Los Feliz Healthcare & Wellness Center, LP

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two sampled resident's (Resident 2) suprapubic urinary catheter (a hollow, flexible tube inserted directly into the bladder [an organ for the storage of urine] through a small incision in the lower abdomen, just above the pubic bone) was not kinked (the flexible drainage tube has become bent, twisted, or pinched) and urine was not backflowing during an observation on 7/15/2026 at 9:16 a.m. The deficient practices had the potential for Resident 1 developing urinary tract infection (UTI, a common infection that occurs when bacteria enter and multiplies in the urinary system).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed when Licensed Vocational Nurse (LVN) 1 did not wear personal protective equipment (PPE - a specialized clothing such as gown, gloves and other garments, designed to protect the wearer from spread of infection) in enhanced barrier precautions (EBP - infection control strategy requiring staff to use gowns and gloves during high-contact care for residents) room for one of two sampled residents (Resident 1) when taking blood pressure and applying lidocaine patch (a medicated adhesive strips applied directly to the skin to provide targeted pain relief). This failure had the potential to contaminate the care environment, increase risk of cross contamination, and place residents at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to remove the intravenous (IV-a thin, flexible tube inserted into a vein, usually in the back of the hand, the lower part of the arm, or the foot to draw blood or give fluids) catheter for one of three sampled residents (Resident 2) after Resident 2 completed the IV antibiotic (medication used to treat infection) on 5/21/2026. This deficient practice had the potential to cause infection and discomfort to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one person towards another) and verbal abuse (the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability) for one of four sampled residents (Resident 1) when:1. On 5/22/2026, around 8:30 p.m., Resident 1, who was in the Facility Recreational Room, was approached by Visitor (VS) 1 who used verbal profanities towards Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to report a physical abuse incident (deliberately aggressive or violent behavior with the intention to cause harm) to the State Survey Agency (SSA) no later than two hours for one of four sampled residents (Resident 1), as indicated in the facility's policy and procedure (P&P) titled, Reporting Abuse, when:On 5/22/2026, around 8:30 p.m., Resident 1, who was in the Facility Recreational Room, was approached by Visitor (VS) 1 who used verbal profanities towards Resident 1. VS 1 and Resident 1 continued to both use verbal profanity and derogatory slur towards each other as they walked down the hallway toward Resident 1's room, VS 1 was in front of Resident 1 and turned around and spat (the intentional, aggressive act of ejecting saliva, phlegm, or other mouth contents directly at another person) at Resident 1's face. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its written abuse policy and procedures (P&P) titled, Abuse Prevention and Management, when one of three sampled residents (Resident 2) had an allegation of physical abuse (includes, but is not limited to, hitting, slapping, punching, biting, and kicking) on 3/31/2026 and the facility did not report this to the State Survey Agency (SSA) and did not conduct a thorough investigation. This failure had the potential to subject Resident 2 to further physical abuse. Cross-reference F609 and F610.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse (includes, but is not limited to, hitting, slapping, punching, biting, and kicking) within two hours for one of three sampled residents (Resident 2) when on 3/31/2026, there was an allegation that Resident 2 was punched in the face. This deficient practice had the potential to place Resident 2 at an increased risk for further abuse and additional unreported incidents. Cross-reference F607 and F610.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and submit the investigation report of all allegations of abuse to the California Department of Public Health (CDPH) within five days of the incident for one of three sampled residents (Resident 2) when the facility failed to thoroughly investigate and submit investigative reports to CDPH when an allegation of abuse was made on 3/31/2024 by Resident 2's Responsible party (RP) that an unidentified staff member hit Resident 2 on right side of the cheek. This deficient practice resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported. Cross-reference F607 and F609.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate clinical records in accordance with acceptable professional standards and practices for one of three sampled residents (Resident 1) when on 5/11/2026, Licensed Vocational Nurse (LVN) 5 failed to accurately document in Resident 1's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) when LVN 5 documented in Resident 1's MAR as if Resident 1 was still in the facility when Resident 1 was already discharged to General Acute Care Hospital (GACH) 1. This deficient practice resulted in inaccurate documentation of Resident 1's records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) received care in accordance with professional standards of practice to attain or maintain the highest practicable physical, mental, and psychosocial well-being when: (A) On 3/13/2026, Resident 1 pressed the call light in order for Resident 1's soiled diaper and bed sheets to be changed. Certified Nursing Assistant (CNA 1) was Resident 1's assigned CNA. CNA 1 entered Resident 1's room, turned off the call light, exited the room and did not return to change Resident 1, in accordance with Resident 1's verbal request. Resident 1 called the facility's front desk and asked to be changed. Resident 1 waited about one hour before Resident 1's soiled diaper and bed sheets were changed by another CNA who was not assigned to Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the personal privacy of one of three sampled residents (Resident 2) was provided when Certified Nursing Assistant (CNA 1) entered Resident 2's room without knocking and began speaking to CNA 4 through a gap in the curtain, while CNA 4 was changing Resident 2's diaper and providing peri-care (the cleaning of genitals particularly for individuals with limited mobility and/or loss of bladder/bowel control). This deficient practice resulted in failing to provide Resident 2 with privacy during personal hygiene care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record of one of two sampled residents (Resident 1) was accurately documented in accordance with the facility's policy, when Licensed Vocational Nurse (LVN) 1 documented in advance that Resident 1 was transferred to a new isolation room (a room that is specifically assigned to a resident who is infected with a specific germ in order to prevent the spread of infection to other residents) when the transfer had not yet occurred. This deficient practice resulted in an inaccurate medical record for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to inform the medical doctor (MD) of one of five sampled residents (Resident 4) when: 1. On 9/9/2025 at 6 a.m. Resident 4 refused fasting blood sugar (FSBS- a measure of the glucose in your blood after you've gone at least 8 hours without eating or drinking anything except water). 2. On 9/9/2025 at 7 p.m. Resident 4's blood glucose (blood sugar- the main source of energy for your body's cells, especially your brain, and comes from the carbohydrates you eat) was 379. These deficient practices had the potential to result in a delay of care to Resident 4.

Inspectors wroteBased on interview and record review the facility failed to ensure one of five sampled residents (Resident 4) received treatment and care in accordance with professional standards of practice when Licensed Vocational Nurse (LVN) 1 failed to follow the physician's orders to contact the physician if blood sugar (blood glucose- the amount of a simple sugar called glucose in your blood, which serves as the main source of energy for your body's cells and brain), is above 250. This deficient practice resulted in a delay in care and treatment for Resident 4 who was transferred to the General Acute Care Hospital (GACH) 2 on 9/9/2025.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 4), who was dependent on enteral feeding (a way to deliver nutrients, liquids, and medications directly into the stomach or small intestine through a tube, bypassing the mouth and throat) was provided the prescribed diet. This deficient practice resulted in Resident 4 not receiving the prescribed diet.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 4) received medications as prescribed:1. On 9/9/2025 at 6 a.m. Resident 4 refused fasting blood sugar (FSBS- a measure of the glucose in your blood after you've gone at least 8 hours without eating or drinking anything except water). 2. On 9/9/2025 at 6a.m. Resident 4 did not receive Novolin N FlexPen 100 units/milliliter (ml- a unit of measurement) suspension pen-injector, inject 10 units subcutaneously (subq- under the skin) in the morning for DM hold if blood sugar is less than 100. These deficient practices had the potential for Resident 4 to be negatively impacted.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate clinical records in accordance with acceptable professional standards and practices for one of five sampled residents (Resident 4) by failing to:1. Ensure Licensed Vocational Nurse (LVN) 4 documented a progress note on 9/9/2025 at 6 a.m. when Resident 4's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) indicated 9 (see progress note). 2. Ensure LVN 5 accurately documented in Resident 4's MAR after Resident 4 was discharged to the General Acute Care Hospital (GACH) 2. These deficient practices resulted in inaccurate documentation of Resident 4's records.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to: 1. Ensure Registered Nurse (RN) 1 completed and signed Resident 1's Discharge Planning Review Form.2. Ensure the Licensed Nurses documented the level of care provided to Resident 1 before the resident's discharge from the facility.3. Ensure the Licensed Nurses documented Resident 1's condition before the resident's discharge from the facility.4. Ensure the Licensed Nurses documented Resident 1's refusal to sign discharge documents. These deficient practices resulted in inaccurate information on Residents 1's medical records and had the potential for delayed and inaccurate medical interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect and dignity for one of four sampled residents (Resident 4), when Resident 4 ' s privacy curtain was not fully pulled closed while Resident 4 showered. This failure had the potential to negatively affect Resident 4 ' s psychosocial well-being (refers to a resident ' s overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one of four sampled residents (Resident 3) by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was withinreach for Resident 3. This failure had the potential to result in Resident 3 ' s inability to call for facility staff assistance and delay in the provision of necessary care and services that could negatively affect the resident ' s well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for one of four sampled residents (Resident 1) by failing to arrange transportation for Resident 1's clinic appointment. This failure had the potential to negatively affect Resident 1 ' s well being (refers to a resident's overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose) and delay care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to document clinic appointment arrangements made for Resident 1. This deficient practice had the potential for inaccurate documentation and interventions for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) and account for six (6) medication emergency kit (eKIT) containing Controlled Medications ([CM] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Drugs or Controlled Substances [CS]) for June 2025, in three (3) of three (3) inspected Medication Rooms (Medication Room Station 1, Station 2 and Station 3). As a result, control and accountability of medications and CMs did not follow state and federal regulations and facility policy and procedures. 2. Have an available supply of tramadol (a medication used to treat pain) in the facility affecting 1 (one) of six (six) observed residents (Resident 8) for medication administration. [...]

Inspectors wrotec. During a review of Resident 31 ' s AR, the AR indicated the facility originally admitted the resident on 5/18/2020 and readmitted in the facility on 4/30/2025 with diagnoses including cerebral infarction (stroke, loss of blood flow to a part of the brain), dementia (a progressive state of decline in mental abilities), and type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 31 ' s History and Physical (H&P) dated 5/7/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 31s MDS, dated [DATE], the MDS indicated Resident 31 was able to understand others and make her needs known but with severely impaired cognition (mental action or process of acquiring knowledge and understanding). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident ' s body that he or she cannot easily remove that restricts freedom of movement or normal access to one ' s body) for four of six sampled residents (Residents 31, 59, 65, and 110) reviewed for physical restraints care area by: 1. Failing to ensure Residents 31 ' s and 59 ' s pillows were not tucked tightly under the fitted sheet. 2. [...]

Inspectors wroteBased on interview and record review, the facility ' s licensed nursing staff failed to provide care in accordance with professional standards to two of five sampled residents (Residents 110 and 6) reviewed for unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites on multiple days. This deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for eight sampled residents (Residents 59, 114, 34, 56, 110, 57, 377 and 6) reviewed under Accidents and two of four sampled residents (Resident 25 and 18) reviewed under Environment facility task, by: 1. Failing to ensure Resident 59 ' s right floor mat did not have the overbed table placed on the top. 2. Failing to ensure Resident 114 ' s left floor mat did not have the overbed table and the right floor mat did not have the visitor ' s chair placed on top. These deficient practices placed Residents 59 and 114 at risk for increased chances of incurring injury such as falls with fracture (a break or crack in a bone) and even death. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), bedrail (an adjustable metal or rigid plastic bars attached to the sides of a bed to assist patients or residents) assessment, and care plan on the use of padded bilateral upper bedrails for one of one sampled resident (Resident 110) reviewed for bedrails. These deficient practices placed the residents at risk for potential accidents such as a body part being caught between the rails, falls if a resident attempts to climb over, around, between, or through the rails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 31 total opportunities contributed to an overall medication error rate of 6.45% affecting two (2) of six (6) residents observed for medication administration (Resident 8 and 87). The medication errors were as follows: 1. Resident 8 did not receive tramadol (a medication used to treat pain) on 6/3/2025 at 9:06 a.m., as prescribed by Resident 8's physician. 2. Resident 87 received a form of multivitamin (a medication used as a dietary supplement for wound healing) that was different than the one ordered by Resident 87's physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two of five sampled residents (Residents 110 and 6) reviewed for unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq - beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: An opened bottle brown coloring for gravy was observed with dried dark brown drippings on the side. The opened container of thickened lemon water was sticky when touched. The opened container of almond milk was sticky when touched A container of thickened apple juice did not indicate the date of when it was opened. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to enforce its policy on storing food bought from outside or brought in by family or visitors when multiple food items including condiments were not labeled with the resident ' s name on the personal food items in the residents ' refrigerator reviewed under the kitchen task. This deficient practice placed the residents at risk for development of food-borne illnesses (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure: 1. Resident 27's glass of water and desk phone were not placed on the floor beside the resident's low bed (a hospital bed designed to be closer to the floor, often with a lower height than standard hospital beds) and urinal bottle (a container used to collect urine) was labeled with the name and/or room number of the resident. 2. Mobile Linen carts A, B, C were not left open after obtaining needed linen supplies on the hallway facing the residents doors. 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure to provide the name of the medications and their indications (reasons for the use of the medications) prior to administration of seven medications, affecting one of six sampled residents (Resident 23) observed for medication administration. This deficient practice violated Resident 23 ' s rights to make decisions regarding their medication regimen, withhold treatment or seek alternatives, potentially resulting in psychosocial (relating to the interrelation of social factors and individual thought and behavior) harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for one of one sampled resident (Resident 87) reviewed under accommodation. The deficient practice had the potential for Resident 87 unable to summon health care worker for help as needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of six sampled residents (Resident 110) reviewed for physical restraints (the use of a manual hold to restrict freedom of movement of all or part of a person's body, or to restrict normal access to the person's body) by failing to develop and implement a care plan on the use of restraint bed placed against the wall. This deficient practice had a potential for delays in the delivery of necessary care and services and adverse effects (an undesired effect of a drug or other type of treatment, such as surgery) to Resident 110.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement resident-centered activities for one of three sampled residents (Resident 54), reviewed under Activities care area, by failing to: 1. Ensure Resident 54 was provided her preferred activities when Resident 54 was not brought to the religious services. 2. Follow the facility ' s policy and procedure to document and maintain a current record for residents participating for each type of activity for Resident 54. These deficient practices had the potential to result in a decline in Resident 54 ' s physical, social and emotional functioning.

Inspectors wrote2. During a review of Resident 23 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 10/23/2024 and readmitted on [DATE] with diagnoses including cognitive communication deficit (a condition characterized by difficulty with attention, memory, reasoning, planning, organization, and/or language skills), type 2 diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), and generalized muscle weakness. During a review of Resident 23 ' s H&P, dated 10/24/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 23 ' s MDS, dated [DATE], the MDS indicated Resident 23 was able to understand others and make his needs known and with an intact cognition (mental action or process of acquiring knowledge and understanding). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (FC - a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one of one sampled resident (Resident 278) reviewed for urinary catheter or UTI by failing to ensure Resident 278 ' s urinary catheter tubing did not have a kink or loop while hanging on the side of the bed. This deficient practice had the potential for Resident 278 ' s urine not to flow freely and which may lead to the development of UTI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of EF for one of one sampled resident (Resident 38) reviewed for tube feeding when the licensed nurse failed to rinse the medication syringe thoroughly after medication administration. This deficient practice had the potential to result in Resident 38 experiencing complications associated with enteral feeding such as gastrointestinal (GI, relating to stomach and intestines) problems such as abdominal pain and diarrhea.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids (are liquids that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice for one of one sampled resident (Resident 278) reviewed during a random observation by failing to ensure Resident 278 ' s midline catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm) indicated the date of the last dressing change. This deficient practice had the potential to place Resident 278 at risk for developing complications such as infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) received treatment consistent with professional standards of practice for one of two sampled residents (Resident 67) reviewed under the Dialysis care area, by: 1. Failing to follow-up with the resident ' s attending physician when Resident 67 missed a dialysis appointment on 5/30/2025. 2. Failing to ensure a dialysis kit (a collection of medical supplies designed to provide immediate care for emergencies, such as bleeding) for dialysis residents was readily available at Resident 67 ' s bedside. [...]

Inspectors wrote2. During a concurrent interview and observation on 6/4/2025 at 9:55 a.m. with RN 1, in Medication Room Station 3, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: 1. One (1) opened epoetin alfa multi-dose (containing more than one dose) vial for Resident 81 stored in the refrigerator containing unused volume of medication and without a date indicating when use first began or when the medication would expire. The manufacturer's product storage and labeling indicated epoetin multi-dose vials should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and to throw away the vial no later than 21 days from first use. [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly provide dental services for one of one sampled resident (Resident 98) being investigated under dental services by failing to ensure: 1. Family Member (FM) 1's verbal complaint of toothache was acted upon by Social Services Director (SSD) and was referred in a timely manner and was acted upon by the Dentist. 2. SSD followed up with FM 1 if the complaint of toothache was resolved. These deficient practices had the potential to result in Resident 98 undue pain while eating that can lead to poor appetite and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to designate a qualified hospice (compassionate care for people who are near the end of life) coordinator who is responsible for working with hospice representatives to coordinate care to the resident provided by the Long-term Care (LTC - ongoing medical, personal, and custodial care provided to individuals who need assistance with activities of daily living [ADLs - activities such as bathing, dressing and toileting a person performs daily] and/or have chronic health conditions) facility and hospice staff for one of one sampled resident (Resident 56) by designating the Medical Records Director (MRD) as a hospice coordinator for the facility. This deficient practice had the potential to result in a delay or lack of coordination in delivery of hospice care and services to Resident 56.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and resident care equipment in safe operating condition by failing to ensure the resident's bed frame control was in good repair when the control box cord had frayed and exposed wires for one of four sampled residents (Resident 25) reviewed under the Environment task. This deficient practice had the potential to place the resident at risk for injury. Cross-reference F584.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practice for two of two sampled residents (Resident 54 and 34) reviewed under the Activities care area by failing to ensure that the activity documentation was completed accurately to reflect the activity staff member who provided the activity for Resident 54 and 34. This deficient practice had the potential to result in inaccurate tracking of activity attendance and provision of care.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe, comfortable, and homelike environment for one of four sampled residents (Resident 1) when Resident 1's patio was observed with belongings from multiple residents including four clear trash bags with facility curtains, three facility mattresses, and a wheelchair all covered in a blue tarp (a piece of material [such as durable plastic or waterproofed canvas] used especially for protecting exposed objects or areas). This deficient practice had the potential to affect Resident 1's homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurately documented for one of four sampled residents (Resident 1). On 9/4/2024 at 11:50 p.m., Resident 1 complained of a possible infection on the dialysis access port (a way to reach the blood for hemodialysis [a machine that filters wastes, salts, and fluid from the body when the kidneys were no longer healthy) and was transferred to the General Acute Care Hospital (GACH) for further evaluation. Licensed Vocational Nurse 2 (LVN 2) documented on Resident 1's Change of Condition (COC) Evaluation form that Resident 1 complained on 9/5/2024. This deficient practice resulted in inaccurate information in Resident 1's clinical record.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for four of nine residents (Resident 52, 8, 179, and 14) investigated during review of the environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to ask assistance from facility staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) to two of two sampled residents (Residents 118 and 378) investigated during review of physical restraints care area by failing to ensure Resident 118 and Resident 378 were properly assessed for risk for entrapment on the use of bed rails and placement of bed against the wall, ensure Residents 118 and 378 or their representative were educated with the risks and benefits of bed rails and placement of bed against the wall, ensure an informed consent was obtained from Residents 118 and [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (a document outlining a detailed approach to care customized to an individual resident's need) for: 1. Two out of two sampled residents (Residents 118 and 378) investigated during review of physical restraints (devices that limits a patient's movement) use (bed rails (metal rails that normally hang on the side of the patient's bed) use and placement of bed against the wall). 2. One (1) out of 1 sampled resident (Resident 79) who received vancomycin hydrochloride (a type of medication used in the treatment of serious bacterial infections), investigated during review of infection control task on the use of These deficient practices had the potential to result in failure in the delivery of necessary care and services. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards to three out of three sampled residents (Residents 7, 118, and 109) investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an environment free from accidents and hazards, ensure residents received adequate supervision, and implement and modify interventions to prevent accidents three of five residents (Resident 326, 6, and 8) reviewed under the accidents care area by failing to: 1. Ensure Resident 326, a resident that used tobacco, did not store cigarettes at bedside. 2. Ensure Resident 326 was appropriately assessed by the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) to identify the resident as an independent or at-risk smoker. These deficient practices had the potential to result in a facility fire from improper disposal of smoking materials and resident injuries from burns. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (any method of feeding that uses the gastrointestinal tract to deliver nutrition and calories) to three out of three sampled residents (Resident 62, 379, and 17) by failing to: 1. Label the water flush bag (a plastic container bag with infusion tubing filled with water used to flush the feeding tube and as a source of hydration for residents on enteral feeding) with the correct rate of infusion per physician's order for Resident 62. 2. Label the irrigation syringe (a specialized medical instrument designed for the irrigation or cleansing of wounds, cavities, or body orifices) pouch with resident identifier and the date the irrigation syringe was last changed for Resident 379. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who received hemodialysis (HD, process of removing waste products and excess fluid from the body) received treatment in consistent with professional standards of practice and the comprehensive person-centered care plan for one of one sampled resident (Resident 52) investigated during review of dialysis care are by failing to: 1. Ensure licensed nurses performed and documented assessments after Resident 52 returned from hemodialysis sessions. 2. Ensure licensed nurses acquired and maintained Resident 52's written documentation from the hemodialysis center. These deficient practices placed the resident at risk for a delay in detecting complications resulting from HD.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the safe and appropriate use of bed rails (adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; [...]

Inspectors wroteBased on interview, and record review the facility failed to: 1. Account for two doses of narcotics (also known as Controlled Medications or Controlled Substances [CM, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Resident 63 and 226 in one of two inspected medication carts (Station 1 Cart 1.) 2. Account for one dose of narcotic for Resident 12 in one of two inspected medication carts (Station 3 Cart 3A.) 3. Document the disposition (destruction) of medications (drugs) on the Drug Disposition Record logs in three of three inspected Medication Rooms. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 67) drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) in accordance with the facility policy and procedure from 3/27/2024 to 5/6/2024 by failing to ensure: 1. Resident 67 had a specific, measurable target behavior related to the use of Risperdal (antipsychotic drug [a medication capable of affecting the mind, emotions, and behavior] used to treat mental illness) 2. Resident 67 was monitored for the number of specific occurrences of delusions with the use of Risperdal 3. Resident 67 was monitored for the side effects (also known as adverse effects - unwanted, uncomfortable, or dangerous effects that a drug may have) of Risperdal 4. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) to three out of three sampled residents (Residents 7, 118, and 109) investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to record the medication refrigerator temperatures twice a day from June 1, 2024 to June 26, 2024 in two of three inspected medication rooms (Medication room [ROOM NUMBER] and 3.) These failures increased the potential for residents in the facility to receive medications that were ineffective or toxic due to the inadequate storage monitoring, and potentially experience medication adverse consequences resulting in the negative impact to residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow and update the facility menu when: a. The menu posted in Resident 105's room was not updated. b. Staff served less than 3 ounces (oz, unit of measurement) of turkey each serving for lunch. This deficient practice had the potential to cause a decrease food intake resulting to unintentional (define) weight loss to 64 of 124 residents, frustrations, and psychosocial harm to the resident 1 (Resident 105).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when: a. Broccoli was mushy, overcooked and did not have a garlic flavor. b. Glazed apple square was dry and served in a paper bowl. This deficient practice placed 120 of 124 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: A. Improper storage of food and food handling a. Raw chicken stored on top of bacon during thawing process. b. Four (4) dented cans were stored with the non-dented cans. c. Staff were not monitoring time and temperature when thawing poultry in the three-compartment sink (a type of sink used in dishwashing). d. Two (2) glasses of milk (42° and 50 degree Fahrenheit ([°F, a scale of measuring temperatures] respectively) were above 41°F e. Resident's food from the outside were not labeled nor dated. B. Kitchen cleanliness and sanitation a. Reach-in refrigerator's gasket had black dirt residue and build up. b. Canned good had flour residue. c. Ice machine vents had dust. d. Pots and pans were stacked wet during storage. e. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by: a. Not completely covering 1 (one) of 1 black dumpsters (large trash container designed to be emptied into a truck) and 3 of 6 blue recycle bins from unknown period of time. b. Three blue boxes were on the floor. c. Flies and a dead rat were found around the trash area. This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 120 of 124 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure the nasal cannula (NC - tubing connected to a device that gives additional oxygen [O2] through the nose) was not touching the floor for three of four sampled residents (Residents 20, 376, and 57) reviewed under the Respiratory care area. 2. Label the urinal bottle (a container used to collect urine) with resident identifier for three of nine sampled residents (Resident 30, 120, and 278) reviewed under the Infection Control task and one of one sampled resident (Resident 106) reviewed under the Urinary Tract Infection (a condition in which bacteria invade and grow in the urinary tract) care area. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to a dignified existence by failing to ensure an indwelling urinary catheter (a flexible tube inserted into the bladder and left in place to continuously drain urine) collection bag (attached to the catheter tube for the purpose of collecting urine) had a dignity cover (privacy cover, a manner of concealing urine in the collection bag) for two of two sampled residents (Resident 328 and 12) reviewed under the dignity care area. This deficient practice had the potential to cause emotional distress, affect residents' self-esteem, and a decline in psychosocial wellbeing when the residents' body fluids were visible to other residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for two of nine sampled residents reviewed under the Environment care area (Resident 8 and 109) when the facility failed to: 1. Maintain the cleanliness of Resident 8's floor. 2. Ensure the bathroom faucet fixture did not develop calcium deposits and rust for Resident 109. These deficient practices had the potential to spread infection and negatively affects the resident's psychosocial wellbeing and violated the resident's rights to a safe, clean, sanitary, and homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's transfer was documented in the resident's medical record for one of three sampled residents reviewed under the hospitalization care area (Resident 64) when the reason for transfer was not indicated in Resident 64's Notice of Proposed Transfer/Discharge, dated 6/12/2024. This deficient practice had the potential for the resident and their representative and the ombudsman (a resident advocate) to not know the reason for the transfer and to not determine if the reason for transfer was appropriate.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were made aware of the facility's bed-hold policy upon transfer to a general acute care hospital (GACH) for one of three sampled residents reviewed under the hospitalization care area (Resident 42) when the facility failed to complete and provide the seven (7) day bed hold agreement to Resident 42. This deficient practice had the potential for the resident and/or the resident's resident representatives to not know if the resident have a room to return to after going to the GACH.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility communicated necessary information to the resident, to the continuing care provider and other authorized persons at the time of an anticipated discharge to one out of three sampled residents (Resident 123) selected for closed record review by failing to complete the following in the Discharge Planning Review: 1. Medication Reconciliation 2. Equipment and Supplies 3. Learning Needs Related to Conditions The deficient practice had the potential to result in provision of inappropriate and untimely care to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident 26) of one sampled resident investigated during a random observation was provided care and services to maintain good grooming and personal hygiene by: 1. Failing to ensure the resident was groomed and provided showers and proper skin care as scheduled. 2. Failing to document accurately shower/bath provided and or refusals. These deficient practices resulted in Resident 26 having poor grooming and personal hygiene that could negatively impact the resident`s quality of life and self-esteem. Cross reference to F684.

Inspectors wroteBased on interview and record review the facility failed to implement their policy and procedure on cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) by failing to maintain CPR certification training that included hands-on practice and in-person skills assessment to one of six sampled licensed staff (Licensed Vocational Nurse 3 [LVN 3]) investigated during review of sufficient and competent nurse staffing task. The deficient practice had the potential for staff to perform substandard life-saving measures to residents that can lead to debility and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 26) investigated during a random observation received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to assess and identify new skin issues when the resident was observed with discoloration around the ankle area. This deficient practice placed the resident at risk for not receiving the necessary treatment and services related to discoloration in the resident's ankle area. Cross reference to F677.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice for one (1) out of 1 sampled resident (Resident 79) during a random observation of a resident with intravenous (IV) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) by failing to indicate the date when the IV catheter dressing was last changed. This deficient practice placed the residents at risk for developing complications such as inflammation of the vein and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who need respiratory care are provided care consistent with professional standards of practice to one of four sampled residents (Resident 376) investigated during review of respiratory care area by failing to ensure administer oxygen at 2 liters per minute (LPM, the flow of oxygen via oxygen delivery device) via nasal cannula (a device that gives additional oxygen through the nose) per physician order. The deficient practice had a potential for Resident 376 to develop shortness of breath that could lead to hypoxemia (a low level of oxygen in the blood).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident receive and consume foods in the appropriate nutritive content as prescribed by a physician and or assessed by the interdisciplinary team to support the resident's treatment and plan of care when: One (1) of 1 resident on large portion diet (a diet which increases calorie and protein on the tray by doubling food portions) did not receive large portion of bread stuffing for lunch service. This deficient practice had the potential to cause weight loss for Resident 66.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and resident care equipment in safe operating condition for one (Resident 57) of nine sampled residents investigated under Environment task when Resident 57s bed controller (device used to change the height and angle of the bed) cable was covered with black plastic tape with exposed wires. This deficient practice had the potential to place residents at risk for injury from accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for residents for one of nine sampled residents reviewed under the Environment task (Resident 17) when Resident 17's cell phone charger was plugged into an extension cord (length of electric cord that permits the use of an appliance at some distance from a fixed socket) that was plugged into a power strip (an electrical device consisting of a cord with a plug on one end and several outlets on the other) that was plugged into an electrical wall outlet (a socket that connects an electrical device to an electricity supply). This deficient practice had the potential to place residents at risk for injury from accidents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the assessment reflected the current resident's status to two out of three randomly selected closed records (Resident 123 and 72) by: 1. Failing to accurately code the Minimum Data Set (MDS, a standardized assessment and care screening tool) of a planned resident discharge. This deficient practice had the potential to result in an accurate assessment and had the potential for the facility to not provide the appropriate services for the resident's discharge. 2. Failing to ensure Resident 72's MDS was coded as Resident 72 was receiving an antiplatelet (a type of medication that prevent blood clots from forming which can cause heart attacks and strokes) instead of an anticoagulant (a type of medication that thins the blood to prevent or reduce clotting of blood). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy and procedure (P&P) for two of three sampled residents (Resident 1 and 2). On 5/6/2024 at 1:40 a.m., Resident 1 alleged Resident 2 threw a piece of ice hitting Resident 1 on his left cheek. Facility failed to report the alleged abuse within two hours to California Department of Public Health (CDPH). This failure placed Resident 2 at risk for further abuse and feeling of intimidation.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy and procedure (P&P) for two of three sampled residents (Residents 1 and 2). On 5/6/2024 at 1:40 a.m., Resident 1 alleged Resident 2 threw a piece of ice hitting Resident 1 on his left cheek. Both Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 1 (LVN 1) left Resident 1 and Resident 2 in their shared room together, unattended by staff after an allegation of abuse. This failure had the potential to place Resident 1 at risk for further abuse and feeling of intimidation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents were free from physical abuse for two of four sampled residents (Resident 1 and Resident 3). The facility failed to: 1. Ensure Resident 1, who had a history of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), was free from physical abuse. On 4/21/2024 at 8:20 a.m., Resident 1 reported to Restorative Nursing Assistant 1 (RNA 1) that Resident 2 threw a cup at Resident 1 ' s face. 2. Ensure Resident 3, who had a cognitive communication deficit (difficulty with thinking and how someone uses language), was free from physical abuse. On 4/19/2024 at 10:30 a.m., Licensed Vocational Nurse 2 (LVN 2) witnessed Resident 4 hit Resident 3 in the left shoulder. These deficient practices resulted in: 1. [...]

Inspectors wroteBased on interview and records review, the facility failed to provide pharmaceutical services (including dispensing and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) when Licensed Vocational Nurse 1 (LVN 1) gave aspirin (medication used to treat pain, swelling, and prevents blood clots) twice on 4/25/2024. This deficient practice had the potential for Resident 1 to experience the side effect of bleeding.

Inspectors wroteBased on interview and record review the facility failed to provide the necessary treatment and services for one of three sampled residents (Resident 5) at risk for developing pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) received the necessary care and services to prevent pressure ulcers from developing by failing to perform timely assessments of Resident 5's pressure ulcers. This deficient practice had the potential for Resident 5 ' s pressure ulcer to (pressure injuries are open wounds, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) to worsen.

Inspectors wroteBased on interview and record review, the facility failed to implement its infection prevention and control program by failing to conduct coronavirus disease 2019, (COVID-19, a highly contagious respiratory illness that can lead to severe symptoms) response testing according to the facility ' s Management of COVID-19 policy and procedures. This deficient practice had the potential to result in an increased transmission of COVID-19 infection among residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to prevent an accident and injury for one of three sampled residents (Resident 1), who was a high risk for falls and was on a low air loss mattress (LALM, a device that operates using a blower-based pump designed to circulate a constant flow of air; the air mattress is covered with tiny holes designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture as well as to relieve pressure). The facility failed to ensure Certified Nursing Assistant 1 (CNA 1) was trained on the changes in setting of the LALM during turning and cleaning Resident 1. As a result, on 11/10/2023, at around 10 p.m., while CNA 1 was turning Resident 1 in bed without the LALM adjusted to firm, Resident 1 fell out of bed hitting the back of the head. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the responsible party for one of three sampled residents, (Resident 1). Resident 1 encountered a change in health condition requiring a transfer to the General Acute Care Hospital (GACH) for further evaluation. Resident 1 ' s responsible party (RP) was not contacted after Resident 1 ' s change in health condition or transfer to hospital. This deficient practice denies Resident 1 ' s RP the information required to make informed decisions for Resident 1 ' s health related care and needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program related to Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) by failing to: a. Ensure Licensed Vocational Nurse 1 (LVN 1) perform hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before and after changing gloves, after touching unclean surfaces, and after exiting Resident 1 ' s room. Resident 1 was in a Person Under Investigation room (PUI- area where residents who were exposed to COVID-19 or were showing symptoms are placed). b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards to ensure food service safety when: 1) Dishwasher 1 (DW 1) failed to wash hands prior to handling cleaned dishes after touching soiled dishes and kitchenware. 2) [NAME] 1 failed to log pureed bread temperature on the food temperature log because the log did not provide a section for pureed bread. These deficient practices had the potential to result in food-borne illness (any illness resulting from the spoilage of contaminated food, bacteria-germs, viruses, or parasites that contaminate food, as well as toxins [poisons]) in 106 of 112 residents who consumed the food prepared by the facility kitchen.

Inspectors wroteBased on interview and record review the facility failed to ensure update residents' medical records to indicate documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information was provided to the residents and or responsible parties for 16 of 19 sampled residents, (Residents 8,11,12, 13, 15, 21,27, 40, 57, 59, 71, 74, 82, 102, 106, and 107). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate advance directives and had the potential to cause conflict with healthcare wishes for Residents 8,11,12, 13, 15, 21,27, 40, 57, 59, 71, 74, 82, 102, 106, and 107.

Inspectors wroteBased on observation, interviews and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services when kitchen staff who oversaw food shelf life failed to mark the shelf life of refrigerated supplement shakes accurately. This failure had the potential to result in unsafe and unsanitary food preparation and production, and had the potential for food-borne illness affecting 106 of 112 residents who received foods from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when a potentially hazardous food in the walk-in refrigerator was stored beyond the use-by-date. This deficient practice had the potential to result in food-borne illness (any illness resulting from the spoilage of contaminated food, bacteria-germs, viruses, or parasites that contaminate food, as well as toxins (poisons)) in 106 of 112 residents who consumed the food prepared by the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an effective infection control program was maintained, as evidenced by: 1) Licensed Vocational Nurse 1 (LVN 1), LVN 6, Certified Nursing Assistant 1 (CNA 1), CNA 2, CNA 4, CNA 6, CNA 12, and Janitor 1 not performing hand hygiene when/where indicated. 2) LVN 1, LVN 2, LVN 8, CNA 7 and Janitor 1 not following proper screening for signs/symptoms of COVID-19 (Coronavirus disease - a severe respiratory illness caused by a virus and spread from person-to-person). 3) Indwelling urinary catheter bag being positioned in touching the floor. 4) CNA 5 not following proper procedure when transporting soiled linens. 5) [NAME] 1 wearing a face mask without covering her nose and mouth. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation to meet the resident's need and implement facility's telephone access policy and procedures by failing to ensure one of four sampled residents (Resident 29) had access to a telephone. This deficient practice denied Resident 29 access to a telephone and to communicate with the resident's family outside of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide privacy during wound care treatment for one of two sampled residents (Resident 67). This deficient practice violated Resident 67's right to privacy and the potential for lowered self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its restraint policy and procedures (P&P), ensure the physician's mitten order was current, and ensure hand mittens (a hand covering enclosing the four fingers together and the thumb separately) were not applied to tightly for one of three sampled residents (Resident 74). These deficient practices place Resident 74 at risk for impaired blood circulation for Resident 74

Inspectors wroteBased on interview and record review, the facility failed to provide the notice of transfer was provided to the resident's responsible party and to the State long Term Care Ombudsman (is a person who investigates, reports on, and helps settle complaints) as soon as practicable for one of four randomly selected residents (Resident 59). This deficient practice had the potential to result in the resident's responsible party being unaware how to contact the State agency and how to appeal the transfer if necessary.

Inspectors wroteBased on interview and record review, the facility failed to ensure and accurately perform a cognitive assessment that reflected and identified the specific issues and objectives for one of nine residents (Resident 86). This deficient practice had the potential to result in the facility ability to identify the needs and develop and implement a person-centered comprehensive care plan to meet the needs of Resident 86.

Inspectors wroteBased on interview and record review, the facility failed to accurately code insulin (a medication used to regulate blood sugar) use on the Minimum Data Set (MDS - a standardized assessment and screening tool) for one of four sampled residents (Resident 15). This deficient practice had the potential to not reflect the true medical status and to negatively affect the plan of care and delivery of necessary care and services for Resident 15. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care planned interventions for one of three sampled residents (Resident 102), with a diagnosed behavioral condition. Resident 102 was identified with behavior a to harm self. This deficient practice had the potential to place Resident 102 at risk for further harm to self.

Inspectors wroteBased on interview and record review, the facility failed to document discharge education provided for one of two sampled residents (Resident 65) prior/upon to discharge to the community. This deficient practice had the potential to result in incomplete or ineffective discharge planning and could result in lack of necessary discharge after care for Resident 65.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of six sampled residents (Resident 40) who was assessed as a high risk to develop a pressure ulcer / injury (damaged skin caused by staying in one position for too long received care and services to promote wound healing) was provided the necessary treatment to promote healing of pressure ulcer by failing to adjust Resident 40's low air loss (LAL) mattress (a mattress used for pressure ulcer prevention) to a setting appropriate for Resident 40's weight. This deficient practice placed Resident 40 at risk for skin breakdown and development of pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide foot care and treatment, in accordance with professional standards of practice for one out of nine residents (Resident 86). This deficient practice could have resulted in decreased mobility, pain, foot wounds, and infection for Resident 86.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment is free from accidents and hazards for one of five by failing to ensure Resident 71's bed was in a low position, bed was in working condition, and the side rails were positioned as per physician's order. These deficient practices placed Resident 71 at high risk for fall and serious injury.

Inspectors wroteBased on observation and interview, the facility failed to flush with water the gastrostomy tube (G-tube, a flexible tube surgically inserted into the abdomen to stomach for feeding and medication administration) after disconnecting the G-tube from the feeding for one of three sampled residents (Resident 59). This deficient practice had the potential to clog the G-tube.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to meet the needs for one of six sampled residents (Resident 106) by failing to ensure Resident 106's Baclofen (a medication used to treat muscle pain, spasm and stiffness; a muscle relaxant) was available for administration to the resident. This deficient practice had the potential to result in ineffective management of Resident 106's back pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of nine sampled residents (Resident 217) took his blood pressure medication administered to him in the morning. This deficient practice could have resulted in an elevated blood pressure causing harm to Resident 217.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an intravenous medication (medication sent directly into your vein using a needle or tube) cart in a common hallway was locked. This deficient practice had a potential for a resident or unauthorized personnel accessing the medications in the cart.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor resident's food preference as written on the tray card for one of three sampled residents (Resident 70). This deficient practice had the potential for placing residents at risk for undernutrition and further impacting their health and well-being.