Lynwood Post Acute Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was not administered antipsychotic medication (medication affecting mood, thoughts, feelings, and behavior) without a confirmed clinical diagnosis. This deficient practice had the potential for Seroquel (an antipsychotic medication) to be used unnecessarily and inappropriately to manage Resident 1's combative behavior. Cross Reference F684.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was seen by the psychiatrist after exhibiting combative behavior and prescribed antipsychotic medication (medication affecting mood, thoughts, feelings, and behavior). This deficient practice had the potential for Resident 1's combative behavior to be mismanaged. Cross Reference F605.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Care Plans - Baseline, which indicated a baseline care plan to meet the resident's immediate health and safety needs should be developed within 48 hours of admission, for one of three sampled residents (Resident 2) who was identified as a high risk for falls. This failure resulted in Resident 2 without safe nursing interventions (actions) to prevent falls for 14 days since admission [DATE] to 4/20/2026), placing the resident at risk for falls, recurrent falls and severe injuries, including hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents' (Resident 1) environment remained as free of accident hazards as is possible and received adequate supervision to prevent accidents. The facility failed to: 1). Ensure the Interdisciplinary Team ([IDT] group of healthcare professionals, including physician, nurses, resident/ resident representative, working together to develop a plan of care for the residents) identified causes of Resident 1's multiple falls and identified new interventions to minimize falls.2). Update Resident 1's care plan after each fall with new interventions for safety and to prevent recurrent falls.3). [...]

Inspectors wroteBased on interview and record review, the facility failed to review one of three residents' (Resident 1) quarterly smoking assessment for safety. This failure had the potential not to identify changes in Resident 1's ability to smoke safely, placing the resident at risk for injuriesFindings: During a review of Resident 1 's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a condition that affects how the brain works causing changes in thinking alertness behavior and consciousness), Diabetes Mellitus(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing)and Chronic obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing). [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure there were adequate privacy curtains available in 17 of 33 rooms (Rooms 2, 3, 4, 7, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31). This deficient practice violated the residents' rights to full visual privacy at any given time.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified in a timely manner of a resident's refusal of a blood laboratory draw for one of six sampled residents (Resident 13). This deficient practice resulted in Resident 13's physician not being informed of Resident 13's refusal, and placed Resident 13 at risk for delayed assessment, treatment, unmanaged change of condition, and potential complications related to medical conditions requiring laboratory monitoring.

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to ensure one of six sampled residents (Resident 90) was free from physical restraints, when bed linen, towels, and pillows were used as a barrier to prevent Resident 90 from falling out the bed. This deficient practice had the potential to restrict Resident 90's freedom of movement, restrict the resident's ability to reposition or exit the bed, and placed Resident 90 at risk for decreased mobility, skin breakdown, and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure an as needed (PRN) order for Ativan (a psychotropic medication- drug that affects mental processes, moods, and behaviors) was not continued beyond 14 days for one of six sampled residents (Resident 14). This deficient practice placed Resident 14 at risk for continued use of unnecessary psychotropic medication without timely physician reassessment and had the potential for Resident 14 to be chemically restrained by the administration of unnecessary psychotropic medication, and/or suffer extrapyramidal symptoms (a group of movement disorders that can occur because of certain medications, particularly antipsychotics) due to prolonged use.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a resident assessment tool) accurately reflected the Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level I Screening for one of six sampled residents (Resident 8). This deficient practice resulted in incorrect data being transmitted to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 8's PASRR and had the potential to negatively affect Resident 8's care plan and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan addressing the use of Apixaban (an oral anticoagulant [blood thinner] used to prevent stroke and blood clots) and risk for pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) development for two of two sampled residents (Resident 4 and Resident 2). This deficient practice placed Residents 4 and 2 at risk for adverse drug reactions, unmonitored medication use, and the development or worsening of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep one of six sampled resident's (Resident 90) fingernails trimmed and clean. This deficient practice had the potential to result in a negative impact on Resident 90's quality of life and self-esteem, and had the potential for the development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were bilateral floor mats to the left and right side of the bed and ensure two intravenous (IV, into a vein) needles were properly disposed of for two of 12 sampled residents (Residents 13 and 2). These deficient practices placed Resident 13 at risk for injury, and the potential for unsafe handling of blood-contaminated sharps (devices with sharp points or edges designed to puncture or cut skin), with the potential for accidental needlestick injuries, and serious harm to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nutritional supplements, as ordered, to two of three sampled residents (Resident 41). This deficient practice placed Resident 41 at risk of not receiving her required amount of calories, protein, and other nutrients, increasing her risk for weight loss and other complications related to malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 demonstrated appropriate medication administration, documentation, and communication with the healthcare team, and failed to ensure licensed nursing staff used warm purified water when flushing (a medical procedure using a sterile sodium chloride [saline, salt and water] solution to clear, maintain, and prevent blockage in intravenous [IV- in a vein] catheters) a gastrostomy (G-tube- medical device inserted through the abdominal wall into the stomach to deliver nutrition, fluids, and medications directly, bypassing the mouth and esophagus) for two of six sampled residents (Resident 57 and Resident 2). This deficient practice did not respect Resident 57's right to be informed of and be involved in the care he was receiving. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Hydrocodone-Acetaminophen (a medication used to treat pain) was administered according to the physician ordered parameters (specific, measurable, and objective clinical criteria set by a healthcare provider that dictate when a medication should be given, withheld, or adjusted) for one of six sampled residents (Resident 7). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%) for one of five randomly selected residents. The outcome was ten (10) medication errors out of 29 opportunities for errors, resulting in an observed medication administration error rate of 34.48%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food properly in the kitchen when one bag of hamburger buns, two bags of wheat bread, ground Italian seasoning, plain salt, soy sauce, and powdered thickener were unlabeled and undated. This deficient practice had the potential to place the residents at risk for foodborne illness (is a sickness caused by eating that has harmful bacteria) or contamination (harmful germs get in food and unsafe to eat).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two large trash containers located in the kitchen were maintained in a closed position. This deficient practice had the potential to contribute to environmental contamination, pest infestation, odors and unsanitary conditions that could negatively impact the health and safety of residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) documentation was maintained and readily available in the resident's medical record for review for two of six sampled residents (Residents 1 and 8). This deficient practice resulted in incomplete medical records for Residents 1 and 8 and limited access to required PASRR documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the required personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) was worn while providing high-contact care to three of five sampled residents (Resident 6, Resident 94, and Resident 103) on enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs]). This deficient practice increased the potential for spread of infection to Residents 6, 94, and 103.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was easily accessible for one of six sampled residents (Resident 40), who had left-sided weakness. This deficient practice placed Resident 40 at risk for unmet care needs, delayed staff response, falls, injury, and inability to request assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment when:1. The area around a circle floor drain cover in the hallway was cracked, uneven, and chipped with an irregular edge.2. There was no signage posted in a visible location, inside or outside of a resident room, to inform residents, staff, and visitors that oxygen was in use. These deficient practices placed the safety of all facility residents, staff, and visitors at risk due to trip hazards and potential fire hazard.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required room size measurement of 80 square feet ([sq. ft.])- a unit of measurement) of room space per resident in rooms with multiple residents. This deficient practice could potentially not provide residents with privacy and could potentially affect residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen therapy (a medical treatment that provides extra oxygen to breathe, typically prescribed for individuals with conditions causing low blood oxygen levels) was administered as ordered by the physician for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk of sustaining complications of oxygen toxicity (e.g., serious tissue damage, respiratory failure, and central nervous system effects).

Inspectors wroteBased on interview and record review, the facility failed to report a resident-to-resident altercation for two of four sampled residents (Resident 2 and Resident 4) to the facility's Abuse Coordinator and the California Department of Public Health (CDPH) . This deficient practice created a delay in the investigation by the Abuse Coordinator and CDPH, and had the potential to result in further abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate a resident-to-resident altercation that occurred on 1/31/2026, for two of four sampled residents (Resident 2 and Resident 4). This deficient practice had the potential to increase the risk for further abuse to occur.

Inspectors wroteBased on interview and record review, the facility failed to implement it's policy and procedure (P&P) titled Resident-to-Resident Altercations, revised 9/2022, following a resident-to-resident altercation on 1/31/2026, for one of four sampled residents (Resident 4). This deficient practice created the potential for Resident 4 to not receive the care and interventions needed after the altercation on 1/31/2026.

Inspectors wroteBased on observation, interview and record review the facility failed to provide one of three sampled residents (Resident 1) palatable food that was pleasant to taste, not overcooked, and appetizing. These failures placed Resident 1 at risk for missed meals and had the potential for weight loss.

Inspectors wroteBased on interview and record review, the facility failed to exercise reasonable care for the protection of one of four sampled Resident's (Resident 1) property by failing to:1. Ensure Resident 1's Inventory List was completed at the time of discharge on [DATE].2. Ensure Resident 1's personal belongings (shirts and pants) were accounted for and provided to the Resident or the Resident's Family Member (FM) on discharge. These failures had the potential for Resident 1's personal belongings to be lost or stolen and could negatively affect Resident 1's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from misappropriation of personal property when Dietary Aide (DA) 1 agreed to withdraw cash and purchase cigarettes with the use of the resident's debit card for one of three sampled residents (Resident 1). This failure resulted in $8,000 worth of unauthorized cash withdrawals from Resident 1's bank account within a four-day span. This failure also violated Resident 1's right to be free from misappropriation and placed other residents at risk for similar exploitation. Cross-reference F609 and F610.

Inspectors wroteBased on interview and record review, the facility failed to follow their Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one out of three sampled residents (Resident 1) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 reported to the California Department of Health (CDPH), ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local authorities within 2 hours on 6/28/2025, after being made aware Dietary Aide (DA 1) was in possession of Resident 1's debit card from 6/25/2025 through 6/28/2025 and a total of $8,000 dollars was withdrawn from Resident 1's bank account without Resident 1's knowledge. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one out of three sampled residents (Resident 1) by failing to initiate and conduct a timely investigation into an allegation of misappropriation of resident property and missing funds when the following occurred: 1. Licensed Vocational Nurse (LVN) 1 was made aware on 6/28/2025, of an allegation that Dietary Aide (DA 1) was in possession of Resident 1's debit card from 6/25/2025 through 6/28/2025 and a total of $8,000 in unauthorized cash withdrawals from Resident 1's bank account occurred from 6/25/2025 through 6/28/2025. 2. Registered Nurse (RN) 1 was made on 6/28/2025 Resident 1's debit card and funds were missing. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was in the facility for at least eight consecutive hours on 12/7/2024, 12/8/2024, 12/15/2024, and 1/4/2025. This deficient practice had the potential to result in initial assessment to be delayed or missed and a potential to result in an overall decrease in the quality of care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled Residents (Resident 77 and 79)'s drug regiment was free of unnecessary medications by failing to: 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure opened boxes of nebulizer solution (Ipratropium and albuterol combination, is used to treat chronic obstructive pulmonary disease (COPD, a condition that blocks airflow and make it hard to breathe) and other lung conditions, such as asthma [wheezing, difficulty breathing], chronic bronchitis [swelling of the air passages that lead to the lungs], and emphysema [damage to the air sacs in the lungs]) had an open date and was stored in accordance with manufacturer's specification for five of five residents (Residents 15, 35, 74, 19, and 12) inside of two of two Medication Carts (Medcart Station 1 and Medcart Station 2). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen when: 1. A container of apple sauce and jelly were not labeled with the product name, the open date, and the use-by date. 2. An opened container of chocolate crème pie was not labeled with the open date and the use-by date. These deficient practices had the potential to result in harmful bacteria growth that could lead to foodborne illness (transfer of bacteria from one object to another).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for one out of eight sampled residents (Resident 9) when: 1. Certified Nursing Assistant (CNA) 3 failed to assist Resident 9 with grooming prior to a medical appointment. 2. Resident 9 was not fed prior to leaving the facility for his medical appointment. These deficient practices had the potential to cause a negative physiological outcome for Resident 9, and resulted in Resident 9 being hungry.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedure) for four of 16 sampled residents (Residents 77, 24, 81, and 85) by failing to: 1. Ensure Resident 77 gave informed consent for the continuation of olanzapine (a psychotropic medication [medication that affect the mind, emotions, and behavior]) after his readmission from the general acute care hospital (GACH) on 10/27/2024. 2. Ensure to obtain informed consent from the residents and/or responsible party (RP) before the use of physical restraints (a physical or mechanical device) for Resident 24, 81, and 85. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations for one of eight sampled residents (Resident 81) by failing to ensure the call light (a device that residents use to request assistance from staff) was within reach. This deficient practice had the potential to negatively impact the Resident 81's psychosocial well-being and/or result in delayed provision of care and services.

Inspectors wroteBased on interview and record review, the facility failed to follow up and obtain a copy of an Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) for one of six sampled Residents (Resident 11). This deficient practice had the potential to result in the facility not honoring Resident 11's medical care directive in the event Resident 11 was to become incapacitated (unable to make informed decisions or care for themselves).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a resident assessment tool) was accurately coded for one of eight sampled residents (Resident 40) to reflect Resident 40's oral and/or dental status. This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 40's dentures (oral appliances that replace missing teeth) and had the potential to negatively affect Resident 40's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, and interview, and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) for three of 21 sampled residents (Residents 24, 40, and 42) by failing to: 1. Develop and implement a care plan for Resident 42's use of side rails (short rails on one or both sides of the bed that can be used to assist in bed mobility). 2. Initiate and implement a comprehensive care plan for Resident 40 who was using dentures (oral appliances that replace missing teeth). 3. Initiate and implement a comprehensive care plan for Resident 24 Restorative Nurse Assistant ([RNA]- a healthcare professional who help residents regain or maintain their mobility) program. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain appropriate grooming and personal hygiene for one of eight sampled residents (Residents 18) by failing to keep Resident 18's fingernails clean and neat. This failure had the potential to result in a negative impact on Resident 18's quality of life and self-esteem and had the potential for the development of an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for use of quarter side rails (short rails on one or both sides of the bed that can be used to assist in bed mobility) for one of two sampled residents (Resident 42), when Resident 42 used bilateral (left and right) quarter side rails for transfer assistance and bed mobility. This deficient practice had the potential to result in the unsafe use of side rails that could result in entrapment (becoming stuck between the bed and railing) and physical harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nursing staff practiced safe and effective medication administration practices for one out of eight sampled residents (Resident 90) by failing to: 1. Ensure Licensed Vocational Nurse 3 (LVN) administered medication to Resident 90 per the doctor's order. 2. Ensure LVN 3 did not falsely document she administered medication to Residents 90. 3. Ensure LVN 3 reordered medication for Resident 90. 4. Ensure LVN 3 did not administer another resident's medication to Resident 90. 5. Inform Resident 90 's doctor a medication was not administered as ordered. These deficient practices caused Resident 90 to have an interruption with medication therapy and pain control and exposed Resident 90 to a potential of a medication error and an adverse effect to their medications.

Inspectors wroteBased on interview and record review, the facility failed to follow and implement the pharmacist recommendation in the Medication Regimen Review (MRR) for one out of three sampled residents (Resident 9). This deficient practice had the potential to place Resident 9 at risk for complications due to bleeding.

Inspectors wroteBased on interview and record review, the facility failed to ensure clinical records were complete and accurately documented for three out of five sampled residents (Resident 1, 143, and 144) by failing to ensure: 1. Licensed nurses documented the dates/times residents left and returned to the facility. 2. The Leave of Absence form (form licensed nurses fill out to clear resident to temporarily leave facility) was completed prior to residents leaving and returning to the facility. These deficient practices had the potential to create a miscommunication of the residents' location, whether the residents were cleared to leave the facility, and also created a safety concern.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed for five of eight sampled residents (Resident 19, 8, 76, 90, and 15) by: 1. Failing to ensure Resident 19's nasal cannula (device used to deliver supplemental oxygen placed directly on the resident's nostrils) and humidifier (a medical device that adds water vapor to oxygen to help relieve dryness and irritation by oxygen therapy) were changed every seven days. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the intervention, as indicated in one of five sampled residents' (Resident 1) care plan titled, Resident has excessive tendencies of crawling and climbing out her bed, was impelmented. This deficient practice had the potential cause injury to Resident 1.

Inspectors wroteBased on interviews, and record review, the facility failed to report to the California Department of Public Health (CDPH), one of three residents (Resident 4), who was positive of Coronavirus Disease 2019 ([COVID-19] highly contagious viral infection). This failure resulted to the delay in investigation by the CDPH and had the potential for COVID-19 virus to spread infecting other residents, staffs and visitors in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff adhered to menus approved by the Registered Dietician (RD), and their respective standardized recipes, while preparing meals for 86 out of 89 facility residents when the following occurred: 1. Resident 11 and Resident 40 received cheese and vegetable quesadillas that did not have vegetables. 2. The Dietary Supervisor (DS) did not make the Registered Dietitian (RD) and the residents of the facility aware of the menu substitution changes made on 1/23/2024 and 1/24/2024. The above failures had the potential for 86 out of 89 residents to not receive the expected calories, proteins, and other micronutrients (vitamins and minerals needed by the body in very small amounts) from the meals served by the facility.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent prior to initiation and administration of psychotropics (medications that affect the mind, emotions, and behavior) to five of seven sampled residents (Residents 43, 52, 64, and 84, and 67). The above failure put Residents 43, 52, 64, 84, and 67 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use. The above failure also removed the Residents' rights to make decisions about the care and treatments they received in the facility. Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement the care plans (document that assists nurses and other team care members organize aspects of resident care) for four of 46 sampled residents (Resident 23, Resident 11, Resident 51, and Resident 45) when facility staff failed to: 1. Develop a care plan for Resident 23 who had fungal dermatitis (a skin infection that causes red, irritated, or scaly rash) to her lower back. 2. Implement Resident 51's care plans for skin breakdown and pressure ulcers (PU, an injury that breaks down the skin and underlying tissue, caused when an area of skin is placed under prolonged pressure). 3. Implement Resident 11's care plans for skin breakdown and pressure ulcers. 4. Implement Resident 45's care plan for her impaired vision. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' food was appealing, appetizing, and palatable (pleasant to taste) when the facility served pale-yellow, square-shaped egg bites for breakfast, when residents verbalized feelings of dissatisfaction of the facility's food due to the lack of palatability and appeal, and food served in disposable Styrofoam dinnerware which did not maintain temperature for nine out of nine sampled residents (Residents 29, 30, 68, 77, 82, 85, 90, 57 and 63). This deficient practice had the potential for the residents to experience poor meal intake and weight loss, and lack of dignity.

Inspectors wroteBased on interview and record review, the facility failed to appoint a responsible party and/or representative for one of 18 sampled residents (Resident 67), who did not have medical decision-making capacity. The above failure put Residents 67 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use. The above failure also prevented Resident 67's from exercising his rights to make decisions about the care and treatments they received in the facility. Cross Reference:

Inspectors wroteDuring an observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services for three of 18 sampled residents (Resident 36, 47, and 84) when: 1. Certified Nurse Assistant (CNA) 3 did not change Resident 36's diaper in a timely manner. 2. Resident 47 was not repositioned every 2 hours or as needed per the physician's order. 3. Resident 84 was not repositioned every 2 hours or as needed per the physician's order. These deficient practices had the potential to cause a negative impact on Resident's 36, 47, and 84's health and psychosocial well-being by not meeting resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 45) received glasses as recommended and prescribed by the optometrist (healthcare provider who specializes in caring for the eyes). This failure created the potential for Resident 45 to suffer from avoidable physical harm related to injury from inability to see, and psychosocial harm related to inability to watch television, which was her preferred activity in the facility. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that precautions were maintained to prevent the development or worsening of pressure ulcers (PU, an injury that breaks down the skin and underlying tissue, caused when an area of skin is placed under prolonged pressure) for two of two sampled residents (Resident 51 and Resident 11) when the following occurred: 1. Resident 51's weight was not accurately set on her low air loss mattress (LALM, a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown). 2. The Treatment Nurse (TN 1) was unaware of Resident 11's weight measurement to monitor accuracy of the LALM settings. The above failures had the potential to cause the avoidable development of skin breakdown for Resident 51 and the complications associated with impaired skin integrity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents with a urinary catheter device (a flexible tube placed in the bladder used to collect urine by attaching to a drainage bag) received proper assessment and the urinary catheter and tubing were off the floor for two sampled residents (Resident 64 and Resident 84). These deficient practices had the potential for Resident 84 to have an undiagnosed urinary tract infection (UTI, bladder infection) and placed Resident 64's and Resident 84's urinary catheter drainage system at risk for possible exposure to infectious agents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to connect the nasal cannula (device used to deliver supplemental oxygen or increased airflow through the nose) to the oxygen concentrator (a device that provides supplemental oxygen) when oxygen therapy was provided to one of three sample residents (Resident 60). This failure had the potential for Resident 60's oxygen saturation (amount of oxygen circulating in the blood, normal value 95 percent [%] to 100%) to decrease which could lead to shortness of breath and respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the licensed staff failed to ensure the accurate and complete documentation of the administration of Lomotil (a controlled medication used to treat loose and watery stools, contains small quantities of narcotics) in the Medication Administration Record (MAR) and the Controlled Drug Record (CDR) to account for all eight doses (16 tablets) for one of three sampled residents (Resident 10). This failure had the potential for Resident 10 to overdose, the doses of Lomotil to become missing or unaccounted for, drug diversion (the act of health care providers stealing prescription medicines or controlled substances such as opioids for their own use), and/or the potential for a medication error to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their medication error rate was less than five (5) percent (5%) when three medication errors out of 38 total opportunities contributed to an overall medication error rate of 7.89%, affecting one of ten residents (Resident 85), based on the following: 1. Resident 85's heart rate was not assessed prior to the administration of hydrochlorothiazide (a medication used to treat high blood pressure and fluid retention) 12.g milligrams (mg, a unit of measurement) and losartan potassium (a medication used to treat high blood pressure) 25 mg. 2. Resident 85 was not instructed to rinse their mouth after the administration of one puff of Fluticasone-Salmeterol (a medication used to treat breathing problems). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medications in a proper storage room for two sampled Residents (Resident 1 and Resident 57) when: 1. Medicated ointment and another unidentified substance was stored in a resident restroom. 2. Medicated ointment and Vaseline was kept at Resident 1's and Resident 57's bedside. This deficient practice had a potential risk for a resident or residents ingesting the medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 6 and Resident 62) were provided the opportunity to make an informed decision prior to entering into a binding arbitration agreement (the submission of a dispute to a neutral party who hears the case and makes a decision) when the following occurred: 1. Facility staff did not inform Resident 6's responsible party about what a binding arbitration entailed, or that entrance into a binding arbitration agreement was optional. 2. Facility staff did not contact Resident 62's responsible party and power of attorney (POA, a legal document that allows someone else to act on your behalf), prior to Resident 62 signing a binding arbitration agreement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement effective infection prevention measures for three of 11 sampled residents (Resident 23, 49, and 74) when the facility failed to: 1. Ensure Treatment Nurse (TN) 1 performed hand hygiene (a way of cleaning one's hands that substantially reduces the potential germs on the hands) throughout Resident 23's wound treatment. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 3) were treated with respect and dignity by failing to knock and request permission before opening the curtain in the residents ' room. This deficient practice had the potential to violate the rights to privacy and negatively affect the psychosocial wellbeing of Resident and Resident 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Infection Prevention and Control Policy and Procedures (P&P) by failing to ensure visitors and staff entering the facility completed screening for signs and symptoms (s/s) of Coronavirus Disease ([Covid-19] a highly contagious respiratory infection caused by a virus that could easily spread from person to person). This deficiency practice had the potential to result in the spread of Covid-19 amongst facility staff, residents and the community.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 26 of 28 coffee mugs were cleaned, washed, and sanitized before the coffee mugs were taken out of the kitchen and placed on the coffee cart A for use and to distribute coffee to the residents in the facility. This failure had the potential to cause cross contamination (transfer of bacteria or any organisms) and illness to the affected residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a room that was assessed and equipped to prevent the resident from eloping (to run away unnoticed) for one of four sampled residents (Resident 1) who was assessed as a high risk for elopement. This deficient practice resulted in Resident 1 eloping from the facility on 9/6/2023 and was missing for three (3) days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report resident to resident abuse within 2 hours for two out of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in failure to protect residents from abuse.