Marlora Post Acute Rehab Hosp

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents' (Resident 1 and 79) had current and accurate Advance Directives ([AD]-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) correctly in their medical records when:The facility failed to obtain a copy of Resident 1's AD despite documentation of acknowledgement, confirming and documenting the resident's wishes when the resident was deemed capable after another individual had signed the form. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for two of five sampled residents (Residents 6 and 8) with ROM concerns by failing to: 1. Ensure Resident 6's left shoulder and left elbow were objectively (unbiased, based on facts) measured and assessed after orthopedics (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) cleared Resident 6 for left shoulder and left elbow ROM exercises. 2. Ensure Resident 6's left wrist and left-hand ROM limitations were objectively measured during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 9/13/2025. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident receiving hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) resident's (Resident 11) blood pressure was not taken in the left upper extremity where Resident 11's arteriovenous (AV) shunt (a direct connection between an artery and a vein, bypassing the capillary network, which can be natural or surgically created for medical access) was located. These deficient practices had the potential to result in clotting (process that prevents excessive bleeding when a blood vessel is injured), damage, or inaccurate high readings.

Inspectors wroteBased on interview and record review, the facility failed to provide medically related social services (professional interventions provided by social workers to help residents manage the emotional, social, and financial impacts of illness) for two of six sampled residents (Resident 27 and Resident 49) as evidence by:A. Failing to ensure Resident 27 was seen by an ophthalmologist (a medical doctor specializing in eye and vision care, qualified to perform complex surgeries and treat severe eye diseases) as requested. B. Failing to ensure Resident 49 did not miss a Nerve Conduction Study (NCS-a test that measures how fast an electrical impulse moves through the nerve) and Electromyography (EMG- measures muscle electrical activity to identify nerve or muscle damage) procedure on [DATE]. This failure had the potential to result in delay in the delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records for two of five sampled residents (Residents 6 and 8) were accurately documented and readily accessible: 1. For Resident 6, the facility failed to:a. Ensure Resident 6's orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) consultation note was in the medical record and readily accessible.b. [...]

Inspectors wroteBased on interview and record review the facility failed to implement infection control policies and procedure (P&P) when:The facility failed to provide documented evidence of all employees, including physicians, Annual Influenza ([Flu] highly contagious respiratory infection) vaccine (medications used to prevent diseases usually given by injection or by mouth) status and the provision of education on benefits and potential side effects and offering of the 2025 to 2026 flu vaccine. The facility failed to ensure one of two residents' (Resident 39) foley catheter drainage bag (collects urine drained from the bladder via a tube) was kept off the floor. These failures had the potential to result in staff and residents contracting infectious diseases which can cause serious illness, hospitalization, and death.

Inspectors wroteBased on interview and record review the facility failed to ensure one of five sampled resident's (Resident 81) influenza ([flu] highly contagious respiratory infection) and pneumococcal (bacterial infection) vaccine (medications used to prevent diseases usually given by injection or by mouth) was administered timely after Resident 81 consented to receive the vaccines. This deficient practice resulted in a delay of services and placed the residents at risk of contracting influenza or pneumococcal disease.

Inspectors wroteBased on interview and record review the facility failed to implement infection prevention policies and procedures (evidence-based practices designed to prevent the spread of infections in healthcare settings, primarily following CDC guidelines) for one of one resident (Resident 81) when the facility failed to:1. Ensure Resident 81 Covid-19 (infectious disease resulting in mild to moderate respiratory illness) vaccine (medications used to prevent diseases usually given by injection or by mouth) was administered within 90 days after Resident 81 agreed to receive it. This failure had the potential to result in staff and residents contracting COVID-19 which can cause serious illness, hospitalization, and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 28 had an Interdisciplinary Team (IDT-group of healthcare professionals) meeting after a change of condition (COC) was identified for increasing delusions (holding a firm, false belief that is not based on reality) and paranoia (unfounded mistrust of others). This failure led to resident feeling ignored and distressed and violates his right to participate in person-centered care.

Inspectors wroteBased on interview, and record review, the facility failed to implement it's policy and procedure (P&P) , titled Change in a Resident's Condition or Status, for reporting a change in condition for one of three sample residents (Resident 1) to the physician when Resident 1's blood glucose levels exceeded 400 per deciliter (mg/dL- a unit measure for concentration of substances, normal blood glucose range 70-99 mg/dL) on 2/6/2026, 2/8/2026, and 2/22/2026. This failure placed Resident 1 at risk for treatment and services for high glucose levels and had the potential to lead to adverse health outcomes, including dehydration, kidney failure and ketoacidosis (breakdown of fat in the body that leads to acid in the blood).

Inspectors wroteBased on interview and record review the facility failed to ensure one of one 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 observation, interview, and record review, the facility failed to implement a care plan for one of five residents (Resident 89) by failing to inform Resident 89 of the risks and consequences of refusing to take Keppra ([generic name - levetiracetam] a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) as indicated in Resident 89's care plan. This deficient practice failed to explain to Resident 89 about the risk of seizures due to refusal of Keppra and had the potential of causing seizures, falls and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of five sampled residents (Residents 6) by failing to follow up with an orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) consultation appointment for Resident 6's left humerus (upper arm bone) fracture (broken bone) per consulting physician's recommendations. This deficient practice resulted in a delay of Resident 6's care and had the potential for worsening of the fracture, delayed healing, and a decline in mobility (ability to move), range of motion (ROM, full movement potential of a joint), activities of daily living (ADL, basic activities such as eating, dressing, toileting), physical comfort and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of one sampled resident (Resident 11) with a nephrostomy tube (thin, flexible catheter inserted through the back into the kidney to drain urine directly into an external bag) had documented evidence of assessing and monitoring of the urine for signs and symptoms of infection. The deficient practice had the potential to result in urinary tract infections ([UTI] an infection in the bladder/urinary tract).

Inspectors wroteBased on interviews and record review, the facility failed to ensure a physician assessed one of three sampled residents (Resident 1) within 72 hours after admission. This failure resulted in a delayed physician assessment which placed Resident 1's health status and safety at risk for timely medical interventions.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one resident (Resident 6) was followed up by a psychologist (medical doctor who can diagnose and treat mental health conditions) as ordered by the resident's primary physician. This failure resulted in Resident 6 not receiving a psychology follow-up while in the facility to attain mental and psychosocial well-beingFindings:During a review of Resident 6's admission Record (Face Sheet), the admission Record indicated the facility originally admitted Resident 6 on 5/06/2022 and was re-admitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool), dated 1/26/2026, the MDS indicated Resident 6's cognition (ability to think and make decisions) was moderately impaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure one of five residents' (Resident 36's) instructions for holding parameters on medication bubble pack (sealed card containing individual, daily, or weekly doses of medication in clear, push-through plastic bubbles) for amlodipine (a medication used to treat hypertension [HTN - high blood pressure] and heart conditions) matched with physician's order, before medication administration during medication pass observation. 2. Ensure one of five residents (Resident 62's) polyethylene glycol powder (a medication in powder form used to treat constipation after being dissolved in a specific amount of water) was dissolved in the correct volume of water, in accordance with physician's order and manufacturer's specifications while preparing for administration during medication pass observation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure one of five residents (Resident 36's) five (5) medications that included amlodipine (a medication used to treat hypertension [HTN - high blood pressure]), gabapentin (a medication used to treat nerve pain), carvedilol (a medication used to treat HTN), lidocaine patch (a medication applied on skin to treat localized pain) and docusate sodium (a medication used to treat constipation) were secured and not left unattended on bedside cart with the resident during medication pass observation.2. Ensure that the discarded medications in two of two inspected medication carts (Station 1 Morning Medication Cart 1 also known as split cart and Station 2 Medication Cart 4) were stored in a closed-lid container and/or disposed of in an irretrievable, safe and secure manner. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure Dietary Staff 1 (DS 1) changed gloves to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, and viruses) in between tasks for 91 out of the 99 residents in the facility. This deficient practice had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Discharge Summary/Post Discharge Plan of Care was provided to the receiving Skilled Nursing Facility (SNF) for one of three sampled residents (Resident 1) when Resident 1 was transferred and/or discharged on 12/11/2025. This deficient practice resulted in the receiving facility obtaining incomplete medical records for Resident 1 and had the potential for Resident 1's discharge care instructions to be overlooked, which could delay the continuity of care at the receiving facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the California Department of Public Health (CDPH) was notified within 24-hours when the facility had a Covid (a highly contagious disease caused by the coronavirus SARS-Cov-2 spread by droplets from coughing, sneezing or talking) outbreak on 10/16/2025 for two of two sampled residents (Residents 3 and 10) and one facility staff. This deficient practice resulted in an increase of Covid positive residents and staff without CDPH knowledge and oversight and had the potential for the Covid to continue spreading amongst residents, staff and visitors due to possible ineffective infection control practice.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who had diagnoses of congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease with acute exacerbation ([COPD] a chronic lung disease causing difficulty in breathing), chronic respiratory failure (a long-term condition where the lungs cannot supply enough oxygen to the blood or remove enough carbon dioxide) and dependence on supplemental oxygen (O2) was not administered a narcotic (a substance used to treat moderate to severe pain by binding to opioid receptors in the central nervous system)-analgesic (a drug or agent used to relieve pain, acting as a painkiller); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of four sampled residents (Residents 10, 30, and 40), who smoked cigarettes, and required safety precautions when smoking which included wearing smoking aprons (a fireproof covering worn over the chest and lap to protect a person and their clothing from burn holes caused by dropped cigarettes, cigars, or ashes), wore the smoking aprons while smoking. This deficient practice has the potential to place Residents 10, 20, 30, and 40 at risk for burns and/or injuries related to smoking.

Inspectors wroteBased on interview and record review, the facility failed to create a care plan for two of four sample residents (Resident 30 and 40) related to Resident 30 and 40 being smokers. This deficient practice places Resident 30 and 40 at risk for injuries or accidents related to smoking.

Inspectors wroteBased on interviews and record reviews, the facility did not ensure that a resident received medication as prescribed by the physician for two out of four sampled residents (Residents 1 and 3). This deficient practice had the potential to place Resident 1 and 3 at risk of receiving unnecessary medication.

Inspectors wroteBased on interview and record review, the facility did not implement and develop a resident-centered fall care plan for one of the five sampled residents (Resident 3). This deficient practice could adversely impact the resident's physical wellbeing and increase the risk of further falls and injuries.

Inspectors wroteBased on interview and record review the facility failed to ensure four out of eight sampled residents (Resident 6, Resident 26, Resident 29, and Resident 30) were free of a significant medication error. The facility failed to: 1. Ensure the licensed nurses checked Resident 6's heart rate prior to administering Amiodarone on as ordered 13 times from 10/1/2024 to 10/31/2024, and 13 times from 11/1/2024-11/20/2024. 2. Ensure Resident 26's Mexiletine (medication for the treatment of life-threatening heart disease including ventricular arrhythmias [an irregular heartbeat], such as sustained ventricular tachycardia [a rapid, irregular heartbeat], a life-threatening arrhythmia [an irregular heartbeat) 150 milligrams ([mg] a unit of weight measurement) was administered every eight hours as prescribed by the cardiologist (heart doctor [MD 2]). 3. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance committee ([QAA] a group of facility staff who identifies, evaluates, and implements measures to improve the quality care and life for the residents in the facility) and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to identify concerns related to significant medication errors (a preventable event that jeopardizes a patient's health and safety) in the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two out of two sampled staff, Licensed Vocational Nurse (LVN) 2 and 3, received mandatory training of effective communications upon hire. This failure had the potential to result in staff with poor communication skills and may negatively affect the residents' quality of care.

Inspectors wroteBased on interview and record review the facility failed to ensure two out of two sampled staff, Licensed Vocational Nurse (LVN) 2 and 3, received mandatory training of Quality Assurance and Performance Improvement (QAPI- systematic and interdisciplinary approach to maintaining and improving safety and quality in nursing homes while involving residents and families in practical problem solving) upon hire. This failure had the potential to negatively affect the residents' quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents medical records were up to date as per the facility's policy and procedure (P/P) titled, Advance Directives ([AD], a legal document of a resident's wishes regarding medical treatment) for two of six sampled residents (Residents 38 and Resident 86). This deficient practice violated the residents' rights to be fully informed of the option to formulate an AD and had the potential to cause conflict with the residents' wishes regarding health care in the event residents became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff. a. [...]

Inspectors wroteBased on interview and record review the facility failed to notify two of eight sampled resident's (Residents 6 and 26) primary care physician immediately when: a. Resident 6, who had a diagnosis of Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and received insulin (a hormone which lowers the level of glucose [a type of sugar in the blood] had a blood sugar reading of 508 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount)/deciliter (dL- a metric unit of capacity) on 11/17/2024. This deficient practice resulted in Resident 6's physician being unaware of Resident 6's elevated blood sugar (BS) level and had the potential for a delay in treatment interventions to decrease Resident 6's BS level. [...]

Inspectors wroteAMENDED 1/2/2025 Based on interview and record review the facility did not protect three of three sampled resident (Resident's 62 and 69) from abuse and neglect: The facility failed to: 1a. Report alleged abuse of Resident 69 by Resident 1 b. Ensure Resident 69 was safe from Resident 1 after alleged abuse. c. Monitor Resident 1 and 69 for alleged abuse. 2a. Ensure Resident 146, who was aggressive and combative toward staff on 8/15/2024 was sent out to a general acute care hospital (GACH) on a 5150 (temporary, involuntary psychiatric commitment of residents who present a danger to themselves or others due to signs of mental illness) hold, was not placed in the in front of the nursing station around other residents. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of physical abuse involving two of four sampled residents (Resident 146 and 62), to the California Department of Public Health (CDPH) within the regulated time frame of two hours. This deficient practice resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of physical abuse and submit the investigation report involving two of four sampled residents (Resident 146 and 62), to the California Department of Public Health (CDPH), within 5 days of the incident. This deficient practice resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two residents (Resident 62 and 146), who was diagnosed with post-traumatic stress disorder (PTSD - mental health condition that can develop after someone experiences or witnesses a traumatic even), received trauma informed care (a model that aims to provide effective mental health services by considering a person's past experiences with trauma). This deficient practice had the potential to result in resident re-traumatization and can be detrimental for the resident's psychosocial status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed nurses were competent during medication administration for four out of eight sampled residents (Resident 6, 26, 29, and Resident 30). These deficient practices resulted in Resident 6, 26, 29, and Resident 30 having significant medication errors and had the potential for all residents in the facility to experience medication errors. (Cross Reference to F760 and F865)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an Interdisciplinary Team ([IDT] team members from different departments working together, to set goals, make decisions that ensure residents receive the best care) Care Conference meeting, involving one of three sampled residents (Resident 86) was initiated after Resident 86 had been to multiple eye doctor appointments and neither staff nor resident were aware of the outcome from the appointments. This deficient practice violated Resident 86's right to be an active participant in the IDT meeting to discuss his plan of care and services with the IDT members and possible delayed discussion of needed care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan for poor/decline in vision for one of three sampled residents (Resident 86). This deficient practice had the potential to negatively affect the quality of life and wellbeing for Resident 86 and to prevent him from achieving his highest practicable well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one resident's (Resident 70) diclofenac sodium external gel (medication for pain) order indicated the dose. This deficient practice resulted to Resident 70's diclofenac was administered from 11/17/2024 to 12/3/2024 without a documented dose which had the potential for overdosing or underdosing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was provided a foley catheter (a thin, flexible tube that drains urine from the bladder into a bag outside the body, also called urinary catheter or indwelling urethral catheter) care to prevent recurrent urinary tract infections ([UTI], a bacterial infection that affects the urinary tract, which includes the bladder, ureters, and kidneys) for one of two sampled resident (Resident 25). This deficient practice had the potential to result in Resident 25 acquiring recurrent UTIs when foley catheter care was not provided according to the doctor's order.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one resident (Resident 45) was receiving the correct concentration of oxygen. This failure has the potential to result in too much oxygen which can cause serious health problems.

Inspectors wroteBased on interview and record review the facility failed to monitor one of two resident's (Resident 146) behaviors while prescribed psychotropic medications (medications can alter brain chemistry, impact body functions, and modify a person's thoughts, moods, feelings, awareness, and perceptions). This failure had the potential to result in unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three resident's (Resident 70) medication was not left on top of the medication cart unattended. This failure had the potential to result in visitors, residents, and staff unauthorized access to Resident 70's medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for 2 of 3 sampled residents (Residents 14 and 69) by failing to: Sanitize the Mechanical lift between caring for Resident 14 and Resident 69 This deficient practice had the potential to spread infections to other residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services to prevent a fall for one of three sampled residents (Resident 1) by failing to ensure: 1. Certified Nursing Assistant (CNA) 1 provided a two-person physical assist (help from two persons) when using a Mechanical Lift (a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from the wheelchair to the bed. 2. Implement the facility policy titled Mechanical Lift indicated a Mechanical Lift is used appropriately to facilitate transfers of residents. At least two people are present while the resident is being transferred with the Mechanical Lift. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two of three sampled residents (Resident 2 and Resident 3) resident rights were upheld and protected when the Administrator (ADM) failed to speak to Resident 2 and Resident 3 in a respectful manner that maintained the resident's dignity, privacy, and individuality. This deficient practice resulted in Resident 2 and Resident 3 feeling anxious, powerless, frustrated, humiliated, angry and distrustful toward the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff called 911 immediately to activate Emergency Medical Services ([EMS] a system that responds to emergencies in need of highly skilled pre-hospital clinicians), delegate staff to retrieve the facility's crash cart (a mobile cabinet that contains equipment and medications used to treat patients in a medical emergency) and obtain a non-rebreather mask (a device that delivers a large amount of O2, between 10 to 15 liters per minute [LPM]) to deliver an effective amount of oxygen (O2), when one of three sample residents (Resident 1), was observed choking while eating and required emergency assistance. [...]

Inspectors wroteBased on interview and record review, the facility failed to document the care provided to one of three sampled residents (Resident 1), who was observed choking while being fed at dinner time, and who required a licensed nurse (LVN 1) to perform the Heimlich maneuver (a first aid and lifesaving technique used to help someone who is choking) on him. This deficient practice resulted in Resident 1's medical record having no documentation to show Resident 1's condition following a choking episode and the care provided to him. This deficient practice had the potential for non-continuity of care to Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled resident ' s (Resident 1) grievance (complaints regarding treatment, care, management of funds, lost clothing, or violation of rights) regarding Resident 1 ' s missing cellphone was resolved to the satisfaction of the resident and representative. This deficient practice violated the resident ' s right to have his grievance resolved promptly with Resident ' s 1 satisfaction.

Inspectors wroteBased on interview and record review, the facility failed to notify a family member on a timely manner when there was a change of condition (COC) for one of one sampled resident (Resident 3). This deficient practice had the potential to affect the resident's care being provided when there is a change of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate the resident for possible injuries obtain and record assessment and notify physician when resident was found on the floor the morning of 1/14/2024 for one of three sample residents (Resident 1) This failure had the potential to result in delayed provision of necessary care and services for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure two of 20 sampled residents (Resident 7 and Resident 33) was properly and adequately assessed for pain and provided with pain medication timely. This failure resulted in Resident 7 and Resident 33 experiencing unnecessary pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (% per hundred). Three medication errors out of 25 total opportunities contributed to an overall medication error rate of 12 % affecting one of three residents observed for medication administration (Resident 7) The deficient practice of failing to administer medications correctly increases the risk for residents to have additional health complications and could have negatively impacted their health and well-being. During a review of Resident 7's admission record, the admission recorded indicated Resident 7 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper Infection control practices were followed by: a. wearing appropriate personal protective equipment (PPE) prior to entering contact isolation room of 1 of 3 residents (Resident 190). b. perform hand hygiene while administering medication to Resident 51. c. Resident 81's indwelling catheter (or known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag is not touching the floor. These deficient practices had the potential to spread diseases and infection to other residents. This deficient practice resulted in contamination of the resident's care equipment and placed the residents at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) Preadmission Screening and Resident Review (PASRR: a tool that is used to identify evidence of serious mental illness) Level I assessment screening was accurately documented. This deficient practice placed the resident at risk of not receiving the appropriate care and services needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled residents (Resident 188) received Oxygen at 4Liters (L - unit of measurement of volume)/minute (min) via Nasal Canula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) continuously as ordered by the physician for a diagnosis of shortness of breath (SOB). This deficient practice had the potential for Resident 188 to experience complications due to lack of oxygen and shortness of breath.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of 20 sampled residents (Resident 15) had an appointment and transportation for a dental recommendation intended for new dentures was arranged since 7/13/2023. This failure resulted in Resident 15 not being able to chew food adequately and had the potential to result in weight loss and low self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to implement the grievance (complaint) policy for one of one resident (Resident 1) when Resident 1 filed a grievance on 9/6/2023 regarding waiting 2 hours for his call light to be answered and there was no investigation or resolution done. This deficient practice violated the residents' right to have his grievance addressed. Findings During a review of Resident 1's admission Record, the record indicated an admission date of 11/22/2022 with the diagnoses including depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) and end stage renal disease (last stage of long-term [chronic] kidney disease, when the kidneys [organ that filters waste from the body] can no longer support the body's needs). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) provided toileting assistance and change the incontinence brief of one of one resident (Resident 3) after the resident had diarrhea (liquid stool). This deficient practice resulted in Resident 3 waiting for 45 minutes with diarrhea in their incontinence brief and delayed Resident 3 from leaving to go to the resident's dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) appointment. Findings During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE] with the diagnoses including end stage renal disease (when the kidneys [organ that filter waste from the body] can no longer support the body's needs). [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor the aggressive behavior of one of two residents (Resident 1) after Resident 1 was found grabbing Resident 2's hands. This deficient practice had the potential to negatively affect the resident's psychological wellbeing and placed other residents at risk for abuse from Resident 1. Findings During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow Resident 4's food preferences when Resident 4 received a pulled pork sandwich and baked beans, when Resident 4's diet card stated Resident 4 preferred two peanut butter and jelly sandwiches for lunch. This deficient practice had the potential to result in decreased meal intake by Resident 4 and can lead to weight loss and malnutrition (not enough nutrients). Findings During a review of Resident 4's admission Record, the record indicated an admission date of 11/22/2022 with the diagnoses including depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) and end stage renal disease (last stage of long-term (chronic) kidney disease, when the kidneys [organ that filters waste from the body] can no longer support the body's needs). [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to implement care plan interventions for one of two sampled residents (Residents 1 ) who were at risk for falls. This deficient practice had the potential to result in injury.