling of one of five residents' (Resident 77's) aformoterol (a medication used to treat breathing difficulty due to chronic obstructive pulmonary disease [COPD - a chronic lung disease causing difficulty in breathing]) nebulizing solution, found in one of one inspected medication rooms (North Station Medication Room), as per manufacturer specifications and facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 02/2023 and Administration and Ordering of Respiratory Medications Policy, undated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and follow up with the necessary dental services for one of two sampled residents (Resident 63). This failure had the potential to put Resident 63 at risk for inability to chew effectively leading to weight loss and mouth discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility's Respiratory Therapist (RT) 1 failed to ensure medical records for one of five sampled residents (Resident 77) were accurate by failing to accurately document on progress notes that aformoterol (a medication used to treat breathing difficulty due to chronic obstructive pulmonary disease [COPD - a chronic lung disease causing difficulty in breathing]) and levalbuterol (a medication used to treat breathing difficulty due to asthma [a chronic lung disease causing inflammation and muscle tightness around airways]) nebulizing solutions were administered to Resident 77 instead of documenting that albuterol (a medication used to treat breathing difficulty due to asthma or COPD) and Atrovent ([Generic name - ipratropium bromide] a medication used to treat breathing difficulty due to asthma or COPD) were administered on 7/7/2026. [...]

Inspectors wroteBased on observation and interview, the facility failed to implement and maintain infection control when Certified Nurse Assistant (CNA) 7 failed to perform hand hygiene in between resident's care and prior to entering and exiting resident rooms. These failures had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for spread of infection.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a urine sample ordered for a urine toxicology test (a test performed to detect evidence of a recent drug use or misuse in a sample of urine) was collected, per the physician's order, for one of six sampled resident (Resident 4). This deficient practice resulted in the facility being unable to determine if Resident 4 had illegal substances present in her system and the potential for mismanagement of Resident 4's care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record one of six sampled residents (Resident 4) had documentation to indicate Resident 4 refused to provide a urine sample for a urine toxicology test (a test performed to detect evidence of a recent drug use or misuse in a sample of urine) ordered by her physician. This deficient practice resulted in documentation of Resident 4's care missing from her clinical record and had the potential for non-continuity of care.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) did not wait over three hours for transportation back to the facility following her 2:45 p.m., appointment on 4/21/2026. This deficient practice resulted in Resident 2 without a means of transportation back to the facility following the completion of her appointment on 4/21/2026 at 3:45 p.m. Resident 2 remained in the lobby of the medical provider for approximately 4 hours without food, water or the use of a restroom until a transportation company arrived at 7 p.m., to take her back to the facility. This deficient practice had the potential for Resident 1 to be hungry, dehydrated, cold and frightened.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an allegation of abuse was documented in the clinical record for one of three sampled residents (Resident 1). This deficient practice resulted in an incomplete depiction of Resident 1's status and had the potential for Resident 1's allegation of abuse to go unrecognized and compromise the investigation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from physical abuse. The facility failed to:1. Ensure Resident 1 did not swung his hands backward and struck Resident 2 on the nose when Resident 2 asked Resident 1 to pick up tissue paper on the floor.2. Follow Resident 1's Care Plan titled Resident 1 has behavioral problem: physical aggression manifested by striking out initiated on 03/01/2026 with interventions of one to one (1:1) supervision by staff.3. Follow the facility's policy and procedures (P&P) titled Resident to Resident Altercation which indicated facility staff will monitor residents for aggressive/inappropriate behaviors towards other residents, facility members, victors, or to the staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to enforce its own policy related to maintaining a safe and sanitary environment and effective infection control practices by not ensuring staff followed required infection control procedures for residents on enhanced barrier precautions (EBP- infection control measure used to prevent the spread of multidrug -resistant organisms (MDRO- refers to bacteria and other germs that have developed resistance to multiple classes of antimicrobial drugs)This deficient practice had the potential for transmission of infectious microorganisms and cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products), placing both residents and staff at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) call light (device that allows residents to request assistance from nursing staff) was accessible and within reach. This failure resulted in the inability of Resident 1 to use her call light to obtain assistance from staff and had the potential to result in a delay of care placing Resident 1 at risk for unmet needs, including assistance with toileting, pain, or other immediate care concerns.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who required a two-person assist with transfers from a sitting to standing position and from a chair to bed, was assisted by Certified Nursing Assistant (CNA 1) and another staff member conducting a full body lift to transfer Resident 1 from a chair to her bed. This deficient practice resulted in Resident 1 standing up and attempting to transfer from a chair to her bed without assistance and falling to the floor. Resident 1 was transferred to a General Acute Care Hospital (GACH) where she was diagnosed with bilateral (both sides) acute distal fibular fractures (a sudden traumatic break in the lower end of the calf bone) of both ankles.

Inspectors wroteBased on interview, and record review, the facility failed to ensure when they were made aware of a missing wallet for one of three sampled residents (Resident 1) and a subsequent allegation of an unauthorized charge of $800.00 made against Resident 1's credit card, that the allegation of suspected theft was reported to the California Department of Public Health (CDPH). This deficient practice resulted in the CDPH's inability to investigate the allegation of misappropriation of Resident 1's wallet and money in a timely manner. This deficient practice had the potential for information to be lost/forgotten and for the property of residents residing at the facility to go missing.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an allegation made by one of three sampled residents (Resident 1) that his wallet was missing and a subsequent allegation of an unauthorized charge of $800.00 was made against Resident 1's credit card, was investigated. This deficient practice resulted in the inability of the facility to determine who at the facility might have been responsible for the theft of Resident 1's wallet and the misappropriation of $800.00 from Resident 1's bank account. This deficient practice placed other residents at risk of their property being stolen due to non-investigation of the allegation.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an oxygen nut and stem adaptor (a tapered, barbed connector shaped like a Christmas tree, used to securely attach suction connector tubing [a flexible medical tube that creates a secure, leak-proof link between the suction source (the machine's vacuum port) and the collection canister (which holds aspirated material)]) was readily available and connected to the portable suction machine (a medical device used during an emergency situation that creates suction to remove obstructions such as blood, saliva, vomit or other secretions from the mouth, throat or nasal passages, helping to clear the airway and make breathing easier) on the south station crash cart (a cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during cardiac arrest or respiratory distress [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported for one of three sampled residents (Resident 1), when Resident 1 reported that a resident (Resident 2) pulled his right arm and touched his right leg multiple times. This deficient practice resulted in the inability of the California Department of Public Health (CDPH) to investigate the allegation of abuse in a timely manner and had the potential for information and recollection of the event(s) to be possibly lost.

Inspectors wroteBased on interview and record review, the facility failed to ensure for four of four sampled residents, who had orders for an electrocardiogram ([EKG/ ECG] a test that measures the electrical activity of the heart), and/or who had a change of condition (COC), that the EKG results and the COC were reported to the physician(s) in a timely manner. The facility failed to: 1. Notify the physician when Resident 2 reported lightheadedness, weakness and feeling dizzy when ambulating to the bathroom on 6/20/2025. 2. Notify the physician(s) of the results of EKGs conducted for Resident 1, Resident 3 and Resident 4. These deficient practices resulted in: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 5) was not verbally abused by Certified Nursing Assistant (CNA) 1, when CNA 1 and Resident 5 got into an argument and CNA 1 used profanity. This deficient practice resulted in Resident 5 being frustrated and upset when during an argument between him and CNA 1, CNA 1 said fuck you. During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including post laminectomy syndrome (a condition where persistent or recurrent pain develops after a laminectomy or other spinal surgery) and depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in previously enjoyable activities). [...]

Inspectors wroteBased on interview and record review, the facility failed to assess one of four sampled residents (Resident 1) after Resident 1 complained of chest pain and a electrocardiogram ([EKG/ECG] a test that measures the electrical activity of the heart) was ordered due to chest discomfort. This deficient practice resulted no documentation or knowledge of Resident 1's medical stats and had the potential for a delay in care and treatment. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including CKD and DM. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's cognition was intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the alleged physical abuse between Resident 1 and Resident 2 to the State Survey Agency (California Department of Public Health-CDPH) within two hours of the occurrence for two of three sample residents (Resident 1 and Resident 2). This failure had potential to result in a delay of an onsite inspection by the CDPH to ensure alleged physical abuse was investigated and lead to a delay in prevention of potential ongoing physical abuse.

Inspectors wroteBased on interview, and record review, the facility failed to prevent unplanned weight loss (a weight loss greater than 5 % in one month) of 29 pounds ([lbs.] 18.59 % percent [%] in 6 months) from 1/2025 to 5/25 for one of three sampled residents (Resident 116). The facility failed to: 1. Ensure Registered Dietician's (RD- expert on diet and nutrition) recommendations for Resident 116's weekly weights, protein supplement ( boost protein [ nutrients body needed] intake ), double portions for breakfast, appetite stimulant (medication that stimulates appetite) and to have a blood test done for a complete metabolic panel (CMP- blood test that measures 14 different substances in the blood) and a prealbumin (blood test used to indicate nutritional deficiencies) were carried out. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of 12 sampled residents( Resident 22, Resident 90 and Resident 96) received necessary care and services by failing to: 1. Document a change in condition ( COC a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral or functional condition ) for Resident 22's missed laboratory blood draw. 2. Assess and perform full body skin assessment when Resident 90 verbalized allegation of physical and sexual abuse against a certified nursing assistant. 3. Identify Resident 96's episodes of hyperglycemia ( high blood sugar) and notify the physician when Resident 96's blood sugar readings was persistently abnormal and elevated from 5/19/2025 to 5/22/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) services provided were accurately documented for three of nine sampled residents (Residents 3, 116, and 121). 1. For Residents 3, the facility failed to ensure RNA daily documentation accurately reflected RNA services provided. 2. For Resident 116, the facility failed to ensure RNA daily documentation accurately reflected RNA services provided. 3. For Resident 121, the facility failed to ensure the RNA daily documentation prompts (questions or cues used to direct the write on the specific focus or task) pertained to the RNA task of services provided. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and observe infection control practices by: 1. Failing to ensure Resident 91's curtains were clean and free of stains. 2. Staff failed to perform hand hygiene when entering and exiting resident's room (Resident 38 and 40) when done with providing care. 3. Failing to ensure Occupational Therapist 1 (OT 1) used the appropriate cleaning agent to effectively clean and disinfect a cloth gait belt after providing occupational therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) services to Resident 24. 4. Failing to ensure Certified Nursing Assistant 9 (CNA 9) performed hand hygiene after touching high contact surfaces in Resident 82's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain electrical therapy (services given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) equipment for three (3) of 3 devices for resident use during therapy treatment in the therapy gym. These failures jeopardized resident and staff safety and had the potential to cause harm and injury to residents using the therapy equipment during electrical therapy treatment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure that staff assisted residents at eye level during feeding for two of the four sample residents (Resident 38 and Resident 40). These deficiencies had the potential to impact the residents' rights, particularly regarding dignity and respect, which could lead to feelings of inadequacy among the residents.

Inspectors wroteBased on interview and record review, the licensed nursing staff failed to ensure the resident and/or responsible party (RP) were informed in advance of the risks and benefits of psychoactive medications (a drug that changes brain function and results in alterations, mood, consciousness, or behavior) for one of four sampled residents (Resident 38). This failure violated the residents' right to make an informed decision regarding the use of psychoactive medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled resident (Resident 23) needs were accommodated when Resident 23's mattress was too small for Resident 23's bedframe. This failure resulted in Resident 23 needs not provided to make it a comfortable and homelike environment.

Inspectors wroteBased on the interview and record review, the facility did not honor the choice and preferences of one of six sampled residents (Resident 90) to have a shower before a medical appointment. This failure had the potential to violate Resident 90's right to have a personal choice which could lead to frustration and anger.

Inspectors wroteBased on interview and record review, the facility failed to inform the physician when one of three sampled residents (Resident 22) laboratory (lab) tests were not successfully drawn by the laboratory for three days. This failure resulted in a delay in care and treatment for Resident 22. This failure resulted in Resident 22 to feel frustrated.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure privacy curtains were provided for one of one sampled resident (Resident 135). This failure had the potential to result in Resident 135 feeling embarrass and loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 96) was free of chemical restraints ( use of medication to control a patient's behavior or restrict the patient's movement and not required to treat the medical symptom) by failing to: 1. Ensure Resident 96 was provided with non-pharmacological interventions( intervention that does not primarily use medicine) before administering a prn (as needed) psychotropic medication. 2. Ensure prn (as needed) psychotropic medication ( any drugs that affects the brain activities associated with mental processes and behavior) use for Resident 96 did not exceed 14 days. These failures placed Resident 96 at risk for adverse consequences ( unintended , harmful events attributed to the use of medication ) due to unnecessary prolonged use of psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to implement an individualized care plan for two of four sampled residents (Resident 22 and Resident 90). This failure had the potential to result in a delay of the delivery of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide one of three sampled residents (Resident 96) with an alternative communication method in a language that the resident could understand. This failure had the potential to place Resident 96 at risk of experiencing frustration, isolation, and inability to communicate their needs to the staff, which could lead to a delay in receiving appropriate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 22 and Resident 78) fingernails were trimmed and free from accumulation of unknown substances underneath their fingernails. This failure had resulted in Resident 22 and 78 fingernails to be long with an accumulation of unknown substances underneath the fingernails. This failure had the potential to cause infection and impaired skin integrity.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of 2 sampled residents (Resident 53) ophthalmology (focused on the diagnosis, treatment, and surgery of eye diseases and disorders) referral was followed up. This failure had the potential to negatively affect Resident 53's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to improve and/or prevent a decline in range of motion (ROM, full movement potential of a joint) for one of nine sample residents (Resident 112) by failing to provide Resident 112 with passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to the left leg in accordance with Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) recommendations on 2/7/2025. This deficient practice had the potential to cause Resident 112 to have a decline in ROM leading to contracture (loss of motion of a joint) development and have a decline in physical functioning and mobility (ability to move).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 15 and 2) oxygen nasal cannula (a small plastic tube, which fits into the person's nostril for providing supplemental oxygen) tubing with the date and change every seven (7) days, or as needed while receiving oxygen therapy and oxygen humidifier (medical device used to humidify supplemental oxygen) were labeled and dated for Resident 2. This failure had the potential for resident harm, as the possibly over-extended use of unchanged nasal cannulas placed Resident 15 at high risk of developing a respiratory infection.

Inspectors wroteBased on interview and record review the facility failed to ensure pain medication was reordered to pharmacy in a timely manner for one of one sampled resident (Resident 77). This failure had the potential for Resident 77 to experience pain and delay in treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Restorative Nursing Aide program (RNA, nursing aide program that helps residents maintain any progress after therapy intervention to maintain their function) was modified by qualified and competent staff when Restorative Nursing Assistant 1 (RNA 1) modified Resident 112's RNA program independently. This deficient practice placed the residents in the facility at risk for harm and injury and had the potential to result in inaccurate and inappropriate provision of necessary care and services, assessments, and interventions.

Inspectors wroteBased on interview and record review, the facility failed to provide social services for two of six sampled residents by failing to: 1. Follow up with Resident 23's request for a larger mattress. 2. Request conservatorship (when a judge appoints another person to act or make decisions for the person who needs help) for Resident 38 who was unable to make medical decisions on his own. This failure resulted in a delay in necessary care and services for Resident's 23, and 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure blood pressure parameters for blood pressure medications prior to administration for one out of four sampled residents (Resident 342). This deficient practice has the potential to result in low blood pressure which can cause light-headedness, dizziness, and fatigue for Resident 342.

Inspectors wroteBased on interview and record review, the facility failed to inform the physician of consultant pharmacist's (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendation for one of one sampled residents ( Resident 69) related to administration of sertraline ( medication used to treat depression [a serious mental disorder characterized by persistent sadness, loss of interest, and changes in thinking, sleeping, eating, and acting]). This deficient practice possibly resulting in medication side effects (a secondary, typically undesirable effect of a drug or medical treatment) and leading to a decrease in resident's physical, mental, or psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure two of two sampled residents (Resident 69 and Resident 129) had dental services. This failure had the potential to lead to weight loss for Resident 69 and Resident 129.

Inspectors wroteBased on interview and record review the facility failed to effectively use its Quality Assessment and Performance Improvement (QAPI) program to identify and address resident care concerns, such as weight loss. a. The facility did not monitor or identify the resident's weight loss. b. The facility did not follow the Restorative Nursing Assistant Program exercises as recommended by Physical Therapy. c. The facility did not ensure accurate documentation by Restorative Nursing Assistant Services. d. The facility did not observe infection control practices. e. The facility failed to ensure staff is not standing over while feeding a resident. f. The facility did not follow up on a missed outpatient appointment. These failures had the potential to negatively impact residents ' care and could lead to a delay of care and treatment to the residents.

Inspectors wroteBased on observation interview and record review the facility failed to ensure one of one sampled resident (Resident 1's) room remained safe from fire hazards. This failure had the potential to result in significant harm during a facility fire.

Inspectors wroteBased on observation and record review , the facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents. This deficient practice had the potential for inadequate space for each resident's privacy and safe nursing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of a change of condition (COC) for one of three sampled residents (Resident 2). The facility failed to: 1. Notify Resident 2's physician when Resident 2, who was receiving Aspirin [ASA] used as a blood thinner to prevent a stroke) and Clopidogrel Bisulfate ([Plavix] a medication used to prevent blood clots [blood cells that clump together and could obstruct the flow of blood]), sustained a head injury on 5/4/2025, that resulted in an abrasion, (a scrape of the top layer of the skin), a laceration (a cut with a jagged or torn wound that is caused by a sharp object), a small bump with substantial (large in size, number, or amount) bleeding to his head. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident (Resident 1) who had an open cast (also referred to as a half cast, a medical device used to immobilize an injured area while allowing room for swelling) and had a physician ' s order to see a surgeon, authorization was obtained promptly for one of four sampled residents (Resident 1). This deficient practice resulted in a delay in Resident 1 being seen by the surgeon and had the potential for Resident 1 to have muscle atrophy (muscle wasting), joint stiffness, decreased range of motion (the direction a joint can move to its full potential), skin irritation, and delayed healing.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and services to maintain or prevent further decrease in joint range of motion ([ROM]full movement potential of a joint) and/or mobility for one of four sampled residents (Resident 1) by failing to: 1. Provided services to maintain and prevent a decline in range of motion for Resident 1 ' s bilateral upper extremities. 2. Provide services to maintain and prevent a decline in Resident 1 ' s mobility. 3. Ensure Rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) Screenings were performed upon Resident 1 ' s readmission from a General Acute Care Hospital (GACH). These deficient practices placed Resident 1 at risk for decline in ROM, mobility, physical functioning, and contractures (loss of motion of a joint).

Inspectors wroteBased on interview and record review, the facility failed to provide rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) services for one of four residents (Resident 1) services when Resident 1 had a physician order dated 10/11/2024 for a physical therapy evaluation. This deficient practice resulted in a delay of providing rehabilitation services to Resident 1 and placed Resident 1 at risk for a decline in range of motion ([ROM] full movement potential of a joint), mobility, physical functioning and contractures (loss of motion of a joint).

Inspectors wroteBased on interview, and record review the facility failed to protect the residents right to be free from physical abuse for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1 did not leave the room when on [DATE] Resident 1 and Resident 2 had verbal argument to prevent physical altercation (punched Resident 1 in the head 10 times) between both residents. 2. Ensure facility investigated CNA 2's grievance dated [DATE] about witnessing Resident 1 being upset towards Resident 2 and had an argument. The facility to develop preventative measure to safeguard both residents from possible physical altercation. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that one out of two sampled residents (Resident 2) were free from a significant medication error when Resident 2 ' s escitalopram (depression medication) was not started on 5/1/2024 as ordered by Resident 1 ' s physician. This failure had the potential for Resident 2 ' s clinical depression to worsen.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1's) was treated with respect and in a dignified manner, when the Social Services Director (SSD) tugged at and eventually took Resident 1's sweater and a bottle of medication ([Norco] medication used to treat moderate to severe pain) from her without her permission and after Resident 1 refused to give the SSD the bottle of medication. This deficient practice resulted in Resident 1's complaint of pain to her left and right shoulders, Resident 1 being afraid of the SSD and not wanting to interact with her anymore. This deficient practice had the potential for long term injury and pain and for care and services to be unprovided to Resident 1 due to fear of interacting with the SSD.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged physical altercation between the Social Services Director (SSD) and one of three sampled residents (Resident 1) to the California Department of Public Health (CDPH) within two hours of them being made aware of the allegation. On 10/18/2024 at approximately 8:30 a.m., Licensed Vocational Nurse (LVN) 1 witnessed the SSD tug Resident 1's sweater, eventually taking it from her (Resident 1) without Resident 1's permission. On 10/18/2024 Resident 1's Responsible Party (RP) 1, reported that LVN 1 had taken Resident 1's sweater from her by tugging on it, causing Resident 1 pain to both of her shoulders and Resident 1 being afraid of the SSD. On 10/25/2024, Resident 1 complained of left and right shoulder on alleging the pain resulted from the SSD pulling/tugging and taking the sweater from her (Resident 1). [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a timely and thorough investigation for one of three sampled residents ( Resident 1) when the Social Services Director (SSD) removed Resident 1's sweater from Resident 1's grasp against Resident 1's consent on 10/18/2024. Resident 1 complained of left and right shoulder on 10/25/2024 alleging the pain resulted from the SSD removing the sweater from her grasp. This deficient practice had the potential to result in unidentified abuse affecting Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was seen by the psychiatrist after she continued to express feelings of sadness on 8/12/2024, 8/22/2024, and on 9/23/2024. This failure resulted in Resident 1 not being seen by the psychiatrist after referrals were made on 8/12/2024 and 9/23/2024, and had the potential to place Resident 1 at risk to suffer further mental anguish and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a care plan addressing specific interventions for one of three sampled residents (Resident 3) who frequently removes her nasal cannula (small plastic tube, which fits into the person ' s nostrils for providing supplemental oxygen). These deficient practices resulted in Resident 3 not receiving oxygen as ordered and staff not being aware of specific interventions to provide to Resident 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure incontinence care was provided for one out of three sampled residents (Resident 2). This deficient practice had the potential to result in Resident 2 having complications from skin break down.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) physician's orders to change Resident 2's nasal cannula and to clean Resident 2's right ischium (lower and back region of the hip bone) pressure injury (an area of skin is under pressure for a long time, causing the skin and underlying tissue to break down) and Stage IV (deep wound that may impact muscle, tendons, ligaments, and bone) sacral coccyx (tail bone) pressure injury with normal saline ([n/s] a mixture of sodium chloride [salt] and water, often used to clean wounds) was followed. [...]

Inspectors wroteBased on interview, and record review, the facility failed to create a care plan for one of three sampled residents (Resident 1) when Resident 1 refused care and treatment to his left buttock stage 2 (outer layer of skin (epidermis) or the deeper layer of skin (dermis) is damaged) pressure injury (injury to the skin and soft tissue that occur when an area of skin is under prolonged pressure), right hip stage 2 pressure injury and bilateral foot diabetic ulcers (open wound caused by poor circulation, nerve damage or infection). This deficient practice had the potential for Resident 1's left buttock stage 2 pressure injury, right hip stage 2 pressure injury and bilateral foot diabetic ulcers to increase in size and delay healing.

Inspectors wroteBased on interview and record review, the facility failed to ensure six of six sampled residents (Residents 3, 4, 5, 6, 7 and 10) who were kept awake during the night and/or who were yelled at, called names, and verbally attacked by a resident (Resident 1) who was known by the facility staff to have disruptive behaviors, were provided a safe, peaceful, homelike environment. This deficient practice resulted in Resident 1's known disruptive behavior causing a toxic living environment for Residents 3, 4, 5, 6, 7 and 10 which resulted in residents' tiredness from not sleeping and the inability of the residents to enjoy the place where they resided. These deficient practices had the potential for Residents 3, 4, 5, 6, 7, and 10 to experience emotional and mental anguish due to the facility's lack of attention to Resident 1's know behaviors.

Inspectors wroteBased on interview and record review, the facility failed to re-admit one of two sampled residents (Resident 1) when Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation of uncontrolled behaviors and was placed on a 5150 hold (an involuntary 72-hour detainment of a person who experiences a mental health crisis and is evaluated to be a danger to others, to himself/herself, or is gravely disabled). When the GACH cleared Resident 1 to return to the facility on 7/31/2024, the facility refused to readmit Resident 1. This deficient practice resulted in Resident 1 not being provided with a bed hold notice when she was transferred from the facility on 7/28/2024, being discharged from the GACH on 7/31/2024 to the care of a family member (FM) and denied readmittance to a facility where she had resided for over eight months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor one of three sampled residents (Resident 1), who eloped (left the facility undetected by staff without their knowledge or approval) from the facility on 7/17/2024 at 9:07 p.m., and who earlier that same day at approximately 9:45 a.m., was brought back to the facility, after being found approximately half a mile away at the Los Angeles river and refused to come back to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document the whereabouts for one of three sampled resident (Resident 1), who eloped (left the facility undetected by staff without their knowledge or approval) from the facility on 7/17/2024 at 9:07 p.m., but multiple facility staff documented they saw Resident 1 in the facility after his elopement at 9:07 p.m This deficient practice resulted in the whereabouts of Resident 1 not being monitored, per Resident 1's Care Plan, from (9:30 p.m., on 7/17/2024 thru 2 a.m., on 7/18/2024 when Resident 1 was discovered missing from the facility). This deficient practice had the potential for other residents who were assessed with wandering/elopement behaviors to go missing due to staff not monitoring residents' and their inaccurate and false documentation of residents' whereabouts.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident ' s (Resident 1) Emergency Contact/Family Member (FM) 1, was informed immediately after receiving a physician ' s order to transfer to a General Acute Care Hospital (GACH) and upon transferring Resident 1 to the GACH. This deficient practice resulted in the FM 1 being unaware of Resident 1 ' s whereabouts and concern regarding the health status of Resident 1. This deficient practice had to the potential to affect other residents who were transferred to a GACH.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as followed: a. Staff failed to verbalize and demonstrate how to check dishwasher temperatures. This failure had a potential to result in cross-contamination (a transfer of bacteria from one object to another), due to un-sanitized dishware, and result in bacterial growth that could lead to food borne illness (an illness caused by contaminated food and beverages) in 122 of 131 medically compromised residents of the facility who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the portion sizes and did not meet nutritional needs of 2 of 2 residents who requested zucchini without carrots on their tray and 1 of 1 resident on a soft mechanical diet (diet consisted of foods that were soft and chopped for residents who had difficulty chewing and swallowing) small portion. This deficient practice had the potential to cause a decreased food intake resulting in unintended weight loss or increased food intake resulting in unintended weight gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food that was palatable when the oven roast barbecue (BBQ) beef roast that was served was chewy. This deficient practice had a potential to cause unplanned weight loss, a consequence of poor food intake to 71 of 131 facility residents on regular diet texture (a diet texture with no restriction) getting food from the kitchen.

Inspectors wroteCross Reference F802 Based 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. Equipment, utensils, and kitchen cleanliness a. Low temperature dishmachine was not dispensing chlorine. b. [NAME] refrigerator bottom shelves had dirt and a torn gasket. c. Reach-in freezer five (5) had dried up sticky residue. d. Reach-in-refrigerator vent had dust buildup. e. Two wall fans by the clean dishwashing area had dust buildup. f. Mixer had white food residue.g. Juice dispensing area had sticky dried up buildup. h. Washed trays had tape residue and debris. i. Trays was stacked wet and not air dried. j. Dish machine temperature log for lunch time on 5/21/2024 was blank. k. Seven of 72 resident's tray were chipped and cracked. l. Ice machine had hard water buildup. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not completely covering two (2) of 2 gray dumpsters (a large trash container designed to be emptied into a truck) for an unknown amount of time. This deficient practice had a potential to attract flies, insects, cats, and other animals to the dumpster area placing 122 of 131 facility residents getting food from the kitchen at risk for cross-contamination (a transfer of harmful bacteria from one place to another).

Inspectors wrote(Cross-referenced with F755) Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 % (percent) during medication pass for three of four sampled residents (Residents 61, 66, and 68), observed during medication administration by failing to: 1. Ensure Resident 66's physician order for Aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [blood supply to brain blocked]) was administered as a chewable according to manufacturer formulation specifications instead of being swallowed, on [DATE]. 2. Ensure Resident 68's physician order for Diclofenac Gel (a medication in form of gel used to treat pain and arthritis, a condition with inflammation of joints) was applied to the neck area as prescribed instead of applying to hands, on [DATE]. 3a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure storage and/or removal of undated and/or expired insulin (a medication used to treat high blood sugar), Latanoprost ophthalmic solution (a medication in form of eye drops used to treat high pressure in the eyes), Advair Diskus inhalation device ([Generic Name: [...]

Inspectors wroteBased on interview and record review, the facility failed to document: a. Resident 94's Informed Consent for the Pneumococcal Vaccine (a shot that helps protect from infections like pneumonia (a lung infection that makes it hard to breathe) accurately and completely. b. Resident 110 had complete advanced directive acknowledgement form. c. Resident 116 had a complete advanced directive acknowledgement form documented. These deficient practices had the potential to result in inaccurate care and services rendered to residents that may have an advanced directive in place to accept or refuse certain medical treatments for two of five sampled Residents (Resident 110 and 116). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for three out of 137 sample residents (Residents 23, 86 and125) by failing to: 1. Ensure Resident 23's indwelling catheter (or known as Foley catheter a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag is not touching the floor and the urinal ( a bottle for urination while still in bed) was not placed on the floor. 2. Ensure facility staff cleaned the utility room door after touching it with soiled gloves . 3. Ensure facility staff did not enter other rooms with a soiled linen bag and place it in the room . These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for the residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 1) was treated with respect and dignity by failing to Ensure Resident 1's indwelling urinary catheter (medical device that helps drain urine from your bladder) drainage bag (holds the urine) had a dignity bag (a bag used to the cover, drainage bag so it was not visible). This deficient practice had the potential to cause Resident 1 to feel embarrassed and have low self-esteem (when someone lacks confidence about who they are and what they can do).

Inspectors wroteBased on record review and interview, the facility failed to implement its abuse policy and procedure by failing to investigate a resident-to-resident altercation between two of four sampled residents (Resident 1 and Resident 109). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.

Inspectors wroteBased on interview and record review, the facility failed to initiate and implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for one of three sampled residents (Resident 75) who had a urinary tract infection (UTI- infection involving any part of the urinary system, including urethra, bladders, ureters, and kidney). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 75.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by failing to: 1. Ensure Resident 37 made it to a scheduled Cardiology (a branch of medicine that specializes in diagnosing and treating diseases of the heart, blood vessels, and circulatory system) follow-up appointment. 2. Ensure Resident 3 who allegedly went out to receive chemotherapy (a drug treatment that uses powerful chemicals to kill fast-growing cancer cells in the body) on 5/20/2024 and did not follow up with transportation company and chemotherapy clinic when Resident 3 did not return back to the facility on 5/20/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Resident 71, 114, 110 and 116) with limited range of motion (ROM - the extent of movement of a joint) and/or limited mobility, received restorative nursing (a program available in nursing homes that helps residents maintain any progress they've made during therapy treatments, enabling them to function at a high capacity) care as ordered by physician and follow through the progress of the residents who received restorative nursing care by: a. Failing to assess, evaluate, and document the progress of Restorative Nursing Assistant (RNA) service and to document frequency and reasons of refusal for Resident 71 before discontinuing the service. b. Failing to assess and evaluate the progress of RNA service for Resident 114 and provide RNA service as ordered due to short staffing. c. [...]

Inspectors wrote(Cross-Referenced with F761) Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 7, was trained and had knowledge on how to store and label refrigerated medications with an opened date and/or expiration date after removal from the refrigerator and ensure removal of expired medications from medication cart in one of four inspected medication carts (Middle Medication Cart). This deficient practice of failing to store medications per the manufacturer's requirements increased the risk that residents could have received medications that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications or hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to follow up on three of 131 sampled residents by: A.Failing to follow up with a missed outpatient appointment for Resident 73. B. The facility failed to initiate the process to obtain a public guardian (provides a vital service to persons unable to properly care for themselves or who are unable to manage their finances)/conservatorship (a judge appoints another person to act or make decisions for the person who needs help) to protect Resident 71 who had fluctuated mental capacity. These deficient practices had the potential to postpone the delivery of care and services provided to the residents. [...]

Inspectors wrote(Cross-referenced with F759) Based on observation, interview, and record review, the facility failed to: 1. Ensure medications were administered and/or available in stock according to physician orders and/or manufacturer formulation guidelines for three of four sampled residents (Residents 66, 68 and 61). 2. Maintain emergency kit ([e-kit] a small quantity of medications that can be dispensed when pharmacy services are not available) usage and accountability documentation. These deficient practices failed to provide pharmacy services, accountability, and oversight of e-kits, and had the potential to result in misuse, drug loss and/or diversion of controlled and non-controlled prescription drugs.

Inspectors wroteBased on observation, interview and record review, the facility failed to define clinical behaviors related to the use of antidepressant medication and attempt a gradual dose reduction (GDR -tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) for one of one resident (Resident 27) who was on bupropion (medication used to treat depression). This deficient practice had the potential for Resident 27 to experience adverse (unwanted or dangerous medication side effects) effects of Bupropion and continue receiving medication which was not targeting clinical behaviors.

Inspectors wroteBased on observation and record review , the facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents. This deficient practice had the potential for inadequate space for each resident's privacy and safe nursing care.

Inspectors wroteBased on observation, interview and record review, the facility failed to employ a qualified social worker (health professional that helps individuals, groups, and families cope with problems in everyday lives) on a full-time basis that met the qualifications specified in the regulation. This failure had the potential to result in 130 out of 130 residents not being assisted and receiving medically related necessary care to attain highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of three sampled residents (Residents 2 and 3) call light devices were within reach. This deficient practice resulted in Resident 2 and 3 being unable to call for assistance and resulted in a delay of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 11 sampled residents (Residents 2, 8, and 9) were treated in a dignified and respectful manner by Certified Nursing Assistant 7 (CNA 7). This deficient practice resulted in Residents 2, 8 and 9 feeling intimidated, fearful of and hesitant to ask for assistance from CNA 7 and had the potential to negatively affect the residents care and future interaction with the facility staff. a. During a review of Resident 2's admission Records (Face sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder (a disorder that involves persistent and excessive worry that interferes with daily activities). [...]

Inspectors wroteBased on interview and record review, the facility failed to administer three medications: Doptelet (used to prevent excessive bleeding in adults with low platelets [small cell fragments whose function is to prevent and stop bleeding]) oral tablet twenty (20) milligrams (mg- unit of measurement), Opsumit (medication used to treat high blood pressure [force of blood] in the lungs) oral tablet 10 mg, and Rifaximin (use to treat liver encephalopathy [a brain disorder that develops in some individuals as a result of severe liver disease) oral tablet 550 mg to one out of three sampled residents, Resident 1 from 3/18/2024 to 3/21/2024. As a result, Resident 1 did not receive necessary medications which could have resulted in complications like in severe high blood pressure and possible bleeding.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of nine sampled residents (Resident 3) was not humiliated and embarrassed by a Certified Nursing Assistant (CNA 2), when CNA 2 in front of other staff and visitors spoke to Resident 3 using a curse word in a loud, angry, and aggressive tone. This deficient practice resulted in Resident 3 with tears in his eyes and a lowered head, expressing how he felt humiliated by CNA 2 and had the potential to affect his care needs and how he interacted with staff in the future.

Inspectors wroteBased on observation, interview and record review the facility failed to implement their policy preventing accidents and ensuring safety when the facility failed to A. Ensure one of one front door entrance of the facility was left unmonitored, unlocked, and accessible to the public at 3:00 a.m. on 12/5/2023. B. Implement their policy to identify the possible causes of a fall for two of three sampled residents (Resident 3 and 4) after Resident 3 and 4 suffered unwitnessed falls. These deficient practices placed the residents at risk for harm from possible trespassers entering the facility and placed Resident 3 and Resident 4 at increased risk for sustaining another fall leading to injury.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1)'s call light was answered timely when Certified Nurse Aide (CNA) 2 stated he ignored the call light because he was busy. This deficient practice violated resulted in Resident 1's anger, humiliation, and distrust to the facility staff.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1) were provided with reasonable accommodations. The facility failed to provide Resident 1, whom has a history of muscular weakness due to spinal bifida, with a touch pad call switch (a device that allows people with limited mobility to summon help) instead of a regular call light. This deficient practice resulted in Resident 1 being unable to call for assistance and resulted in a delay of care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Coronavirus disease (COVID-19 a potentially severe respiratory illness caused by a corona virus and characterized by fever, coughing, and shortness of breath) outbreak response measures (acts and procedures to minimize the spread of a disease) as evidenced by the facility's failure to: a. [...]

Inspectors wroteBased on interview and review the facility failed to develop resident centered care plans for three of three residents (Resident 1,6, and 8) positive for coronavirus disease (COVID-19 a potentially severe, highly contagious illness caused by a corona virus and characterized by fever, coughing, and shortness of breath). This deficient practice had the potential to result in inadequate care and services for Resident 1, Resident 6, and Resident 8.

Inspectors wroteBased on interview and record review the facility failed to ensure the isolation (used to reduce transmission of infection) orders for three of three Coronavirus disease (Covid-19 a very contagious infectious disease) positive residents (Resident 4, 5, and 6) were for specifically for Covid-19 transmission-based precautions (preventive measures based on the way the infection is transmitted). These deficient practices had the potential for the continued spread of Covid-19 to other residents and staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to include the Infection Prevention and Control Program ([IPC]practical, evidence-based approach preventing residents and health workers from being harmed by avoidable infections) in the Facility Assessment for 140 of 140 residents. These deficient practices had a potential to result in the provision of inadequate care and services to the facility ' s resident population.

Inspectors wroteBased on interview and record review, the facility failed to assess residents for eligibility for the pneumonia (an infection of the lungs) vaccination (medication to prevent a particular disease) and offer the vaccination based on eligibility to one of one sampled residents (Resident 8). This deficient practice placed Resident 8 at a higher risk of acquiring and transmitting pneumonia to other vulnerable and immunocompromised residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to offer the coronavirus disease (Covid-19 a potentially severe respiratory illness caused by a corona virus and characterized by fever, coughing, and shortness of breath) vaccine for two of two sampled residents (Resident 1 and 5). This deficient practice placed Resident 1 and Resident 5 at higher risk for acquiring Covid-19.

Inspectors wroteBased on interview and record review the facility failed to ensure the Coronavirus disease (Covid-19 a very contagious infectious disease) tests details indicating the type of test, who completed the test, test results, and the date and time the test was completed were documented for 126 out of 140 residents. These deficient practices had the potential to result in an inaccurate depiction of care rendered and received by the residents.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from Resident 2 by not assessing and treating Resident 2 when Resident 2 was already very agitated and yelling at another resident and staff earlier that day (9/1/2023). This deficient practice resulted in the Resident 2 slapping Resident 1 on the left side of his face and left Resident 1 feeling disturbed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was assessed and treated with nonpharmacological (any type of health interventions like exercise, distraction, not based on medication) approaches and/or Lorazepam (medication to treat anxiety [mental health disorder characterized by feelings of worry or fear strong enough to interfere with one's daily activities]) after Resident 2 was very agitated and yelling at another resident and staff on 9/1/2023 at 1:00 p.m. This deficient practice resulted in the escalation of Resident 2's agitation and on 9/1/2023 at 2:30 p.m. Resident 2 slapped Resident 1 on his face, unprovoked and has caused Resident 1 to feel perturbed (disturbed).