Longwood Manor Conv.hospital

Inspectors wroteBased interview and record review, facility did not meet professional standards of quality, by failing to ensure administered medications were documented timely for one of three residents (Resident 3). This deficient practice had the potential to lead to medication errors, like double medication administration, affecting resident's health.

Inspectors wroteBased on interview and record review, the facility failed to inform and provide the Notice of Medicare Non-Coverage (NOMNC, a notice that indicates when your care is set to end from a skilled nursing facility) form 48 hours prior to the end of skilled nursing services to resident representatives for three of three sampled residents (Residents 128, 136, and 164). This deficient practice had the potential to result in the resident representative not being able to exercise their right to file an appeal.

Inspectors wroteBased on interview and record review, the facility failed to:Ensure medication was administered within the required timeframe as ordered by the physician for one of 28 sampled residents (Resident 164). Ensure two licensed nurses conducted and signed as witnesses in the destruction of non-controlled discontinued medications for five out of five sampled residents (Residents 3, 43, 99, 134, and 152). This deficient practice had the potential for Resident 164's prescribed medication to be ineffective and had the potential of misuse of discontinued medications and drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure:Food items were labeled and not expired in the kitchen. Food items were labeled and dated in one out of one sampled resident (Resident 20)'s room. This deficient practice had the potential to place residents at risk for foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to obtain and document informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of four sampled residents (Resident 144) prior to administering treatment with psychotherapeutic medications (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior). This deficient practice violated Resident 144's and their responsible party (RP)'s right to make an informed decision regarding the use of psychotherapeutic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of four sampled residents (Resident 83). This deficient practice had the potential for Resident 83 not to be able to call for assistance when needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six sampled residents (Resident 7 and 144) had completed Advance Healthcare Directive Acknowledgement (AHCD, a legal document indicating resident preference on end-of-life treatment decisions) by failing to:Inform and offer Resident 7's representative the right to formulate an AHCD. Maintain a current copy of Resident 144's AHCD in his clinical records. This deficient practice had the potential to cause conflict with resident's wishes that could delay treatment or life sustaining procedures in the event of an emergency for Residents 7 and 144.

Inspectors wroteBased on interview and record review, the facility failed to ensure a change of condition (COC, any new, worsening, or significant deviation from a patient's normal baseline health status) was completed for one of four sampled residents (Resident 20). This deficient practice had the potential for information regarding Resident 20's change in condition to not be accurate.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written Notice of Proposed Transfer and Discharge Form was provided to the resident representative and sent to local ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for one of six sampled residents (Resident 164). This deficient practice had the potential to compromise Resident 164's due process rights related to transfer.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a structured, personalized roadmap that outlines an individual's health conditions, care needs, and specific goals) for two of 36 sampled residents (Resident 8 and 14) by failing to ensure a care plan was created for:Resident 8's diagnosis of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). Resident 14's diagnosis of dementia (a progressive state of decline in mental abilities). This failure had the potential to result in a lack of meeting necessary care and addressing medical needs for Resident 8 and had the potential for Resident 14 to not receive monitoring of dementia behavior symptoms and medication management.

Inspectors wroteBased on interview and record review, the facility failed to update the care plan for one of eight sampled residents (Resident 4). This failure had the potential to result in Resident 4 not receiving current and relevant care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:a. a pack of cigarettes was safely stored for one of four sampled residents (Resident 20).b. Resident 65 who requires supervision (the helper provides verbal cues or touching/steadying as resident completes activity) during feeding was properly assisted for one of four sample residents (Resident 65). These failures had the potential to increase Resident 65's the risk of aspiration (inhalation of food, liquid, saliva, vomit, or other foreign material into the airway or lungs) and at risk for injury for Resident 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nasal cannula (NC, a flexible device used to deliver supplemental oxygen to people who have difficulty breathing) tubing was changed weekly per policy for one of four sampled residents (Resident 128). This deficient practice had the potential for Resident 128 to develop a respiratory infection (an infectious disease of the upper or lower respiratory tract).

Inspectors wroteBased on interview and record review, the facility failed to ensure Gabapentin (a medication used to relieve nerve pain) and Duloxetine (a medication used to treat various forms of chronic pain) prescriptions were refilled in a timely manner for one of seven sampled residents (Resident 97). This deficient practice had the potential to cause unnecessary pain for Resident 97.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1. Staff food was not stored in medication storage 2 refrigerator.2. Discontinued ondansetron hydrochloride (medication that prevents and treat nausea and vomiting) was removed from medication cart one for one out of one sampled resident (Resident 141).3. Aerosol nebulizers (a liquid prescription converted into a breathable mist to treat respiratory conditions) were properly stored for one out of one sampled resident (Resident 20). These deficient practices had the potential to result in cross contamination (transfer of harmful bacteria from one place to another) that could compromise the efficacy of the medications, prolonged use of the discontinued medication for Resident 141, and Resident 20 using the medication unsafely.

Inspectors wroteBased on interview and record review, the facility failed to implement the physician's orders to draw laboratory tests (a medical analysis of a body sample (blood, urine, tissue) to check health, diagnose diseases and monitor chronic conditions) for one of one sampled resident (Resident 2). This deficient practice had the potential to result in the delay of the identification of medical concerns, which could delay the care and services necessary for Resident 2.

Inspectors wroteBased on interview, and record review, the facility failed to ensure:1. The notes for ordering the laboratory tests (a medical analysis of a body sample [blood, urine, tissue] to check health, diagnose diseases and monitor chronic conditions) were documented in the progress notes for one of one sampled resident (Resident 2).2. The out on pass (OOP, temporary permission to leave a confined facility) log was complete for one of one sampled resident (Resident 20). This deficient practice had the potential to place Resident 2 at risk of not receiving appropriate care and delay in communication among staff due to incomplete medical records and placed Resident 20 at risk for medical complications while OOP.

Inspectors wroteBased on observation and interview, the facility failed to ensure a foam pool noodle (used for swimming) was not used as a siderail for one of 7 sampled residents (Resident 85). This deficient practice had the potential to result in contamination due to a porous (a material or surface containing tiny holes, spaces, or gaps) foam pool noodle being used as a siderail, which can hold bacteria and viruses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffs' personal belongings were not stored in 1 of 3 residents' room (Resident 2), who was on Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) related to wounds. This failure had the potential to result in cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one object or person to another, with harmful effect) or organisms and placed other residents and staff at high risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure the door to the smoking patio was kept closed so smoke would not enter the building. This deficient practice resulted in smoke entering the building and had the potential to cause respiratory issues for those in the hallway and nearby rooms. During an observation on 11/13/2025 at 1:16 p.m. in the hallway in front of the smoking patio, the patio door was noted to be open. There was a sign on the door that read Keep Doors Closed. Smoking on Patios Only. Cigarette smoke could be smelled in the hallway near rooms 131, 130, 129, and 128. During a concurrent observation and interview on 11/13/2025 at 1:21 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 was noted to enter the building from the patio. The patio door was noted to be open upon CNA 1 entering. CNA 1 left the door open. [...]

Inspectors wroteBased on interview and record review, the facility failed to:1. Ensure one of three sampled residents (Residents 3) received splint application by the Restorative Nurse Assistant ([RNA]- a healthcare worker who helps residents improve and maintain function in physical abilities) five days a week as ordered by the physician. This deficient practice put Residents 3 at risk for decreased range of motion and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). During a review of Resident 3's admission Record, the admission Record indicated Resident 3 bwas admitted to the facility on [DATE], with a readmission on [DATE]. Resident 3's diagnoses included muscle weakness, artificial hip joint, and contracture of left lower leg. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered as ordered by the physician for four (4) of 4 sampled residents' (Residents 1, 2, 3 and 4). This failure placed the affected residents at risk for ineffective disease management and had the potential to affect the recovery process of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Novolin insulin (medication used to control blood sugar levels in residents with diabetes [DM- a disorder characterized by difficulty in blood sugar control and poor wound healing]) was stored in the medication cart with the correct label (information including resident name, medication name, dosage and directions of the medication) for one of three sampled residents (Resident 1). This deficient practice had the potential for medication administration errors that could lead to hypoglycemia (low blood sugar), altered mental status and hospitalization for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure call lights were placed within reach for 2 of 3 residents (Residents 2 and 3). 2. Provide oral care to 1 of 3 residents, (Resident 3) This deficient practice had the potential for the residents to not be able to call for help and assistance when needed and could result to the delay in care and interventions needed for the residents' safety. This deficient practice had the potential to cause Resident 2 the feeling of neglect, affecting psychosocial well-being and the risk of developing tooth decay and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one Registered Nurse had the specific competencies, and skill sets necessary to assess a newly admitted resident for one of three sampled residents (Resident 1 and Resident 2). This deficient practice led to Resident 1 to received unnecessary medications and delayed wound treatment.

Inspectors wroteBased on interview and records review, the facility failed to ensure, 1 of 3 residents (Resident 1): 1). Had documented assessment to support the diagnosis of bipolar disorder in the resident ' s clinical records. 2). Had an adequate indication for the use of Seroquel (antipsychotic medications that treat several kinds of mental health condition including schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions)] and bipolar disorder [a mental health condition characterized by extreme shifts in mood, energy, and behavior]) for 1 of 3 residents (Resident 1). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure three out of seven sampled residents (Residents 68, 76, and 177) had a low air loss([LAL] -a specialized medical mattress designed to prevent and treat pressure ulcers by reducing pressure and moisture buildup on the skin) mattress, as ordered. 2. Ensure two out of seven sampled residents (Resident 106 and 145) LAL mattress had the correct settings, as ordered. This deficient practice had the potential for Residents 68, 76, 106, 145 and 177 to develop pressure ulcers (injuries to the skin caused by prolonged pressure).

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure two of seven sampled residents (Residents 74 and 76) received Restorative Nurse Assistant ([RNA]- a healthcare worker who helps residents improve and maintain function in physical abilities) services seven days a week as ordered by the physician. This deficient practice put Residents 74 and 76 at risk for decreased range of motion and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion).

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one of seven sampled residents (Resident 67) smoking paraphernalia (an electronic cigarette device that heats a liquid containing nicotine) had been properly stored. 2. Ensure one of seven sampled residents (Resident 124) bed rails were properly padded. 3. Ensure one of seven sampled residents (Resident 95) lighter was stored in a safe location. These deficient practices had the potential to cause serious injuries.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 123) had a Complete Blood Count ([CBC]- a blood test that measures the number and type of cells in your blood), Comprehensive Metabolic Panel ([CMP]- a blood test that measures fourteen different substances in the blood) and Ammonia (a waste product found in blood) level completed per physician's order. 2. Ensure one of two sampled residents (Resident 156) had weekly pre-albumin (a lab test measures the level of prealbumin in the blood, a protein made by the liver) laboratory order drawn as ordered by the physician. These deficient practices had the potential for a delay in healthcare services and interventions for Residents 123 and 156 .

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 by failing to: 1. Ensure food item was labeled in dry food storage 2. Ensure the outside compartment of ice machine was clean These deficient practices had the potential to result in foodborne illness and cross contamination (transfer of harmful bacteria from one place to another).

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Ensure two of five sampled residents (Resident 152 and Resident 441) was offered the flu vaccine for the 2024-2025 flu season. This deficient practice had the potential for Resident 152 and Resident 441 at higher risk of acquiring and transmitting the flu to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of seven sampled residents (Resident 49) had an accurate assessment for the use of four bed rails. This deficient pracfailure had the potential for Resident 49 to not have received necessary care and services.

Inspectors wroteBased on interview and record, the facility failed to ensure a Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for one of 35 sampled residents (Resident 40) by failing to: 1. Ensure Resident 40's diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) was encoded under MDS section I5800 (Active Diagnoses). This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Resident 40.

Inspectors wroteBased on interview and record review, the facility failed to complete and re-submit the Preadmission Screening and Resident Review ([PASARR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer one of one sampled resident (Resident 175) who had a diagnoses of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder ([MDD] - a mood disorder that causes a persistent feelings of sadness and loss of interest) to the appropriate state-designated authority for PASARR Level two (II) evaluation and determination. This deficient practice had the potential to result in Resident 175 to not receive the appropriate medical treatments for mental illness diagnoses.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of seven sampled residents (Resident 106) had a revised care plan (a structure written document that outlines the care a nurse will provide to a patient based on their specific needs and goals) for the low air loss ([LAL] -a specialized medical mattress designed to prevent and treat pressure ulcers by reducing pressure and moisture buildup on the skin) mattress. This deficient practice of not having revised care plan for the use of the LAL mattress placed Resident 106 at risk for not being provided with the appropriate, consistent, and individualized care.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 56) received a weekly weight per physician's order. This deficient practice resulted in inadequate monitoring of Resident 56's weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to: 1. Provide compression stockings (elastic garments that squeeze the legs to improve blood flow, circulation, and to reduce swelling) per physician's order for one of one sampled resident (Resident 170) who had an edema (swelling caused by an accumulation of excess fluid in the body's tissues) of bilateral (both) lower extremities. This deficient practice had the potential to result in a delay in reducing the swelling of bilateral lower extremities of Resident 170 that would result in medical complication requiring hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure resident with long thick elongated (nail plate grows longer than the nail bed) toenails received podiatry (profession dealing with specialized care of the feet) care services for one of one sampled resident (Resident 170). This deficient practice had the potential to result in discomfort and decline in physical mobility of Resident 170.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 175) was provided with a scheduled toileting plan (a technique that involves using a set schedule to go to the bathroom) or bladder training (type of training that will help a person manage urinary incontinence), per bowel and bladder assessment. This deficient practice had the potential for decline in bladder function for Resident 175.

Inspectors wroteThe facility failed to: 1. Ensure one of four sampled residents (Resident 62) oxygen (O2) tubing was labeled with date last changed. This failure resulted in Resident 62 not having a clean and patent tubing and placed at risk for developing a respiratory infection.

Inspectors wroteBased on observation, interview, record review the facility failed to: 1. Ensure one out of seven sampled residents (Resident 49) appropriate alternatives were used prior to installing all four bed rails. This deficient practice of having all four bed rails up had the potential for Resident 49 to feel entrapped.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 170) was evaluated by a physician at least once every 30 days for the first 90 days following admission and document his visit in resident's clinical records. This deficient practice had the potential for Resident 170's current medical condition not timely assessed by a physician that can lead to delay in necessary care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the correct prescribed eyedrops were in the Sub-Acute Medication Cart according to physician orders for Resident 84. This deficient practice had the potential to result in medication errors.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Act on the pharmacist consultant's (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendations timely, for one of five sampled residents (Resident 39). This deficient practice placed Resident 39 at risk for unnecessary medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure insulin pens were discarded for Resident 21. 2. Ensure a valproic acid (to treat seizures) bottle had a legible label for Resident 64.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure licensed staff performed hand hygiene for one out of seven sampled residents (Resident 34) during a dressing change. This deficient practice had the potential to spread infections throughout the facility, which is transferred through direct contact from contaminated hands.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the results of their last recertification survey were in a place easily accessible and viewed by residents/the public. This deficient practice had the potential to result in residents/the public not being well informed about the quality-of-care residents receive at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure residents in rooms 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, and 13 had at least 80 square feet ([sqft]- a unit of measure) of living space. This deficient practice had the potential to result in residents not being able to move around freely or store personal items. Staff may also have difficulty providing care due to a lack of space.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) were free from verbal abuse by Certified Nursing Assistant (CNA) 1. This deficient practice had the potential for Resident 1 to feel upset and that his needs were not being met.

Inspectors wroteBased on interview and record review, the facility failed to: 1). Provide a written notice of discharge to one of three sampled residents (Resident 1). 2). Provide a copy of the notice of discharge to the Office of the State Long-Term Care Ombudsman (Patient Advocate), for one of three sampled residents (Resident 1). These failures resulted in the resident not knowing the facility where he was going and unaware of his appeal rights. This failure also resulted in the Ombudsman not aware of the resident ' s discharge to another facility.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Personal Property, which indicated the facility would inventory and pack the personal property of a resident , place in a secure location to prevent its loss, during a resident's absence of undetermined length, for one of three sampled residents (Resident 1). This failure had the potential for the residents' belongings missing if not properly inventoried.

Inspectors wroteb. A review of Resident 71's admission Record (Face Sheet), dated 4/17/2024, the Face Sheet indicate Resident 71's was admitted to the facility on [DATE], and was re-admitted on [DATE], with a diagnosis including heart failure (a chronic condition in which the hear doesn't pump blood as well as it should), type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a change of condition was completed for two of seven sampled residents (Resident 117 and 7) skin assessments. This deficient practice has the potential to negatively affect the provision of necessary care and services.

Inspectors wroteb. During observations and interviews, on 5/22/2024 at 1:11 p.m., with Resident 150 in his room, Resident 150 stated he had difficulty in reading the newspaper and he had been asking the nursing staff to schedule him for eye surgery. Resident 150 further stated that he was anxious and afraid of losing his sight. A review of Resident 150's admission Record, the admission Record indicated, Resident 150 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 150's diagnoses included left eye visual loss and type 2 diabetes mellitus ([DM] a chronic condition that affects the way the body processes blood sugar). A review of Resident 150's History and Physical (H&P), dated 7/19/2023, indicated, Resident 150 had the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Provide a complete Restorative Nursing Assistant (RNA) treatment per physician's order by failing to provide hand rolls and splints seven days a week for three of 14 sampled residents (Residents 115, 124, and 145). This deficient practice had the potential to promote the worsening development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the residents' extremities.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure accurate destruction of all medications including narcotic (drug which relieves pain and induces drowsiness, stupor, or unconsciousness) were conducted with the signature of licensed nurse, per facility's Policy and Procedure (P&P) titled, Discarding and Destroying Medications. This deficient practice increased the risk of loss or diversion of controlled medication.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure an informed consent was obtained from resident representative for the use of psychotropic drug (any drug that affects brain activities associated with mental process and behavior) for one of one sampled resident (Resident 2). This deficient practice had the potential for the resident representative to have a lack of knowledge to make an informed consent and not knowing in advance the potential risk and benefits of the psychotropic drug.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure the low loss air mattress was in functioning condition for one of one sampled resident (Resident 177). This deficient practice resulted in Resident 177 sleeping in a bed that was not functioning and uncomfortable, which had the potential not to meet the resident's needs.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure a Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment screening was resubmitted to determine the facility's ability to provide special care and needs for one of 7 residents (Resident 38). This deficient practice has the potential to negatively affect the provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Correctly fill out the Preadmission Screening and Resident Review ([PASRR], a tool to determine if the person had, or was suspected of having, a mental illness, intellectual disability, or related condition) level one screening and refer one of seven sampled residents (Resident 147) who had a diagnoses of schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior) and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread and uneasiness) to the appropriate state-designated authority for PASRR level two evaluation and determination. This deficient practice had the potential to result in Resident 147 not receiving appropriate treatment recommendations for schizoaffective and anxiety disorder.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the low air loss mattress ([LALM] a mattress designed to prevent and treat pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) was set and maintained at correct setting for one of three sampled residents (Resident 82). This deficient practice placed Resident 82 at risk for further skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Resident 164 did not have a cigarette lighter in his possession. This failure had the potential to result in a fire being started in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Remove opened expired medication of diltiazem solution (medication to treat high blood pressure and chest pain) in subacute medication refrigerator room storage for Resident 115. This deficient practice had the potential to result in prolonged use and loss of strength of the expired medication and can lead to ineffective treatment of Resident 115's hypertension ([HTN] high blood pressure) and possibly can cause severe adverse reactions (an unintended effect of a medication that is harmful or unpleasant) including hospitalizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the cook was wearing a beard restraint (device used to keep hair from falling onto food) while working in the kitchen. This failure had the potential to result in food being contaminated with hair.

Inspectors wroteBased on interview and record review, the facility failed to monitor, document and inventory emergency crash cart supplies for 2 of 2 facility crash carts. This failure had the potential for the emergency crash cart supplies not completely available and a poor quality emergency medical intervention during an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician ' s Order for Life Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) for 1 of 5 residents (Resident 1) was completed, discussed with resident ' s representative and followed up with the attending physician. This failure had violated Resident 1 ' s right to decide and request the preferred medical services in the event of medical emergencies.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 1) received treatment and care in accordance with the physician ' s orders by failing to: 1. Monitor and identify when the resident last had a bowel movement. 2. Administer medications as ordered by the physician. This deficient practice had the potential to cause fecal impaction in Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to report Coronavirus Disease ([Covid-19] a highly contagious infection caused by a virus that could easily spread from person to person) outbreak (at least one confirmed case of COVID-19 who had resided in the facility for at least 7 days) to the California Department of Public Health (CDPH) District Office for 3 out of 4 residents (Residents 1, 2 and 3) as indicated in the All Facilities Letter (AFL, a letter to all nursing facilities informing of new changes or updates) 23-09. This deficient practice delayed the infection control investigation by the DO and had the potential for further residents to be infected and become ill requiring hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of four sampled residents (Resident 1, Resident 2, and Resident 3), were provided clean bed linens and Resident 1 with clean wheelchair and curtains. This deficient practice resulted to an unclean resident's environment and had the potential to affect the highest practicable mental, physical, and psychosocial wellbeing of the affected residents.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Abuse and Mistreatment of Residents, which indicated residents will be free from verbal, sexual, and mental abuse, corporal punishment, involuntary seclusion for two of three sampled residents (Resident 1 and Resident 2) by a License Vocational Nurse (LVN 1). LVN 1 cursed, yelled and pushed Resident 1 on to his bed. LVN 1 was rude and yelled at Resident 2. This deficient practice resulted in Resident 1 crying and feeling fearful. It also resulted in Resident 2 feeling inhuman, withdrawn and anxious (feeling uneasy).

Inspectors wroteBased on interview and record review, the facility failed to report allegations and incidents of abuse for two of three sampled residents (Resident 1 and Resident 2) to the California Department of Public Health (CDPH) within 24 hours, and failed to implement its policy and procedure by not reporting Resident 1's allegation of abuse to the State Survey Agency (SSA) within two hours after being made aware of the allegation when: 1. Licensed Vocational Nurse (LVN) 1 was observed yelling and being physically and verbally abusive to Resident 1. 2. Resident 2 disclosed to staff of receiving verbal mistreatment from LVN 1. These deficient practices delalyed the investigation of the abuse allegations by the CDPH, and had a potential to place Resident 1 and Resident 2 and other residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) by not placing Licensed Vocational Nurse (LVN) 1 on immediate suspension after he was observed mishandling one of three sampled residents (Resident 1). This deficient practice had the potential to expose other residents to the same harsh treatment and care, potentially causing physical, emotional, and psychosocial injury and requiring hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 3 residents (Resident 1) was evaluated for Physical Therapy ([PT], treatment of disease, injury, or deformity by methods such as exercises to relieve pain, help resident move better or strengthen weakened muscles) in a timely manner per physician ' s order and facility policy and procedure (P&P). This deficient practice had the potential to cause harm to Resident 1 ' s newly amputated right lower limb and placed him at risk for decline in health and delay in recovery.

Inspectors wroteBased on Interview and record review the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for one out of three sampled residents (Resident 2) by failing to accurately document administration of medications in the residents Medication Administration Record (MAR). This deficient practice placed Resident 2 at risk for medication errors and of not receiving appropriate medication due to incomplete medication administration documentation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had bilateral (both) bed rails up and padded to prevent injuries according to the physician's order, the bed in lowest position and the bedside table within reach according to the facility's policy and procedures (P&P). These deficient practices had the potential to cause further falls and accidents with injury for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an injury of unknown origin for one of three sampled residents (Resident 1) within two hours after being made aware of the injury. This deficient practice had the potential to result in unidentified abuse in the facility and a failure to protect residents from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the bed was in a low position, with a fall mat at the bedside, for one of three sampled residents (Resident 2), who was at risk for falls. This deficient practice had the potential to cause avoidable harm to Resident 2 from falling onto the floor from an elevated height and landing onto the floor without a fall mat in place.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse (LVN) 2 failed to implement infection control measures for one of three sampled residents (Resident 3), when the following occurred: 1. LVN 2 did not perform hand hygiene (cleaning one's hands by washing hands with soap and water or antiseptic hand rub [i.e. alcohol-based hand sanitizer]) prior to or after providing direct patient care to Resident 3. 2. LVN 2 did not don (put on) the required personal protective equipment (PPE, specialized clothing or equipment worn by an employee for protection against infectious materials) while providing care to Resident 3, who required enhanced standard precautions (ESPs, a resident-centered and activity-based approach for preventing transmission of multi-drug resistant organisms [MDROs] in skilled nursing facilities [SNFs]). [...]