Madera Post Acute Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 3) received necessary care and services when: 1. Resident 3 did not receive the necessary assistance during mealtimes. 2. Resident 3 had the appropriate call light to request assistance.3. Resident 3 received appropriate care for a skin issue. 4. Resident 3's mobility assessments (a clinical evaluation used to determine how safely and independently a person can move, change positions, and carry out daily tasks) reflected Resident 3's current physical abilities. These failures had the potential for Resident 3 not receiving appropriate and necessary care timely. During an observation on 5/12/2026 at 1:11 p.m. in Resident 3's room, Resident 3's food tray had a full boneless chicken and chopped carrots. Food was untouched. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 and LVN 3 administered medications at scheduled medication administration times for two of three sampled residents (Resident 1 and Resident 2). This failure placed Resident 1 and Resident 2 at risk for medication errors and adverse health outcomes.

Inspectors wroteBased on interview and record review the facility did not immediately notify the family for one of three sampled residents (Resident 1) regarding Resident 1's fall on 5/4/2026. This failure violated Resident 1's right and had the potential for Resident 1's family member (FM 1) of not being informed of Resident 1's change in condition and not making an informed decision (decision based on facts, relevant information, and clear understanding of potential risks, benefits, and alternatives) regarding Resident 1's fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly respond to call lights (a device used by a resident to signal his or her need for assistance from staff) and/or promptly respond to a resident's request for toileting assistance for two of four sampled residents (Residents 6 and 11). This failure placed Resident 6 and Resident 11 at risk for a delayed emergency response, accidents, or prolonged incontinence (lack of voluntary control over urination or defecation/bowel movement) and had the potential to result in Resident 6 and Resident 11 feeling like their concerns were unheard and to feel frustrated.a. [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly notify one of three sampled residents' (Resident 8's) doctor of Resident 8's fever and complaint of pain when urinating. This failure had the potential for Resident 8 to not receive timely treatment for Resident 8's pain and fever.(Cross Reference F842)During a review of Resident 8's Face Sheet, (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated the facility admitted Resident 8 on 10/8/2020 and readmitted Resident 8 on 4/1/2026 with diagnoses including pancytopenia (having low levels of red blood cells, white blood cells and platelets), muscle weakness, and acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan to prevent a resident from falling for one of 11 sampled residents (Resident 10). This failure had the potential to increase the risk of serious injury to Resident 10 after a fall. During a review of Resident 10's Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 10 was originally admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing); major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and fracture (a partial or complete break in the bone) of unspecified part of neck of left femur (upper part of left thigh bone). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a complete and accurate medical record for one of three sampled residents (Resident 8) when Licensed Vocational Nurse (LVN) 2 documented inaccurately in Resident 8's medical record that Resident 8's doctor (MD 1) was notified of Resident 8's fever and pain on 4/22/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to ensure that the call light requests for assistance were answered promptly for two of three sampled residents (Residents 7 and Resident 9). This deficient practice had the potential not to meet the residents' needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan with interventions for two of three sampled residents (Resident 1 and 2). 1. Facility did not ensure Resident 1's care plan indicated Resident 1 required two-person assistance during transfers. 2. Facility did not ensure Resident 2's care plan indicated resident 2 had a bile drainage bag. These deficient practices placed Resident 1 at risk of injury and falls during transfers, and placed Resident 2 at risk for a delay in the delivery of necessary care and services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents' right to privacy for one of three sampled residents (Resident 3) when: 1. Facility staff searched Resident 3's room without Resident 3's consent. This deficient practice had the potential to cause psychosocial harm, loss of dignity and feelings of frustration for Resident 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe storage for one medication by: 1. Not ensuring medications were stored in a secure and locked manner. 2. Not ensuring medications were discarded after resident was discharged from facility. These deficient practices had the risk of medication theft and diversion of medication (redirection of prescription medication from its intended path (manufacturer to patient) for unauthorized use).

Inspectors wroteBased on record review and interview, the facility failed to follow their smoking policy and procedure (a structured framework of rules and guidelines that ensure consistency, legal compliance, and operational efficiency within an organization) for one of one sampled resident (Resident 3) by: 1. Not ensuring Resident 3 had a current smoking assessment on medical record. 2. Not reassessing Resident 3's ability to smoke safely quarterly or after a significant change. These deficient practices placed Resident 3 at risk of fire or burn injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 7), received hydration through the gastrostomy tube (GT - a tube inserted into a surgical opening to allow feedings to be administered directly to the stomach common for people with swallowing problems) as ordered by the physician. This failure resulted in Resident 7 receiving insufficient hydration.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse for three of five sampled residents (Resident 3, Resident 4, and Resident 9) to the State Agency within two hours, in accordance with the facility's policy and procedure (P&P) titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, revised April 2025. These failures resulted in the delay of notification to the State Agency and had the potential for Resident 3, Resident 4, and Resident 9 to be subjected to abuse while at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure (P&P) titled, Fall Management System, for two of three sampled residents (Resident 6 and Resident 7) when: a. Resident 6's bed sensor pad alarm (an assistive electronic device that makes alerts/sounds to warn caregivers when the resident tries to get up from the bed) was in the off position while Resident 6 was in Resident 6's bed. b. The facility's Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) failed to implement new interventions to address Resident 7's falls on [DATE] and on [DATE]. The IDT also failed to update Resident 7's care plan following Resident 7's falls on [DATE] and [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Labeling and Dating of Foods, and Refrigerated Storage Guide, by failing to ensure: 1. A box of orange-colored, shredded cheese was labeled with an open date, a use by date or expiration date, and labeled with what kind of cheese was in the box.2. A box of Parmesan cheese was labeled with an open date and a use by date or expiration date.3. A plastic bag which contained three (3) blocks of orange-colored cheese was labeled with a use by date or expiration date. These failures had the potential to result in food borne illnesses (any illness resulting from eating contaminated/spoiled foods) for all residents in the facility who received food from the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services to one of three sampled residents (Resident 1) by failing to:A. Ensure Resident 1's physician's orders were followed when Licensed Vocational Nurse 1 (LVN 1) held administration of Tresiba (a once-daily medication used to manage high blood sugar). B. Ensure accurate medication administration documentation for Resident 1, when LVN 2 did not document the Tresiba administration for Resident 1 on 8/9/2025. These deficient practices had the potential to result in serious health complications for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of seven sampled residents (Residents 48, 50, and 64) who required supervision while smoking (breathing in smoke from cigarettes [tobacco wrapped in paper]) had an environment free of accident hazards (risk) by failing to:1. Implement the facility's Policy and Procedure (P&P) titled, Smoking Policy, which indicated no lighting materials (e.g. matches, lighters), tobacco products, or smoking devices (e.g. tobacco cigarettes, cigars) will be allowed to be kept in the possession of the residents, either on their person or in the facility. 2. Ensure Residents 48, 50, and 64 were not in possession of smoking materials (cigarettes and lighters). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and treat four of four sampled residents (Residents 10, 34, 61 and 102) with respect, privacy and dignity by failing to ensure:a. The Director of Staff and Development (DSD) close the privacy curtain while checking Resident 102's Gastrostomy tube (G-tube, feeding tube that is surgically placed through an opening into the stomach from the abdominal wall) site. b. Resident 34's nephrostomy (a thin catheter that drains urine from kidney into a bag) drain was covered and provided Resident 34 with privacy. c. Certified Nursing Assistant 8 (CNA 8) and Restorative Nursing Assistant 2 (RNA 2) closed the privacy curtain completely while providing care to Resident 61.d. Resident 10 was offered to get up to go to the bathroom between 7:30 am and 11:02 am on 7/9/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote continence (ability to control the bladder and bowels) for one of two sampled residents (Resident 10), according to the facility's policies and procedures (P&P) titled, Bowel and Bladder Assessment, and Resident Assessment and Associated Processes, by failing to:1. Ensure Resident 10 was placed on a scheduled toileting program (taking resident on a planned schedule to the toilet) after Resident 10 was assessed to not be a candidate for bowel and bladder retraining on 4/18/2025 and 6/18/2025. 2. Ensure Resident 10's bowel and bladder assessments (BBA) dated 6/18/2025 and Minimum Data Set (MDS- a resident assessment too) dated 6/18/2025 provided an accurate assessment of Resident 10's continence level based off the facility staff's observations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan (CP) for four of four sampled residents (Residents 4, 335, 61 and 44).a. Resident 4's CP was not initiated and implemented for the use of Buspirone (anxiolytic - medication used to treat anxiety disorders).b. Resident 335's CP was not initiated and implemented to address chronic abdominal pain.c. Resident 61 CP was not initiated and implemented to address recurrent Urinary Tract Infection (UTI - common infections that happen when bacteria, often from the skin or rectum, enter the urethra and infect the urinary tract).d. Resident 44's CP was not initiated and implemented for the use of Hydrocodone (narcotic pain medication). These deficient practices had the potential to not provide adequate care and services to address specific needs of Residents 4, 335, 61 and 44.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 20 cups of milk were maintained at temperature of 41 degrees Fahrenheit (41 F) during the meal service (Food Service- Meal service may include, but is not limited to, the steam table where hot prepared foods are held and served, and the chilled area where cold foods are held and served. This deficient practice had the potential to affect microbial (germs) growth that could lead to food poisoning (Food poisoning can happen to anyone who swallows food or water that's contaminated by 'germs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure policies and procedures (P&P) on Infection Prevention and Control were implemented for five of five sampled residents (Residents 105, 122, 61, 53, and 34) by failing to:a. Ensure Resident 105's urinal was stored appropriately and labeled with a resident identifier.b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 109) had a bedroom wall that was not missing part of the baseboard. This failure had the potential to result in the exposure of Resident 109 and Resident 109's visitors to dust and other unknown contaminants and failed to provide a safe, clean, comfortable, and homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a change of condition was developed and the physician was notified for one of one resident (Resident 335) who had an alert notification for no bowel movement for three days. This deficient practice had the potential to lead to a bowel obstruction, bowel rupture and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician order and an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) were obtained before the installation of side rails for one of two sampled residents (Resident 83). This failure placed Resident 83 at risk for entrapment (an event in which residents were caught, trapped, or entangled in a tight space around the bed) and injury from use of side rails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with a physician order to have a plate guard (a dining aid that can help people with limited control, grip, or dexterity eat with one hand and reduce the risk of spills) during meals for one of one sampled resident (Resident 83). This failure had the potential to result in Resident 83's decline in nutritional status and inability to maintain independence during mealtimes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the bed alarm was functioning properly for one of two sampled residents (Resident 10), to alert staff when Resident 10 attempted to get up unassisted. This deficient practice had the potential to result in residents being at risk for further falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to post nursing hours in a prominent place readily accessible to residents and visitors. This failure had the potential to result in the residents and visitors not knowing whether there was sufficient staff to provide quality care for the residents and resulted in nurse staffing information being inaccessible to visitors.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Significant Change of Condition, Response, for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1, reported to a charge nurse or supervisor an incident involving Resident 1 ' s left leg that got caught on the shower chair during 7 am - 3 pm shift. 2. Ensure Resident 1 ' s left leg was assessed by a charge nurse or supervisor during 7 am - 3 pm shift. These deficient practices had the potential to delay the necessary care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Charting and Documentation, by failing to have complete documentation for one of three sampled residents (Resident 2). Resident 2 was found with purplish discoloration (any alteration in the skin's color, texture, or pigmentation) on the right great toe. This deficient practice resulted in not providing complete information about how Resident 2 sustained the purplish discoloration on the right great toe which had the potential to put Resident 2 ' s safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to promptly (quickly/with little or no delay) notify the physician for one of eight sampled residents (Resident 8) who experienced a change of condition (COC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains) as indicated in the facility's policy and procedure (P&P) titled, Significant Change of Condition, Response, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 3 promptly notified Resident 8's Primary Care Provider/Medical Doctor (MD) 2 when LVN 3 observed an increase in swelling in Resident 8's left leg and foot on 1/15/2025. 2. Ensure LVN 3 promptly notified MD 2 on 1/20/2025 when Resident 2's left leg and foot condition did not improve. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor and document a change of condition for one of eight sampled residents (Resident 8) as indicated in the facility's policy and procedure (P&P) titled, Significant Change of Condition, Response, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 3 completed a Situation-Background-Assessment-Recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations)/Change of Condition (COC) form when LVN 3 observed an increase in swelling in Resident 8's left leg and foot on 1/15/2025. 2. Ensure LVN 3 completed an SBAR/COC form on 1/20/2025 when Resident 2's left leg and foot condition did not improve after 72 hours. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide skin treatment in accordance with the professional standards of practice for one of three sampled residents (Resident 1) by failing to: a. Ensure a Licensed Vocational Nurse (LVN) instead of a Certified Nursing Assistant (CNA) 1 applied ointments to Resident 1. b. Ensure there was a physician's order for the ointments being applied to Resident 1. These failures had the potential to result in improper use and application of skin treatment for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse involving one of ten sampled residents (Resident 1) and a family member of Resident 2 (FM 1) to the California Department of Public Health (CDPH), the local law enforcement, and the Ombudsman (an official appointed to advocate for residents of nursing homes) within two hours as indicated in the facility's policy and procedure (P&P) titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment. This deficient practice violated Resident 1's rights, had the potential to compromise Resident 1's safety, and could subject Resident 1 to potential further verbal, mental, and emotional abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) with psychotropic medication (any drug that affects the brain activities associated with mental processes and behavior) order was free from unnecessary drugs, according to the facility's policy and procedure (P&P) titled, Psychotropic Medications, by failing to: Ensure Resident 1 was not ordered Seroquel (medication used to treat symptoms of psychosis [severe mental condition in which thought and emotions are so affected that contact is lost with external reality] and other mental health disorders) 25 milligrams (mg- unit of measurement) for false accusations towards staff for unspecified psychosis not due to a substance (drug) or known psychological condition on 8/23/2024 when Resident 1 was not diagnosed by Psychiatrist/Medical Doctor (MD) 2 with unspecified psychosis. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of need for three of three sampled residents (Residents 32, 84 and 89) who were assessed as at risk for fall, by failing to ensure the residents call light was within reach as indicated in the facility's Policy and Procedure (P&P), titled Call Light and resident's plan of care. These deficient practices had the potential for Residents 32, 84 and 89 not to receive or received delayed care that could result in a fall or accident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with a communication device with the language that the resident understood for two of three sampled residents (Residents 50 and 80). These deficient practices had the potential to prevent Residents 50 and 80 from communicating with the staff and had the potential to receive delayed care, treatment, and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accidents for two of four sampled residents (Residents 12 and 339) by failing to: a. Implement Resident 12's Medical Doctor (MD) order and care plan to place floor mats at the edge of Resident 12's bed to prevent injury for fall. Implement Resident 12's Care Plan (CP) and Policy and Procedure (P&P) on Seizure Precaution to pad the bed side rails to prevent injury during a seizure (uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements) b. Implement the facility's P&P on smoking when Resident 339 was observed to have cigarettes on Resident 339's position on 7/16/2024. These failures had the potential to result in accident and hazard for Residents 12 and 339.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility's Policy and Procedure (P&P), titled Resident with Indwelling Catheter in Placed and the resident's Care Plan (CP) for three of three sampled residents (Residents 30, 106, and 128) by failing to: a. Ensure Resident 30's indwelling catheter (known as foley catheter [FC], a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) was assessed and monitored for the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria, fungi, parasites in the urine that could indicate infection or dehydration [fluid deficit]) in the urine. b. Ensure Resident 106's FC was assessed and monitored for the presence of white sediments in the urine and tubing and was not kinked. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 30 and 128 ) who had gastrostomy tube (GT- a tube inserted through the abdomen that delivers nutrition directly to the stomach) received appropriate treatment and services as indicated in the facility's Policy and Procedure (P&P) titled Enteral Formulas, Administration of Closed System, Gastrostomy Tube Care Management, and the resident's plan of care by: a. Failing to ensure Resident 30's GT formula bottle was labeled with time started. b. Failing to ensure Resident 128 received the recommended amount of GT water flush, as ordered. These deficient practices had the potential to result in adverse consequences for Residents 30 and 128.

Inspectors wroteBased on observation, interview and record review, the facility failed to attempt the use of appropriate alternatives to bed rails before its installation for two of two sampled residents (Residents 26 and 99). These deficient practices placed Residents 26 and 99 at risk for entrapment and injury from the use of bed rails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food sanitation and safe handling practices by: a. Placing a container of raw meat for thawing next to the container of ready to eat carrots, at the lowest shelf inside one of one facility walk-in refrigerator. b. Placing spoons with food particles in one of one clean knife holding rack. These failures had the potential to result in contamination and food borne illnesses (illness caused by consuming contaminated food or beverages) to the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide information on Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) for one of three sampled residents (Resident 48). This failure had the potential for facility staff to provide treatment and services against the resident's will.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply elbow splint as ordered by the physician for one of four sampled residents (Resident 27) This failure had the potential risk to result in the resident's decline in Range of Motion (ROM, full movement potential of a joint) that cause stiffness (inability to move easily and without pain) and contractures (deformity and joint stiffness).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with breathing problem receive continuous oxygen therapy as ordered by the physician for one of one sampled resident (Resident 4) This deficient practice placed Resident 4 at risk for severe difficulty of breathing.

Inspectors wroteBased on interview and record review, the facility failed to implement a hospice (program that gives special care to residents who are near the end of life and have stopped treatment to cure or control disease) diet order for one of two sampled residents (Resident 68). Resident 68 had an order of puree diet (food that has been ground, blended, or chopped into a thick paste or liquid for easier swallowing and digestion) with thin liquids from the hospice physician but Resident 68 was currently receiving mechanical soft diet (foods that are soft in texture) with thin liquids. This failure had the potential to result in adverse consequences for Resident 68 including weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to post actual nursing information in one of one sampled location (Hallway) by failing to: a. Post actual number of nursing staff at the beginning of each shift on 7/17/2024 and 7/18/2024. b. Post accurate numbers of nursing staff who worked on 7/15/2024 morning shift (7:00 AM to 3:00 PM) and evening shift (3:00 PM to 11:00 PM); on 7/16/2024 morning and evening shift; on 7/17/2024 morning shift and on 7/18/2024 evening shift and night shift (11:00 PM to 7AM). These failures had the potential to result in posting inaccurate staffing information and affect the quality of care for the residents.

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures (P&P) titled, IV (an intravenous [within a vein] line is a soft, flexible tube placed inside a vein, usually in the hand or arm) Administration (send directly into the vein), and Central Venous (a thin, flexible tube that is inserted into a vein, usually below the right collarbone [a bone at the base of the front of the neck] and Midline Catheter (a catheter inserted in the upper arm with the tip located just below the axilla [armpit]) Care, and follow the manufacturer's instructions for care of the central venous catheter (CVC - an indwelling device inserted into a large, central vein to administer fluid, medication, and/or treatment) for one of one sampled resident (Resident 1) by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate clinical record for one of one sampled residents (Resident 1) when Registered Nurse Supervisor (RNS) 3 did not document that RNS 3 flushed with saline (a solution of salt in water), clamped, and capped Resident 1's permanent catheter (Permacath- a type of central venous catheter [CVC- an indwelling device inserted into a large, central vein to administer fluid, medication, and/or treatment] used for short-term or long-term hemodialysis [a treatment to filter wastes and water from the blood, as the kidneys did when the kidneys were healthy]) after the completion of Resident 1's intravenous (IV, within a vein) infusion (a method of putting fluids into the bloodstream) on Resident 1's clinical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its own policy and procedure to ensure there was sufficient staff available to assist one of five sampled residents (Resident 1) who required assistance with feeding in a timely manner. Resident 1 had to wait 30 minutes to be fed after his meal tray was placed at the bedside. This failure had the potential to result in the food getting cold and to not be appetizing to the resident and could result in potential risk of weight loss for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of five sampled residents (Resident 2) by failing to ensure the call light was not wrapped to the top of the left side of Resident 2's bed frame. This failure had the potential to result in Resident 2 being unable to notify staff of Resident 2's needs, and possibly, sustain an injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to formulate Advance Directives were exercised for eight of 14 sampled residents (Residents 79, 104, 99, 55, 41, 5, 34, and 217). This deficient practice has the potential for residents future health care decisions or wishes not be determined and identified by the facility staff to implement in the event of medical emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow safe food storage and food handling practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to: 1. Label/date prepared food items in the kitchen's refrigerator. 2. Label opened/used dry food item stored in the kitchen dry storage pantry. 3. Discard opened/used dry food item on the shelf in the kitchen dry storage pantry within the time specified. 4. [NAME] (put on) gloves during food preparation in the kitchen. These deficient practices had the potential for food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the palatability of the meal to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices when: a. Resident 109's percutaneous cholecystostomy catheter (tube placement for gallbladder, small organ that helps with digestion, content drainage) bag was observed touching the floor. b. During initial tour, there was trash and dark spots on the floor in Resident 6's room. In addition, Resident 6 hung one of two urinals (urine plastic bottle) on the trash bin and his urinals were unlabeled. c. Laundry staff (unidentified) were eating and drinking in the clean linen laundry area. d. Water temperature was not maintained at 150 degrees Fahrenheit for washing linens, the gauge read 115-125 degrees F. e. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent for the use of psychotropic medication (any medication capable of affecting the mind, emotions, and behavior) was obtained from the resident who had the capacity to make decisions and not from the family member, for one of 23 sampled residents (Resident 167). This failure had the potential to violate the Resident 167 rights to be informed of the adverse effects of taking the psychotropic medication and to choose the type of care or treatment to be received, or alternatives the resident preferred.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a communication board (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) for one of one sampled residents (Resident 34). Resident 34 had a language barrier, and the facility did not provide the resident with a communication board as indicated in the facility's Language/Communication Barriers policy. This deficient practice had the potential for Resident 34 not to communicate effectively with staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy for one of one sampled resident (Resident 104). Certified Nursing Assistant 3 (CNA) 3 was providing care to Resident 104, and left the room. Resident 104 was left lying on her bed with her gown up to her hip area, and both legs were exposed. This deficient practice has the potential to violate the resident's right for personal privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized care plans for three of 23 sampled residents (Residents 109, 6, and 417) as indicated on the facility policy and procedure. a. Resident 109 who had a percutaneous cholecystostomy catheter (tube placement for gallbladder, small organ that helps with digestion, content drainage) with a drainage bag did not have a care plan developed for the care of the catheter. b. Resident 6 did not have a care plan with appropriate interventions to address resident's consistent behavior of hanging his urinal on a trash bin and propelling himself on the wheelchair with no foot rest. c. Resident 417 did not have a care plan upon admission for grieving and emotional distress due to the loss of her son. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to modify the care plan for one of 23 sampled residents (Resident 3) to address impaired vision. This deficient practice had the potential for Resident 3 not to receive specific interventions to address needs, which can result in falls and injury and decline in functional ability.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist one of two sampled residents (Resident 98) to obtain an ppointment with an audiologist (a physician who evaluates hearing disorders) for the need of a hearing device (a device used to improve hearing). This deficient practice had the potential to result in increased hearing loss, difficulty with communication and decline in Resident 88's quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment to prevent the development of a pressure ulcer (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 and/or friction) for one of one sampled Residents (Resident 28) by failing to ensure the low air loss mattress (LAL, special type of mattress used for both the prevention and treatment of pressure ulcer) was set on the correct setting as indicated on the facility policy. This deficient practice had the potential to result in the development of new pressure ulcers or result in reoccurrence of pressure ulcer, which could lead to complications and affect Resident 28's total well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safety measures for one of two sampled residents (Resident 104). On 10/18/2021 at 9:39 am, Certified Nursing Assistant 3 (CNA 3) left Resident 104 unattended in bed during perineal (involves cleaning private areas) care and did not lower Resident 104's bed when she left the room. This deficient practice had the potential for Resident 104 to experience injuries and or a fall.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled residents (Resident 23) who required an ileostomy (where the small intestine is diverted through an opening in the tummy to move waste out of the body) received care in accordance with the resident's physician's order by failing to: 1. Address Resident 23's ileostomy defective bag in a timely manner. This deficient practice resulted in Resident 23's emotional well-being to be affected and had the potential to develop breakdown to the resident's skin surrounding the ostomy (or stoma, an artificial opening in the body, created during an operation such as a colostomy or ileostomy).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate pain management for three of four sampled residents (Resident 270, Resident 218, and Resident 267), according to the residents' plan of care. This deficient practice resulted for the residents to experience pain, and had the potential to decline in function.

Inspectors wroteBased on interview and record review, the facility failed to document and account for controlled medications (medications that can cause physical and mental dependence), as indicated in the facility's Medication Administration policy and procedure, for two of two sampled residents (Resident 57 and Resident 100). This deficient practice had to potential for the loss of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 167) had a self-administration assessment for the use of albuterol inhaler (inhaled spray to treat narrowing of the airways). The facility was not aware Resident 167 was self-administering an albuterol inhaler brought from home. This deficient practice had the potential to result with unsafe administration of the inhaler for Resident 167.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide rehabilitative services (help people return to daily life and live in a normal or near-normal way) to one of one sampled residents (Resident 55). Resident 55 did not receive rehabilative services for 13 days (10/9/21 to 10/21/21), while waiting for his insurance company to approve physical therapy (focuses on helping improve your movement, mobility, and function), and occupational therapy (focuses more on how clients perform activities and roles that are most important to their daily lives). This deficient practice had the potential for Resident 55 to decline in functional ability or deterioration of muscle strength.

Inspectors wroteBased on interview and record review, the facility failed to ensure coordination of care between the hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) team and the facility for one of two sampled residents (Resident 167) by not having a calendar hospice staff sign in sheet and no documented evidence of scheduled Licensed Vocational Nurse (LVN) and Registered Nurse (RN) visits were conducted in accordance with the facility policy and procedure. This failure had the potential for Resident 167 not to receive the hospice services necessary to promote comfort and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) policy for two of three sampled residents (Resident 22 and Resident 55) for the use of antibiotics (a medication used to treat bacterial infections). a. For Resident 22, regarding the use of Doxcycline Monohydrate (antibiotic) b. For Resident 55, regarding the use of Cephalexin (antibiotic). This deficient practice had the potential to result in the development of antibiotic-resistant organisms (organisms not affected to antibiotics).