Madera Rehabilitation & Nursing Center

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain essential equipment in a safe operating condition when one of two boiler systems (a device that heats the facility's water) was not monitored, maintained and failed to operate from 2/21/26 to 2/24/26. This failure resulted in a non-functioning boiler system, unable to heat water throughout the facility's resident rooms, nurses' stations and shower rooms and placed the residents at risk for poor hygiene, infectious disease and discomfort. The facility's residents were unable to shower for three days, and nursing staff were unable to wash their hands in hot water for infection prevention. During an interview on 2/24/26 at 1:32 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for four of 15 sampled residents when the Infection Preventionist (IP) performed influenza (a highly contagious respiratory illness) tests and did not document the tests in Residents 5, 8, 12, and 14's electronic medical record (EMR). This failure resulted in an inaccurate and incomplete medical record for Residents 5, 8, 12, and 14. During a review of Resident 3's admission Record (AR), undated, the admission record indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses that included dementia (decline in mental ability such as memory, thinking, reasoning and communication) and anxiety (feeling or fear, dread and uneasiness). During a review of Resident 3's Change in Condition (CIC), dated 1/30/26, the CIC indicated, . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective infection control program when 12 of 65 hand sanitizer dispensers tested were not dispensing alcohol-based hand rub (ABHR-an alcohol-containing preparation [liquid, gel or foam] designed for application to the hands to inactivate germs) when used. These failures had the potential for staff not performing hand hygiene and could have caused cross contamination (accidental transfer of harmful bacteria, viruses or allergens from one surface or person to another) spreading infections to residents and staff. During a concurrent observation and interview on 2/11/26 at 10:49 a.m. with the Infection Preventionist (IP), 65 hand sanitizer dispersers in the hallways and nurses' stations were tested for function. The dispensers in the following areas did not dispense ABHR: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents' environment remained free of accident hazards as possible when: 1. In the memory care unit, facility staff were aware an exit door was secured by a slide barrel lock (a type of lock that requires the user to slide the barrel of the lock in order to unlock the device) and placed on the door in a position that was out of reach for most individuals. An environmental hazard risk assessment was not done for the lock on the door. Some staff were unaware of the placement of the slide-barrel lock and residents were not trained to unlock the device. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure two of sixteen sampled residents (Resident 2 and Resident 4) maintained acceptable parameters of nutritional status when:1. Resident 2 was at risk of unplanned weight loss, and did not receive adequate nutritional interventions to maintain acceptable parameters of nutritional status. This failure resulted in a severe weight loss of 7.95% in less than 2 months from 6/2/25 to 7/28/25 without timely assessment, monitoring, or physician notification. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice for nine out of 15 sampled residents (Residents' 95, 96, 14, 68, 86, 87, 129, 144 and 164) when:1. Resident 95's tramadol (opioid pain medication used to treat moderate to severe pain) medication lacked an appropriate indication and an associated pain scale to guide administration. This failure resulted in Resident 95's tramadol medication order not having complete and appropriate administration instructions which could lead to inappropriate administration, overmedication, or overdose. 2. Resident 96's oxygen therapy (a colorless, odorless, tasteless gas essential to living organisms) was not administered per the physician order. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food reached an appetizing temperature when temperatures for gravy sauce, french fries, grounded burger patty, food in cups and diced pears did not reach desired temperatures during tray line on 8/6/25. This failure placed all residents receiving food from the kitchen not eating their meal and placed their nutritional status at risk which could potentially lead to weight loss. FacilityDuring on observation on 8/6/25 between 11:30 a.m. through 12:45 p.m. in the kitchen during tray line, observed dietary cook (DC) and DC 2 checked temperatures of the food on the steam table. Temperature of french fries, gravy sauce, grounded burger patty, food in cups and diced pears were not checked. During an interview on 8/8/25 at 9:24 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the planned menus were followed when residents on fortified diet (foods that have extra nutrients, like vitamins and minerals to improve the food's nutritional value to prevent nutrient deficiencies) were not served fortified food as prescribed by their Medical Doctor (MD) on 8/6/25. This failure had the potential for all residents on fortified diets to receive inadequate amounts of nutrients, potentially leading to weight loss and malnutrition. During review of facility's document titled, WEEK 2 WEDNESDAY Cambridge [NAME] CYCLE 2 2025 Spring, undated, the document indicated, . Lunch. FORTIFIED HIGH PROTEIN. SUPER SOUP 6 oz [ounces-unit of measurement]. During observation on 8/6/25 between 11:48 a.m. to 12:45 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in accordance with professional standards for food services safety when:1. One of two ice machines and food preparation sink was not equipped with an air gap (a vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water). This failure had the potential for contaminated water to flow back into the sink and ice machine and result in pathogenic (viruses, bacteria and other types of germs that can cause disease) microorganism (an organism that is so small it can only be viewed under a microscope) growth that could inadvertently (accidentally) be transferred to food and served to 173 residents in the facility, causing foodborne illness.2. Two opened bags of parmesan cheese and one and one-half loaves of bread did not have an opened or used by date. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a facility wide assessment specific to the facility needs when:The facility did not include an evaluation of the physical environment in its facility assessment to ensure the needs of the resident population were met for 26 of 26 residents in the memory care unit and 15 of 15 smokers in the facility. These failures placed residents in the memory care unit unable to exit the door in an emergency and could lead to entrapment and placed smoking residents safety at risk. During a concurrent interview on 08/14/2025 at 3:25 p.m. with the Administrator (ADM) and the Director of Nursing (DON), the DON stated they did not identify any issues with how the Resident smoking area was set up in the past. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect and promote the rights of the residents for 13 of 28 sampled residents (Residents' 2, 14, 30, 148, 38 50, 4, 9, 28, 59, 67, 68 and 130) when: 1a. Staff did not use an alternate communication method with Spanish speaking residents (Residents 2 and 14) such as language assistance, interpreters or translated materials. 1b. Staff was speaking in a foreign language during resident care for Residents 30, 148, 38 and 50. These failures violated Residents 2, 14, 30, 148, 38 and 50's rights to understand the care provided to them in a language they understood. 2. Three female residents in room [ROOM NUMBER] shared a bathroom with three male residents in room [ROOM NUMBER]. 3. Resident 4 watched other residents on her table eating while she waited for over five minutes for her food to be delivered on 8/5/25. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for four of 22 sampled residents (Resident 6, 49, 68 and 185), when1. Resident 6's care plan interventions to minimize fall related injuries were not implemented. Resident 6 did not have a bilateral floor mat and reacher at bedside. This failure had the potential to place Resident 6 at risk for an avoidable fall and obtaining fall-related injuries. 2. Resident 49's care plan interventions to address communication problem related to diagnosis of Expressive Aphasia (a disorder that makes it difficult to speak) and Resident 49's primary language was Persian were not implemented. Resident 49 had no communication book and/or translator/interpreter service. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all prescribed medications were available and administered to residents as scheduled for three of seven sampled residents (Resident 53, 82 and 144) when the facility did not have the medications available for administration. This failure placed Residents 53, 82 and 144 at risk for not receiving the physician ordered medical treatment, placing residents at risk for ineffective management of their medical conditions.

Inspectors wroteBased on observation, interview and record review the facility failed to provide assistive devices during meals for three of 12 residents (Resident 44, 68, and 67) when: 1. Resident 44 was not provided with a right-hand built-up spoon (an adaptive dining aid [a device used to assist with feeding] designed for people who have limited grasp or face difficulties in supination) during his lunch on 8/5/25. This failure resulted in for Resident 44 not being able to feed himself and had the potential risk of losing his independence when eating. 2. Resident 68 was not provided a scoop plate (an assistive plate which helps people scoop up food onto a utensil) during his lunch on 8/5/25 This failure had had the potential to result in Resident 68 to not be able to eat his meal 3. Resident 67's food was not served in bowls on her meal tray during lunch on 8/5/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a completed physician informed consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication used to treat mental and behavioral disorders) was obtained for two of nine sampled residents (Resident 95 and Resident 108) when:Resident 95 had an active order for sertraline (psychotropic medication used to treat conditions such as depression) oral tablet, ordered on 7/5/25, with no electronic provider signature prior to administration. Resident 108 had an active order for aripiprazole (psychotropic medication used to treat conditions such as schizophrenia), ordered on 3/19/25, with no name of the licensed nursing staff that prepared and verified the consent form. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS -assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of six sampled residents (Resident 13) when Resident 13's antidepressant medication (used to treat depression and mental health conditions), and anticoagulant medication (used to prevent blood clots from forming) use were inaccurately coded on the MDS assessment. These failures had the potential to result in Resident 13's care needs not met. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nail care was provided for one of nine sampled residents (Resident 49) when Resident 49's fingernails were long, jagged (sharp, uneven edges) and dirty with brownish to blackish dirt built up underneath the nails. This failure had potential for Resident 49 in obtaining avoidable skin related injuries and infection (the invasion and growth of germs in the body). During a concurrent observation and interview on 8/5/25 at 11:02 a.m. with Resident 49, in Resident 49's room, Resident 49 was lying in bed. Resident 49 was awake with slurred (indistinct and difficult to hear or understand) speech and was able to respond during conversation by nodding his head using yes and no questions. Resident 49 was unable to move his right upper extremity and right lower extremity. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to act upon reported drug regimen review irregularities when one of nine sampled residents (Resident 108) had suggested drug regimen updates and there was no action taken to address it or documentation as to why no change in medication was taken. This failure had the potential to lead to unresolved medication related issues and negative health outcomes of Resident 108.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of nine sampled residents (Resident 95) drug regimen was free from unnecessary drugs when Resident 95 received tramadol (opioid pain medication- a controlled substance used to treat moderate to severe pain) prescribed for pain management, despite reporting no pain. This failure resulted in over-medication and inadequate pain management practices of Resident 95 which had the potential to result in adverse consequences and complications which could lead to serious medical conditions.

Inspectors wroteBased on observation, interview and record review the facility to provide food in a form to meet individual needs for two of 15 sampled residents (Resident 68 and 143) when:1. Resident 68 received hard toast for lunch on 8/5/25 while he was on a mechanical soft diet.2. Resident 143 was served hard toasted bread during lunch on 8/5/25. Resident 143 attempted to eat the hard toasted bread. Resident 143's prescribed diet was mechanical soft texture diet. These failures had the potential to place Resident 68 and 143 at increased risk of choking (is a blockage of the upper airway by food or other objects, which prevents a person from breathing effectively).1. [...]

Inspectors wroteNumber of residents sampled:nineNumber of residents cited:oneBased on observation, interview and record review, the facility failed to follow the policy and procedure (P&P) for Foods Brought by Family/Visitors for one of nine sample residents (Resident 49) when perishable food (food that spoil, decay, and unsafe to eat if not stored properly) was stored in Resident 49's bedside table. This failure had the potential for Resident 49 at an increased risk of acquiring food-borne illnesses (referred to as food poisoning, are caused by eating or drinking something that is contaminated with germs/spoiled). During a concurrent observation and interview on 8/5/25 at 11:02 a.m. with Resident 49, in Resident 49's room, Resident 49 was lying in bed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program to provide a safe and sanitary environment to prevent infections for one of four sampled residents (Resident 13) when Resident 13's handheld nebulizer tubing (device that delivers medication into fine mist directly into the lungs) had a date of 7/17/25. This failure had the potential to put Resident 12 at risk for possible respiratory infection. During an observation on 8/5/25 at 10:01 a.m. during initial tour in Resident 13's room, Resident 13 was not in his room. Observed a handheld nebulizer at bedside inside a plastic bag a handheld nebulizer tubing dated 7/17/25. [...]

Inspectors wroteBased on observation during the survey period of 8/5/25 to 8/14/25, the facility failed to provide and maintain minimum square footage for each resident in 33 of 74 rooms (Rooms 16, 17,18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35,38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50) During an observation of the facility on 5/19/19 to 5/23/19, the following rooms did not provide the minimum square footage as required by the regulation: Rooms 16, 17,18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35,38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50. The residents had a reasonable amount of privacy. Closets and storage spaces were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and comfortable environment for two of 13 sampled residents (Resident 1 and Resident 8) when Resident 1 and Resident 8 ' s wheelchairs were covered with black and brown unknown substances and were visible to passersby. This failure violated Residents 1 and Resident 8 ' s rights to a comfortable and homelike environment that would respect the residents' dignity and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when two of ten sampled residents (Resident 1 and Resident 8) when Resident 1 and Resident 8 ' s wheelchairs were covered with black and brown unknown substances. This failure placed Resident 1 and Resident 8 at an increased risk to develop healthcare-associated infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent falls for two of five sampled residents (Residents 1 and 9) when: 1. Resident 1 was assessed to be at risk for falls on 3/23/25 and staff were aware of Resident 1's frequent positioning in bed lying on his back leaning against the side rail, right sided paralysis (inability to move), and inability to reposition himself and effective individualized interventions to prevent falls were not implemented. Resident 1 experienced an unwitnessed fall on 4/2/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP) have the specific competencies, and skill sets to ensure facility staff were properly trained and educated to properly managed and care for residents with infections and to prevent the risk for infections to other residents, staff and visitors when the IP did not provide on-going in-service training and education to facility staff when facility had an outbreak of Noro virus (highly contagious virus [easily spread] that causes vomiting and diarrhea) and Influenza virus (contagious respiratory illness). These failures placed residents, staff and visitors at increased risk for exposure to infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report abuse allegations to the California Department of Public Health (CDPH) within the required timeframe for two of four sampled residents (Resident 10 and Resident 7) when: 1. CNA 5 alleged CNA 6 pushed Resident 10 roughly onto her bed while providing care on 4/5/25 and did not report the allegation of abuse to the facility until 4/6/25. 2. Family Member (FM) 1 contacted the local police department (PD) alleging Resident 7 was abused by facility staff on 3/5/25 and 3/27/25, the PD went to the facility for welfare checks and the facility staff was made aware of the abuse allegations. The facility staff did not report the abuse allegations to CDPH on 3/5/25 and 3/27/25 according to federal regulations and the facility's policy and procedure (P&P). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent falls for three of six sampled residents (Residents 1, 2 and 6) when: 1. Resident 1 was assessed as being a fall risk, had poor safety awareness and needed to be supervised while ambulating (walking) and the facility did not implement effective interventions to prevent falls, including adequate supervision, consistent with the resident ' s needs, goals and care. [...]

Inspectors wroteBased on interview and record review, the Administrator (ADM) failed to provide consistent administrative oversight and resources to ensure residents received adequate supervision and care planning when the ADM was aware of 63 resident falls between 1/1/25 and 3/4/25 and did not establish an effective fall prevention program. This failure resulted in three of six sampled residents (Residents 1, 2 and 6) having unwitnessed falls with injury requiring transportation to the acute care hospital (ACH) for treatment and placed other residents at risk for falls with injury. (cross reference F689)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan was developed and implemented to meet the identified needs for two of six sampled residents (Residents 1 and 2) when: 1. Resident 1 was admitted to the facility with a history of falls, assessed as being a fall risk and a known behavior of not calling staff for assistance and the facility did not develop and implement effective care plan interventions including assistance and supervision to prevent falls. This failure resulted in Resident 1 ' s unwitnessed fall on 1/30/25, sustaining an intertrochanteric fracture (a type of hip fracture [broken bone] where the femur [upper thigh bone] meets the pelvis), pain, decreased mobility and required transportation to the emergency room and admission to the acute care hospital (ACH) for seven days. (cross reference F689) 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff with the appropriate competencies and skill sets to provide nursing services to ensure residents receive services to maintain their highest practicable physical, mental, and psychosocial well-being when seven of seven sampled nursing staff (Registered Nurse [RN] 1, RN 2, Licensed Vocational Nurse [LVN] 1, LVN 2, Certified Nursing Assistant [CNA] 1, CNA 2, CNA 3) did not have their fall prevention competency (ability to do something successfully) skills checked within the last year and there were 42 falls between 1/1/25 and 2/12/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) policy and procedures (P&P) for two of 12 sampled residents (Resident 8 and Resident 14) when Resident 8 and Resident 14 were receiving hospice services with unsigned hospice agreement. This failure had the potential to place Resident 8 and Resident 14 at risk of not receiving appropriate medical, physical, psychosocial, and spiritual support to manage symptoms associated with terminal illness.

Inspectors wroteBased on interview and record review, the facility failed to identify, develop and implement an effective Quality Assurance and Performance Improvement (QAPI- a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) program when the facility did not establish an effective fall prevention program and there were 63 resident falls between 1/1/25 and 3/4/25. This failure resulted in three resident falls (Residents 1, 2 and 6) with significant injury requiring transportation to the acute care hospital for treatment and placed other residents at risk for falls with significant injury and had the potential to affect the quality of care, quality of life, services and safety of the facility's residents. (Cross reference F835, F689)

Inspectors wroteBased on interview and record review, the facility failed to notify the Responsible Party (RP) for one of six sampled resident ' s (Resident 2) when Resident 2 ' s room was changed on 2/23/25 and he fell on 2/26/25. This failure violated Resident 2 ' s rights when his RP was not informed of a change in care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and comfortable environment for one of 13 sampled residents (Resident 9) when Resident 9 ' s hospital bed ' s footboard was loose and detached from the bedframe, and visible to passersby. This failure violated Residents 9 ' s rights to a comfortable and homelike environment that would respect the residents' dignity and well-being.

Inspectors wroteBased on interview and record review, the facility failed to report an unwitnessed fall with injury to the California Department of Public Health (CDPH- State survey agency) within the required time frame for one of ten sampled residents (Resident 2) when Resident 2 fell twice from his bed on 2/20/25, unwitnessed on both occasions. Resident 2 hit his head during a fall on 2/20/25 at 6:15 a.m. causing a skin tear to his left eyebrow and fell again on 2/20/25 at 10:35 p.m. hitting his head in the same area causing further trauma to the left eyebrow resulting in a laceration (cut or tear in the skin caused by blunt force). Resident 2 required transportation to the emergency room for sutures (threads used to close wounds) to repair the wound. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of 12 sampled residents (Resident 3) when Resident 3 ' s low air loss (LAL - a special mattress used to prevent skin injuries, often occurring in individuals who are bedbound) mattress setting was not used according to the manufacturer ' s recommendation. This failure had the potential to result in Resident 3 to develop pressure ulcer (injury to the skin and underlying tissues by prolonged pressure on the skin) and placed Resident 3 at an increased risk for falls and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when one of 12 sampled residents' (Resident 8) oxygen concentrator filter was found covered with dust and lint. This failure placed Resident 8 at an increased risk to develop respiratory and healthcare-associated infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent falls for two of five sampled residents (Residents 2 and 8) and to prevent elopement for one of two sampled residents (Resident 1) when: 1. Nursing staff were aware of Resident 2 ' s decline in functional status, poor safety awareness and need to be supervised while ambulating and failed to assign staff to supervise Resident 2. On 1/2/25 Resident 2 was left unsupervised, and he ambulated unassisted to the outdoor patio where he was found on the ground after an unwitnessed fall. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective infection control program when: 1. One of 11 sampled Certified Nursing Assistants (CNA 1) assisted Resident 1, who was on contact precautions for symptoms of norovirus (a highly contagious virus [infectious agent] that causes nausea, vomiting and diarrhea), from the bathroom to his bed and failed to wear personal protective equipment (PPE-includes protective gowns, gloves, face shields or goggles and face masks to protect the wearer from injury or the spread of infection or illness) according to the facility ' s policy and procedure (P&P) for norovirus prevention and control. This failure had the potential for CNA 1 to spread norovirus to other residents and staff. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to prevent falls for two of four sampled residents (Residents 2 and 8) when: 1. Nursing staff were aware of Resident 2 ' s decline in functional status, poor safety awareness and need to be supervised while ambulating and did not develop and implement effective care plan interventions to prevent falls. This failure resulted in Resident 2 ' s fall on 1/2/25 sustaining a laceration (cut in the skin caused by an injury) above the left eyebrow requiring transportation to the emergency department (ED) for sutures (a row of stitches holding together edges of a wound). 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure services provided met professional stands of practice for six of nine sampled residents (Residents 1, 2, 3, 6, 7 and 8) when: 1. Nursing staff were aware that four of four sampled residents (Residents 2, 3, 7 and 8) with severe cognitive impairment, poor safety awareness and a history of falls did not perform fall risk assessments (medical evaluation that determines likelihood of falling by examining factors such a medical history, physical abilities, balance, gait, and medications) after falls and quarterly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the quarterly Minimum Data Set Assessment (MDS-a resident assessment tool used to identify resident cognitive and physical function) accurately reflected the residents healthcare and functional status for one of nine sampled residents (Resident 2) when Resident 2 ' s plan of care addressed an unsteady gait (manner of walking) and declining health status on 11/2/24 and Minimum Data Set Coordinator (MDSC) 2 assessed his ambulation (ability to walk) status as independent in the MDS Assessment Section GG-Functional Abilities on 11/23/24. This failure resulted in an inaccurate assessment of Resident 2 ' s functional status as not needing supervision to ambulate, and the resident was left on an outside patio unsupervised and fell on 1/2/25 sustaining a laceration above his left eye. (Cross reference F689)

Inspectors wroteBased on interview and record review, the facility failed to protect and promote resident rights to be free from abuse for one of three sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 and other facility staff left Resident 1 in her room during a verbal altercation between four facility visitors, in a manner that made Resident 1 felt threatened and fearful. This deficient practice resulted in the violation of Resident 1's right to be treated with respect and dignity, and free from emotional distress.

Inspectors wroteBased on observation, interview, facility policy review, the facility failed to implement their water management plan and failed to conduct an assessment to identify where bacterium Legionella and other waterborne pathogens could grow. This had the potential to affect all residents in the facility who consumed water.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure that six (Residents (R) 5, R9, R21, R33, R70, R148) of 12 residents reviewed out of a total sample of 36 residents for Advance Directives and/or their representatives were informed and provided written information to formulate an advanced directive upon admission to the facility. Failure to provide residents and/or their representatives with this information upon admission has the potential to result in residents' needs or wishes not being met.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or representative; and the Ombudsman with written notification of a facility-initiated transfers for five of six sampled residents (Resident (R) 2, R32, R96, R130, R148) reviewed for hospitalization out of 36 total sampled residents. This failure had the potential to affect the residents and/or their representative about the reason for the transfer and the resident's appeal rights.

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to ensure residents and/or their responsible party was given a written bed hold policy/notice at the time of their hospital transfer for four of six residents reviewed for hospitalizations (Resident (R) 2, R96, R130, and R148) out of a total sample of 36 residents. This failure had the potential for the residents to be denied return to their original room or denial of the resident returning to the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop comprehensive care plans that reflected the residents' current status for 10 residents (Resident (R) 5, R9, R21, R33, R70, R93, R96, R148, R161, and R420) of 38 sampled residents. The residents' care plans were developed; however, the care plan did not reflect the residents' right to refuse treatment (Do Not Resuscitate (DNR)) and did not reflect residents' sex offender registry status. These failures had the potential for staff not to be informed of residents' care needs or offender history of residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide and maintain a minimum of at least 80 square feet per resident in 32 of 73 rooms (Rooms 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49 and 50). This failure had the potential for residents to not have reasonable privacy or adequate space.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure there was a dialysis contract for two of six residents (Resident (R) 44 and R87) reviewed for dialysis of 36 sample residents. This has the potential to affect the residents overall care between the facility and dialysis center.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) was provided treatment and care in accordance with professional standards of practice when nurses did not act on the deterioration of Resident 1's physical condition, which included Congestive Heart Failure (is a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen) and edema (swelling caused by too much fluid trapped in the body's tissues) and weight gain. Facility staff failed to provide the necessary treatment, personalized plan of care, nutritional support, and the facility's Interdisciplinary team (IDT) did not collaborate to address the resident's critical medical needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurse immediately consulted with resident's physician during a significant change in resident's physical status for two of three sampled residents (Resident 1 and 2) when: 1. Licensed nurses did not immediately notify Resident 1's physician, after Resident 1 experienced a severe unplanned weight loss of 18 pounds (lbs- a unit of measurement) or 9.8% in 28 days; on 12/3/23 weighed 166 lbs. Nursing staff obtained weekly weights documenting the rapidly declining weights and did not notify the physician of the change in condition (CIC) in accordance with physician expectations and policy and procedure; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline resident-centered care plan was developed and implemented for two of three sampled residents (Resident 3, and 4) when: 1. Resident 3 did not have a care plan for chronic obstructive pulmonary disease (COPD- lung disease making it difficult to breathe) until after being discharged from the facility and Resident 4 did not have a care plan until onsite investigation. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services which met professional standards of quality for two of four sampled residents (Resident 3, and 4) when Licensed Nurses 's (LN)'s did not administer oxygen per physician's order for residents (Resident 3 and 4) when physician ordered parameters for oxygen administration were not followed. This failure had the potential for Resident 3 and 4 to receive inadequate amount of oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely revise and implement a person centered comprehensive care plan for one of 10 sampled residents (Resident 1) when Resident 1's care plan did not accurately reflect Resident 1's refusal for staff to consistently use a mechanical lift during Activities of Daily Living )ADL) transfer. This failure resulted in Resident 1 to experience a fall on (indicate the date) . Resident 1 complained of pain, sustained a fracture of the right femur and placed Resident 1 at risk to experience re-occurring falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility verbal abuse policy and procedure for one of four sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 3 reacted aggressively and told Resident 1, If I had my way, I would have straightened you out right now. This failure resulted in the violation of Resident 1's right to be free from verbal abuse and placed Resident 1 at risk to experience psychosocial trauma related to the incident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the results of the annual Recertification and Abbreviated survey results were posted in a readily accessible location for the residents and the public when 7 of 7 sampled residents (Resident 36, Resident 150, Resident 72, Resident 98, Resident 84, Resident 75, Resident 97) did not have access to the survey results. This failure denied Resident 36, Resident 150, Resident 72, Resident 98, Resident 84, Resident 75, Resident 97 and the public access to survey results.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare and distribute food safely when an undated opened bag of shredded cabbage was stored and ready for use in the walk-in refrigerator and an opened bag of flour was stored and ready for use in the pull out cabinet with no opened date. These failures had the potential to cause foodborne illness to residents, staff and visitors who were served meals from the kitchen.

Inspectors wroteDuring observation in Resident 62's room, on 4/22/19, at 9:21 a.m., Resident 62 was in bed and her call light was on the floor not within reach. During an interview with CNA 13, on 4/22/19, at 9:25 a.m., she stated Resident 62 was independent and yelled when she needed something. CNA 13 stated, [Resident 62's] call light had to be within resident reach at all time. During an observation on 4/22/19, at 10:17 a.m., in Resident 37's room, Resident 37's call light was on the floor and not within reach. During an interview with CNA 15, on 4/22/19, at 10:21 a.m., she stated, [Resident 37's] call light should be within the resident reach all the time. The facility policy and procedure titled Answering the call light dated 10/2010, indicated The purpose of this procedure is to respond to the resident's request and needs. General Guidelines . 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean and homelike environment for six of 80 sampled residents (Residents 26, 42, 44, 51, 125 and 133) when their shared restroom remained accessible for use after having smeared feces on the toilet seat, toilet bowl and on the floor. These failures resulted in an unsanitary and unhomelike environment for Residents 26, 42, 44, 51, 125 and 133

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedure titled Medication Storage in the Facility and Labeling of Medication Containers when: 1. Artificial eye drops and ear wax removal drops were stored together with no divider between the medications in the Central Supply room. 2. Two of two tuberculin solution vials (to test for tuberculosis, a bacterial infection affecting the lungs) were stored and ready for use with no open date nor expiration date on the vial. These failures had the potential to place residents at risk of receiving expired tuberculin solution, experience adverse reactions from expired medication and placed residents at risk for potential medication errors from the potential incorrect medication use or route when medications were not stored separately.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide 80 square feet per resident in multiple resident room for 33 of 74 rooms when there were two to three residents in a room that did not meet the square footage requirement. This practice failed to provide the resident in these rooms with 80 square feet of space and increased the risk for residents not to have enough space for mobility and to accommodate their personal belongings.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and sanitary environment for six of 80 residents (Residents, 51, 42, 125, 133, 26, and 44) when Resident 51, 42, 125, 133, 26, and 44's shared restrooms had feces stain on the toilet seat, sides and restroom floor. This failure resulted in unsafe and unsanitary restrooms for Resident 51, 42, 125, 133, 26, and 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 80 sampled residents (Residents 16 and 116) were treated with dignity and respect in an environment that promoted and enhanced their self esteem when: 1. Resident 16's shirt was not changed after being soiled and stained from spilled drink and food particles. For Resident 16 this failure placed him at risk for feeling embarrassed from being left with soiled clothes. 2. Resident 116's urinary catheter (a catheter inserted into the bladder through the urethra to allow urine to drain) bag was left uncovered. For Resident 116 this failure placed him at risk for feeling embarrassed from an exposed urinary catheter drain bag.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 74) was free from physical abuse when Resident 112 tossed her cup of iced tea at Resident 74 five times in a period of 11 months. The interdisciplinary team (IDT) (team composed of a nurse, social worker, activity staff and physician) did not implement effective interventions to address Resident 112's known behavior of impulsivity and did not implement interventions to keep Resident 74 safe. This failure resulted in Resident 112 feeling afraid, emotional distress and the potential to cause serious physical injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure services provided met professional standards of practice for one of 13 sampled residents (Resident 119 when: Resident 119's nasal cannula (a plastic tubing used for the delivery of oxygen through the nose) tubing did not have a date label (start date) as ordered by the physician and medications were administered crushed without having a physician's order to administer crushed medications. These failures placed had the potential for Resident 119's nasal cannula to be used for more than the ordered number of days and placed Resident 119 at risk to experience stomach upset from the administration of crushed medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services to maintain personal hygiene for one of 80 sampled residents (Resident 16) when Resident 16's shirt was visibly soiled from breakfast and was not changed. This failure resulted in Resident 16 not receiving assistance in dressing which resulted in her wearing a visibly soiled shirt.

Inspectors wroteBased on observation, interview and record review, the facility failed follow their Foods Brought by Family/Visitors policy and procedure for residents' personal food storage when four apples and one mango were found in a plastic bag labeled for Resident 38 with no use by date in one of two resident refrigerators. This failure had the potential for Resident 38 to receive spoiled fruits and experience adverse side effects from ingesting spoiled fruits.