Manchester Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to investigate when one of seven sampled residents (Resident 1) found a condom (rubber used for safety during sexual intercourse to prevent pregnancy and sexually transmitted diseases) on her bed. This failure had the potential for the facility to not identify nonconsensual (non-consented) sexual activity in the building, violate Resident 1's right to privacy and placed the resident and other residents at risk for potential non-consensual (non-consented) sexual abuse.

Inspectors wroteBased on interview and record review, the facility failed to review and act on the Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) conducted for all facility residents on 12/10/2025. This deficient practice resulted in delays to adjustments to multiple residents' medications and/or plans of care due to lack of physician notification of the facility's consultant pharmacist's recommendationsFindings: During a review of the facility's Medication Regimen Review (MRR), dated 12/20/2025, the MRR indicated the facility's consultant pharmacist made recommendations for 24 of the 44 residents reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the privacy curtain and window closed during medication administration for one of six sampled residents (Resident 14). This deficient practice had the potential to compromise Resident 14's dignity, privacy, and emotional well-being during the provision of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the administration of Depakote ([psychotropic medication] -a medication that affect the mind, emotions, and behavior) was completed for one of three sampled residents (Resident 2). This deficient practice resulted in the violation of Resident 2's right to make an informed decision regarding the use of psychotropic medication and had the potential for increased risk of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) leading to impairment or decline in Resident 2's mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the wall next to a residents' bed was maintained in good repair for one of six sampled residents (Resident 10). This deficient practice had the potential to negatively impact Resident 10's comfort and well-being and contributed to an environment that was not consistent with a clean, safe, and home-like setting.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of six sampled residents (Resident 14, Resident 1, and Resident 52) were free from chemical restraints when staff failed to: 1. Ensure Resident 1 and Resident 52's as needed (PRN) psychotropic medications (drugs that affects mental processes) were limited to an administration period of 14 days. 2. Document attempted gradual dose reductions (GDR, the stepwise tapering of a medication dose to determine if symptoms can be managed by a lower dose or if the medication can be discontinued) for Resident 14's fluoxetine (medication to treat depression) and olanzapine (antipsychotic medication). 3. Develop and document non-pharmacological interventions provided to Resident 14 for her behavioral manifestations, from 2/2/2025 to 11/24/2025, for which staff administered fluoxetine and olanzapine. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code Section N of the Minimum Data Set (MDS, a resident assessment tool) for one of 12 sampled residents (Resident 14). This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS, the federal agency that runs the Medicare, Medicaid, and Children's Health Insurance Programs, and the federally facilitated Marketplace) regarding Resident 14's health status and increased the potential for Resident 14 to not receive the care and services to address the medications she was receiving.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one sampled resident's (Resident 6) Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder are placed in facilities that can provide the appropriate care) was filled out to indicate an existing psychiatric condition. This deficient practice had the potential to result in improper placement and unidentified specialized services for Resident 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review ([PASRR] - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) screening was completed for one of six sampled residents (Resident 1), who had diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), upon admission. This deficient practice had the potential to result in Resident 1 not receiving a required evaluation and identification of the resident's need for specialized mental health services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for three of 18 sampled residents (Residents 1, 32, and 5 ), by failing to:Develop and implement care plan interventions for Resident 1's diagnoses of major depression major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety (a feeling of fear, dread, and uneasiness). Develop and implement care plan interventions for Resident 1's use of Buspirone (an antianxiety medication). Develop and implement care plan interventions for Resident 32's risk for falls and convulsions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain fingernails clean and neat for one of six sampled residents (Resident 18). This deficient practice had the potential to result in a negative impact on Resident 18's quality of life and self-esteem and had the potential for development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment were provided with professional standards of practice for two of three sampled residents (Residents 3 and 14) by failing to ensure:1. Resident 3 and 14's tube feeding bottles were correctly labelled.2., Staff verified Resident 14's gastrostomy tube ([g-tube]- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement and patency prior to medication administration. These deficient practices had the potential to place Residents 3 and 14 at risk for unsafe care, improper treatment administration, and avoidable complications and serious medical complications requiring medical intervention and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, therapeutic support surfaces designed to prevent and treat pressure ulcers [PU, localized damage to the skin and/or underlying tissue usually over a bony prominence]) was set to the correct weight setting for one of two sampled residents (Resident 3). This deficient practice created the potential for Resident 3 to develop a PU.

Inspectors wroteBased on interview and record review, the facility failed to ensure accident hazards were identified and care planned for two of four sampled residents (Resident 14 and Resident 32) when: 1. Staff did not conduct quarterly fall risk evaluations for Resident 14. 2. Staff did not develop care plans for Resident 32's high fall risk and diagnosis of convulsions (sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). This deficient practice increased the potential for Resident 14 to experience falls and fall-related complications. This deficient practice also increased the likelihood that Resident 32 would not receive the care and services required to prevent falls, and to prevent convulsions and/or complications from convulsions (e.g., falls, injuries).

Inspectors wroteBased on interview, and record review, the facility failed to ensure trauma-care evaluation was conducted for one of one sampled resident's (Resident 5) who had a history of trauma (a lasting emotional response to distressing events that overwhelm a person's ability to cope, causing fear, helplessness, and shattered safety). This failure had the potential to result in Resident 5 experiencing re-traumatization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure signage for enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs]) and personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) were placed outside of the room for one of 12 sampled residents (Residents 3). This deficient practice increased the potential for spread of infection to Resident 3 and other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident had 80-square feet (sq. ft., a unit of area measurement) of living space in Rooms: 101, 102, 103, 104, 105, 107, 109, 111, 112, 114, 115, 117, 201, 202, 203, 204, 205, 207, 209, 211, 212, 214, 215, and 217. This deficient practice increased the potential for facility residents to be unable to move around freely, and also increased the potential for staff to have difficulty providing high quality care due to a lack of space.

Inspectors wroteBased on interview and records review, the facility failed to create an individualized care plan and implement interventions to prevent, one of three sampled residents, Resident 1, who was identified on admission with a significant actual risks for wandering (traveling/ walking from place to place, especially without any clear aim or purpose) and elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision), from leaving the facility unsupervised. This deficient practice without an individualized intervention resulted in Resident 1 leaving the facility on 1/30/2026, between 8:30 pm and 8:45 pm, undetected and was later found at a recovering unit in a general acute care hospital (GACH) after 2 days (2/2/2026).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision for 2 of 6 sampled residents (Residents 2 and 3), who were assessed as requiring supervision while smoking. This failure had the potential to cause accidental burns and injuries to Residents 2 and 3.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent for psychotropic medications (drugs that alter brain chemistry to manage mental health conditions like depression, anxiety, schizophrenia) prior to administering psychotropic medications to one of four sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for experiencing unexpected and/or unwanted adverse effects or complications from the medications, including increased risk of suicidal thoughts, cognitive impairment, and tardive dyskinesia (a chronic movement disorder that causes involuntary, repetitive movements in the body).

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR, a screening tool that helps identify possible serious mental illness [SMI], and if the resident requires specialized services) was submitted for one of four sampled residents (Resident 1). This deficient practice placed Resident 1 at risk of not receiving recommended or required treatments for diagnosed SMIs, or appropriate placement in a facility to meet Resident 1's needs.

Inspectors wroteBased on interview and record review, the facility failed to care plan the psychiatric (relating to mental illness or its treatment) diagnoses for one of four sampled residents (Resident 2). This deficient practice prevented facility staff from identifying and developing interventions to address Resident 2's behavior of striking out at others, due to his diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a low-air-loss-mattress (LALM, a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) as ordered to one of four sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for the development of pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence).

Inspectors wroteBased on interview and record review, the facility failed to obtain a written informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the resident and/or conservator (a person appointed by court to manage a person deemed unable to manage their life, such as health, and medical treatment) prior to treatment with Olanzapine (a psychotropic medication [a medication that affect brain activities associated with mental processed and behavior]) for one of four sampled residents (Resident 1). The deficient practice of failing to obtain informed consent prior to initiating treatment with psychotropic medication could have prevented Resident 1 from exercising their right to decline treatment with antipsychotic medications. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive care plan with interventions that addressing the resident's schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) for one of four sampled residents (Resident 1). This deficient practice had the potential to negatively affect Resident 1's physical well-being and placed the resident at risk of not receiving care and resident-centered interventions to meet and address Resident 1's needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Situation, Background, Assessment, Recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents) was completed for one of four sampled residents (Resident 1) when Resident 1 had a change of condition and eloped (the act of leaving a facility unsupervised and without prior authorization) on 7/1/2025. This deficient practice had the potential to result in miscommunication among staff and Resident's 1 attending physician to have a detailed explanation of what happened to Resident 1 before he eloped on 7/1/2025, and lack of appropriate response.

Inspectors wroteBased on interview and record review, the facility failed to provide emergency care (the provision of care for conditions that require rapid intervention to avoid death or permanent disability) to the resident, who had an altered mental status (a change in a resident's level of awareness, cognition, often indicating an underlying medical or neurological issue [any condition that affects the nervous system, including the brain, spinal cord, and nerves) and high blood pressure (BP- of 200/109 millimeters of mercury ([mmHg, a unit of measurement], reference range is120/80 or lower) to prevent intracerebral hemorrhage ([ICH] a type of stroke involving bleeding within the brain tissue) for one of four sampled residents (Resident 1). The facility failed to: 1. Assess Resident 1 immediately (instantly/ without delay) after Resident 1 had altered mental status on [DATE] at 2:14 p.m. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its Policy and Procedures (P&P) titled, Insulin Administration which indicated individual administering the medication must check to verify the right dosage before giving the medication, for one of 3 sampled residents, (Resident 1), by failing to: 1). Ensure Resident 1's physician's order for Insulin Glargine-yfgn (injection medication for diabetes) was correct. 2). Ensure Resident 1's blood sugar levels were documented in the resident's electronic medical record. These failures placed the resident at risk to receive high doses of insulin and had the potential to cause complications like severe hypoglycemia (low blood sugar), coma, hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet resident's needs for three of three sampled residents (Residents 1, 2 and 3) when Licensed Nurses: 1. Failed to administer medications within one hour of scheduled time for Residents 1, 2 and 3. 2. Failed to ensure the Catapres transdermal patch (medication applied to the skin to treat hypertension [high blood pressure]) was available and administered for Resident 1 as ordered by the physician. 3. Did not monitor Resident 1, 2 and 3 for side effects and vital lights as ordered by the physician. 4. Failed to document medication administration for Residents 1, 2 and 3. These failures resulted in Resident 1 feeling scared and sad. [...]

Inspectors wroteBased on interview and record review, the facility failed to promote the dignified existence and self-determination of 2 of 14 sampled residents (Resident 13 and 14) who required assistance with activities of daily living (ADLs), by failing to answer the resident's call lights in a timely manner. This deficient practice had the potential to result in Resident 13 and 14 feeling of angry for being ignored by nurses and could negatively affect the resident's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan for two of twelve sampled residents (Resident 7 and Resident 9) who were a high risk for elopement (the act of leaving a facility unsupervised and without prior authorization). This deficient practice had a potential to result in unidentified interventions which could lead to Resident 7 and Resident 9 eloping from the facility leading to accidents and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four exit doors were locked and had alarms turned on. This deficient practice had the potential to result in resident's eloping (the act of leaving the facility unsupervised and without prior authorization) leading to accidents and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to trim, three of six sampled Residents' (Resident 2, Resident 5 and Resident 6) long and dirty fingernails. This deficient practiced placed Resident 2, Resident 5 and Resident 6 at risk for infections, injury and bacterial growth under the fingernails.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1), did not wait 3 hours to get assistance from the Certified Nurse Assistant (CNA) 3 to get out of bed to the chair. This deficient practice had the potential to affect the resident ' s self-esteem, self-worth, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate Activities of Daily Living (ADLs) documentation for two of six sample residents, (Resident 1 and Resident 2). This deficient practice had the potential to cause miscommunication that ADLs were not provided to Resident 1 and Resident 2.

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

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure four out of five sampled employees had a completed orientation skills check list upon hire. This deficient practice had the potential to result in residents receiving substandard quality of care because staff had not been deemed competent through a skills assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the Nursing Hours Per Patient Day ([NHPPD]- a measure of the average number of hours of nursing care provided to each patient in a hospital or nursing facility) information was posted in an area that was easily viewable by residents/the public. This deficient practice had the potential to result in residents/the public not being aware if the facility had enough staff to provide safe/quality care.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure four out of eight sampled residents (Residents 4, 5, 10, and 24) had a Medication Regimen Review ([MRR]- a review of medications to identify problems/errors) completed monthly by the pharmacist. This deficient practice put Residents 4, 5, 10, and 24 at risk of having a drug interaction or being overmedicated.

Inspectors wroteBased on observation, and interview, the facility failed to: 1. Keep the dry food pantry area clean and free from food debris. 2. Ensure open packages of food are sealed and closed. 3. Ensure leaking food items in the freezer are cleaned up. These deficient practices had the potential for cross-contamination and can attract pests and rodents to the area.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure payroll-based journal (PBJ) data was submitted to CMS quarterly as mandated by the Centers for Medicare and Medicaid Services (CMS). This deficient practice prevented CMS from knowing if the facility was meeting required staffing levels for safe/quality patient care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure routine room temperature monitoring and documentation were in place to ensure medications were within the temperature ranges as specified by the drug manufacturers, in one of one medication storage room. 2. Label with an opened date one vial (a small container, usually made of glass or plastic used to store liquids) of Aplisol (a medication that is used as a diagnostic tool to help identify tuberculosis infections in individuals who are at a higher risk of developing the active disease) solution found at medication storage refrigerator. 3. Label with an opened date one vial of lorazepam (a medication indicated for treatment of anxiety) for Resident 9 found at medication storage refrigerator. 4. [...]

Inspectors wroteBased on interview, and record review the facility failed to: 1. Ensure one of two residents (Resident 21) had a physician order to transfer out to the hospital. This deficient practice had the potential to result in miscommunication amongst the facility staff and physician.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure Resident 21 had a Change in Condition Form completed when they had to be transferred to the general acute care hospital (GACH). This deficient practice had the potential for staff to miss appropriate monitoring and interventions for Resident 21.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Transmit the Minimum Data Set ([MDS] - a resident assessment tool) within 14 days after completion to Center of Medicare and Medicaid Services (CMS) for two of 12 sampled residents (Resident 29 and 34). This deficient practice had the potential to result in billing error and inaccurate data on resident care needs.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one out of four sampled residents (Resident 40) received a Pre-admission Screening and Resident Review ([PASRR] - 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 II assessment. This deficient practice had the potential to result in Resident 40 not receiving the required services for her mental health condition.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Develop a care plan for a peripherally inserted central catheter (PICC- a thin, soft tube that is placed into a vein, usually in the upper arm to deliver fluids or medication) line for one of three sampled residents (Resident 18). This deficient practice had the potential to result in a lack of meeting necessary care goals.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Ensure one out of three sample residents (Resident 21), had vital signs taken every shift as ordered by the physician. This deficient practice had the potential for Resident 21 to experience a delay in interventions if there were any significant changes in their vital signs.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a vision care service was provided for one of one sampled resident (Resident 15). This deficient practice had the potential to result in Resident 15's worsening of eye vision that would negatively affect his quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure resident with long thick elongated (nail plate grows linger than the nail bed) toenails received podiatry (profession dealing with the specialized care of the feet) care services for one of one sampled resident (Resident 24). This deficient practice had the potential to result in foot discomfort, infection, and decline in physical mobility for Resident 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one out of one resident (Resident 18) had their peripherally inserted central catheter (PICC- a thin, soft tube that is placed into a vein, usually in the upper arm to deliver fluids or medication) line monitored and the dressing changed as indicated. This deficient practice had the potential for staff to miss any complications associated with a PICC line and for Resident 18 to experience a delay in interventions.

Inspectors wroteBased on observation, and interview, the facility failed to: 1. Ensure one of one sampled residents (Resident 195), had a dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit at the bedside. This deficient practice had the potential for Resident 195 to experienced delayed interventions due to bleeding of the dialysis site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a Narcotic Count Record (a log signed by licensed nurses during shift change endorsing over responsibility for the controlled substances in the cart) was completed accurately. This deficient practice increased the risk of loss or diversion of controlled medication. 2. Ensure Resident 96's medications of Zinc Sulfate (vitamin mineral supplement used to treat or prevent low levels of zinc) and Olopatadine HCL Ophthalmic solution (an eye drops used to treat itching of the eye) are available in the medication cart. This deficient practice had the potential to result in harm to Resident 96 by not administering medication and following physician orders to meet resident individual medication needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure it was free of a medication error rate of five percent (5%) or greater, as evidenced by the identification of two out of 26 medication opportunities (observations during medication administration) for error, to yield a cumulative error rate of 7.69% for one of four sampled residents (Resident 96) observed during the medication administration facility task by failing to: 2. Administer Resident 96's Zinc Sulfate (vitamin mineral supplement used to treat or prevent low levels of zinc) and Olopatadine HCL Ophthalmic solution (an eye drops used to treat itching of the eye) as prescribed by the physician. This deficient practice had the potential to result in harm to Resident 96 by not administering medication and following physician orders to meet resident individual medication needs.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 5) had a Complete Blood Count ([CBC] a blood test that measures the number and type of cells in your blood), and Comprehensive Metabolic Panel ([CMP] a blood test that measures 14 substances in your blood to provide an overall picture of your body's chemical balance) completed monthly per physician's order. This deficient practice resulted in a lack of required monitoring of Resident 5's health status.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Implement the antibiotic stewardship program (coordinated program that promotes the appropriate use of antibiotics by clinician) by failing to monitor and address antibiotic (a drug used to kill bacteria or to treat infection) use for one of one sampled resident (Resident 96) who was on antibiotic for pneumonia (infection of the lungs) was not evaluated upon admission to the facility. This deficient practice had the potential for Resident 96 to receive an inappropriate antibiotic and develop antibiotic resistance (when bacteria change and becomes resistant to antibiotic).

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure each resident had 80 sqft of living space in rooms 101, 102, 103, 104, 105, 107, 111, 112, 114, 115, 117, 201, 202, 203, 204, 205, 207, 209, 211, 212, 214, 215, 217. This deficient practice had the potential to result in residents not being able to move around freely or store personal items. Staff may also have difficulty providing care due to a lack of space.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of five sampled residents (Residents 1, 2, 3, 5) were free from accident and hazards by failing to: 1. Complete a Wandering and Elopement (leaving the facility unsupervised and without prior authorization) Risk Assessment for (Residents 1, 2, 3, 5) upon readmission to the facility and quarterly according to its policy and procedure (P&P) titled, Wandering & Elopement. 2. Ensure facility door alarms were always armed according to Resident 1 ' s care plan. 3. Maintain a photograph in the medical record for Resident 1 who was a risk of elopement, according to the facility ' s undated P&P titled Wandering & Elopement These failures had the potential to result in Residents 1, 2, 3, and 5 eloping from the facility, be exposed to harsh environmental conditions, motor vehicle accident, and death. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse (RN) in the facility for at least 8 consecutive hours a day, 7 days a week. This failure resulted in the facility not having an RN responsible to oversee the care provided by Licensed Vocational Nurses (LVN) or Certified Nurse Aides (CNA), conducting residents' assessments and placed all the patients' health and safety in jeopardy. Findings A review of the staff employee phone numbers, dated 4/12/2024, indicated the Director of Nursing (DON) was the only Registered Nurse (RN) in the facility. A review of the staff schedule, dated 4/2024, did not indicate the DON was scheduled on the weekends between 4/19/2024 until 4/30/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating , which indicated to report immediately suspicions of abuse to the state licensing/certification agency within two hours of an allegation of abuse. This deficient practice delayed the investigation by the CDPH and placed Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to prevent one of five sampled residents (Resident 2), from eloping (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) the facility on 4/23/2024. This failure had the potential for Resident 2 to be exposed to medical complications,motor vehicle accidents, hospitalization or death. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to develop a comprehensive person-centered plan of care for three of four sample residents (Resident 1, 2 and 3) for the Restorative Nurse Assistance (RNA) therapy as ordered by doctor. This deficient practice has the potential to result in a lack of provision of necessary care and potential for further decrease mobility and possible contractions (prolonged static positioning of the limbs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Sixty-four medication errors out of 82 total opportunities contributed to an overall medication error rate of 78 % affecting 17 out of 20 residents observed during medication administration (Resident 1, 2, 3, 4, 6, 8, 14, 15, 16, 18, 22, 25, 26, 35, 38, 44, and 99). The medication errors were as follows: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed vocational nurses (LVNs) administered medications and provided nursing services in a timely manner for three out of three residents (Resident 1, 2, and 15) This deficient practice resulted in delayed in care and services and had the potential for harm to residents when care and treatment was not provided in a timely manner and could had led to coma, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Monitor the expiration dates of over the counter (OTC) medications. 2. Monitor the expiration date of hygiene products such as denture cleanser, hand & body lotion, and hand sanitizer. 3. Monitor the expiration date of medical supplies such as syringes, Excelginate (non-woven calcium alginate dressing) wound dressing, and Isosource feeding (nutritionally complete tube feeding formula). This deficient practice had the potential to cause resident harm, due to the loss of effectiveness of the OTC medications and the potential of loss of strength of the hygiene products and medical supplies, and the potential for residents for skin irritation along with abdominal discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly clean their ice machine in the kitchen and properly store a bag of protein powder in the dry storage room. Thess deficiencies had the potential to cause foodborne illness to residents.

Inspectors wroteBased on interview and record review, the facility failed to submit the payroll-based journal quarterly as mandated by the Centers for Medicare and Medicaid Services (CMS). This deficient practice has the potential to cause the staffing data to not be accurate and quality of care could decline. Findings During a review of the Payroll-Based Journalling (PBJ) Staffing Data Report, dated 2/1/2024, the report indicated for the fiscal year of 2023 from October 1 until December 31, the facility failed to submit data for the quarter. During an interview with the Director of Nursing (DON) on 2/4/2024 at 1:59 p.m., the DON stated she did not know what the PBJ was, and she did not know who reported it. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of twelve sampled residents' (Resident 15 and Resident 32) medical records were updated to show documentation the Advance Directive (AD - legal document of a resident's wishes regarding medical treatment) was discussed, and written information was provided to the resident and/or responsible party (RP - individual responsible for making medical decisions for a resident). This deficient practice violated Resident 15's and Resident 32's and/or their RP's right to be fully informed of the option to formulate their AD and had the potential to cause conflict with the residents' and/or RP's wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 39 and Resident 46) fingernails and toenails were trimmed. This deficient practiced placed Resident 39 and Resident 46 at risk for an infection, injury, and bacteria growth of the fingernails and toenails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan for Restorative Nursing Aide (RNA) services for one of 25 sampled residents (Resident 18). This deficient practice had the potential to cause Resident 18 to have a decline of range of motion (ROM). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 15) received Admelog Solution ([insulin] medication used to treat elevated blood sugar) 100 unit/ml ([mg][ml] unit of measurement) and metformin HCL 850 mg at their scheduled time of 8:00 a.m. per standards of nursing. As a result of this failure, Resident 15 was without his blood sugar medication for three hours and twenty-four minutes which resulted in elevated blood sugars, and could have led to shakiness, fast heart rate, drowsiness, confusion, loss of consciousness, hospitalization, coma, and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 15 sampled residents (Resident 43) received prompt assistive devices to maintain vision abilities by not assisting in finding the prescribed eyeglasses (order written by an optometrist) since 11/2023. This failure had the potential to result in feelings of frustration when Resident 43 was unable to adequately read and watch television (TV).

Inspectors wroteBased on observation, interview and record review, the facility failed to document the administration of a controlled medications (medications that are regulated by a government), Norco (an opioid pain medication) 10-325 milligrams (mg-unit of measurement), and Tramadol (an opioid pain medication) 50 mg in the medication administration record (MAR) and in the narcotic log for two of three residents (Resident 1, Resident 2) as indicated in the facility policy. This failure resulted in a discrepancy between Resident 1 ' s and Resident 2 ' s narcotic log sheet and MAR and had the potential of not only drug diversion but double dosing Resident 1 and Resident 2.