Meadowood Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to revise and implement a comprehensive, person-centered care plan following a significant change in condition for one of three sampled residents (Resident 1) reviewed for falls. The facility's failure to revise Resident 1's fall interventions following the fall on 4/9/26 may have contributed to Resident 1 sustaining a subsequent fall on 6/7/26, resulting in a left hip fracture requiring hospitalization. Record review of Resident 1's face sheet indicated the resident was admitted to the facility in 5/22 and readmitted on [DATE] following hospitalization for a left hip fracture sustained during a fall on 6/07/26. Relevant diagnoses included unsteadiness on feet, difficulty walking and moving safely, history of falls, chronic pain, and major depressive disorder. [...]

Inspectors wroteBased on interview and records review, the facility failed to ensure one resident out of two sampled residents (Resident 1) was free from abuse when Resident 2 hit him on the left arm. This failure had the potential to result in physical injury and/or psychological issues that can cause further decline in the residents' already frail health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice were met for three of seven sampled residents (Resident 1, Resident 2 and Resident 4) when:1. Following falls, Resident 4's neurological assessments (an assessment of an individual's nervous system following a fall to help identify neurological injuries and measure the severity of damage caused by head trauma), alert charting, and post fall skin assessments were not completed as required by facility policy and nursing standards of practice,2. Resident 4's abnormal neurological assessment

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of seven sampled residents (Resident 1 and Resident 2) were protected from abuse when profanity and a physical altercation occurred between Resident 1 and Resident 2 during which Resident 2 kicked Resident 1 on the knee. The facility's failure to prevent and promptly intervene in the resident to resident altercation placed Resident 1 and Resident 2 at risk for physical harm, emotional distress, and an unsafe environment. Cross reference F658. A review of Resident 1's admission record indicated she was admitted to the facility in October, 2020 with medical diagnosis which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide quality of care for one of seven sampled residents (Resident 4) when a fall was not documented in his medical record, and the facility's fall protocol was not initiated status post (after) fall. Cross reference F658. These failures resulted in an unaddressed head injury, inadequate monitoring and implementation of the facility's fall protocol, and a delay in care for Resident 4. A review of Resident 4's admission record indicated he was admitted to the facility in January, 2026 with medical diagnosis which included multiple fractures of ribs (broken ribs), traumatic subdural hemorrhage (a life-threatening brain injury where blood collects between the dura mater [a protective layer of the brain] and the brain), and repeated falls. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, homelike environment when one of five sampled residents (Resident 1) had a soiled privacy curtain and food splattered on the ceiling above his bed. This failure made Resident 1 feel frustrated that facility staff were not doing their jobs to maintain a clean place for him to live. Review of Resident 1's face sheet (demographics) indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including cervical radiculopathy (a pinched nerve in the neck) and depression, among others. During an observation and concurrent interview on 4/28/26 at 12:25 p.m., Resident 1 pointed out a stain on the privacy curtain between his and his roommate's beds. Resident 1 stated the curtain had not been washed for over a year. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free of significant medication errors when Resident 1's order for suboxone (prescription medication used to treat opioid use disorder by reducing cravings and withdrawal symptoms) was not renewed timely and the medication was not available for administration. This failure had the potential to result in Resident 1 experiencing withdrawal symptoms (the physical and psychological symptoms that occur when stopping or reducing the use of addictive substances).

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) right to self-determination was honored when Resident 1 was not discharged from the facility per his request on 1/28/26. This failure left Resident 1 at risk for feeling upset and frustrated.

Inspectors wroteBased on interviews and record reviews, the facility failed to report a possible financial abuse for one out of two residents sampled for financial abuse (Resident 1), when facility staff suspected financial abuse by Resident 1's Care Giver (CG) that was not reported to law enforcement nor the State Agency (California Department of Health [CDPH]) .This failure could lead to Resident1 experiencing a loss of money and continued financial abuse.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure services provided met professional standards for one out of two residents sampled for professional standards (Resident 2), when Resident 2 was not provided an alternating pressure pad (APP, a specialized medical-grade mattress system designed to prevent and treat pressure ulcers in patients with limited mobility) as prescribed by the physician. This failure put Resident 2 at increased risk of developing or worsening pressure ulcers (PU, localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), which could cause severe pain, and infection.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure all drugs were in locked compartments for one out of four medication carts, when a medication cart was unlocked when it was unattended. This failure could result in access to medications by unauthorized people leading to medication theft and unauthorized medication ingestion with a risk of overdose, drug interactions, or severe adverse effects.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain infection control measures for two out of two residents sampled for infection control concerns (Residents 2 and 3) when:1. three pillows that were on the floor were picked up by the Licensed Nurse (LN) and placed back on Resident 2's bed; and2.the mouthpiece of Resident 3's nebulizer (medical device that converts liquid medication into a fine, breathable mist for direct inhalation into the lungs) was not kept in a clean, dry, and sealed container to prevent cross contamination (happens when bacteria or other germs are unintentionally transferred from one object to another). These failures could put the residents at risk for infection transmission, illness, and worsening of chronic conditions.

Inspectors wroteBased on interview and record review, the facility failed to properly care for one of three residents' (Resident 1) Peripherally Inserted Central Catheter (PICC line, a long, thin, flexible tube inserted into a peripheral vein and threaded into a large central vein near the heart to provide long-term access for administering medications, fluids, or blood products, and for drawing blood, reducing the need for repeated needle sticks) during several shifts by failing to follow flushing and monitoring protocols. This finding could have led to inability to maintain PICC line patency, the formation of blood clots which could have caused a stroke or heart attack, and a potentially life-threatening infection for Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure eight out of eight sampled residents (Resident 7, Resident 25, Resident 53, Resident 59, Resident 69, Resident 90, Resident 94 & Resident 95) were aware of how to file a grievance and had their complaints resolved when the facility had no current grievance process or appointed officer. In addition, complaints brought up during resident council meetings were not being tracked or responded to. This failure resulted in all eight residents feeling frustrated with the lack of facility response to their complaints. During a Resident Council Meeting on 1/07/26 at 11:00 a.m. in the dining hall, all eight residents present could not describe what the current grievance process was. The entire group expressed frustration with the lack of response to various concerns that had been brought up repeatedly. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review Level II evaluation (PASRR-following a Level 1 screening, the Level 2 evaluation determines appropriate placement of an individual with a serious mental illness, considering the least restrictive setting, and whether specialized services are needed) was completed for three of six sampled residents (Resident 23, Resident 41, and Resident 68), based on each Resident's documented psychiatric diagnoses and functional status. This failure had the potential for Resident 23, Resident 41, and Resident 68 to receive inappropriate and ineffective care/treatment, or to be inappropriately placed in a long-term care facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide face-to-face and in-person physician visits at least once every 60 days for six (6) of 12 sampled residents (Residents 5, 19, 23, 41, 98, and 99). This deficient practice had the potential to result in a decline in medical, health or psychosocial conditions and a delay in necessary care, treatment and services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food at a palatable temperature for three of eight sampled residents (Resident 90, Resident 7, & Resident 53) at a confidential resident council interview. This failure had the potential to cause loss of appetite and weight loss in a vulnerable population when food is too cold to be appetizing. During a resident council meeting on 1/07/26 at 11:00 a.m. in dining hall, 3 residents who resided in Hall 4 (Resident 90, Resident 7 & Resident 53) complained that the food was always cold because they were served last. A review of the resident council notes indicated that cold food was reported in 08/25, again in 11/25, and in 12/25. During a tray line observation in the kitchen on 1/07/26 at 12:05 p.m., the cook began to plate the food for the residents' lunch. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store residents' food when the two refrigerators used to store residents' personal food from outside the facility were not monitored for proper labeling or outdated items. This failure had the potential to cause food-borne illnesses. During an observation and concurrent interview on 1/06/26 at 2:20 p.m., Licensed Nurse (LN) B stated there was a refrigerator at each nurses' station that was for residents' foods brought in from outside the facility. The refrigerator for residents' foods at Nurses' Station 2 contained several items that were not labeled or were outdated. LN B stated Housekeeping Supervisor (HKS) was responsible for monitoring the foods in the refrigerators and throwing away foods when they needed to be thrown out. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents' private health information when lunch tray tickets containing residents' names and diet orders were found thrown in the garbage in the dining room. This failure had the potential for residents' private health information to be obtained by persons who did not have a need to know the residents' information. During an observation on 1/05/26 at 12:46 p.m. in the RNA (Name of dining hall) Dining Hall, resident tray tickets were observed in the trash can. During an interview on 1/08/26 at 2:45 p.m., the Assistant Director of Nursing (ADON) stated that no tray tickets should be in the trash as they contain protected health information. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the ombudsman's office (a public agency that provides free advocacy services for residents of nursing homes) of a transfer to the hospital for one of three residents sampled for closed record review (Resident 98). This failure had the potential to result in a lack of advocacy services for Resident 98. [...]

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) program for one of six sampled residents when Resident 5's Level I PASSR did not accurately reflect a serious mental disorder, and Resident 5 was not referred for a Level II PASRR (a level II PASRR screening determines appropriate placement of an individual with a serious mental illness, considering the least restrictive setting, and whether specialized services are needed) screening. This failure had the potential for Resident 5 to receive inappropriate or ineffective care, treatment, and services. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to initiate and implement a resident-centered nursing care plan for depression for one of six sampled residents (Resident 32). This failure had the potential to worsen or delay improvement of Resident 32's diagnosed psychiatric condition. A review of Resident 32's admission Record, indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body), hemiparesis (one-sided muscle weakness), and major depressive disorder (a serious mood disorder causing persistent sadness, loss of interest, and significant impairment in daily life). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 73), received services to maintain functional abilities when staff did not transfer him out of bed and into his wheelchair for an undetermined length of time. This failure had the potential to decrease Resident 73's functional mobility, which could have resulted in skin breakdown, and increased dependency on staff for Activities of Daily Living (ADL's, activities related to self-care such as bathing and toileting). [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure accurate documentation for one of six sampled residents (Resident 1), when Resident 1's Medication Administration Record (MAR) did not indicate the reason, a medication was not administered. This failure had the potential to cause physical discomfort and delayed healing of Resident 1's eye.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of nursing practice were followed for a census of 89 residents when:1: One resident's (Resident 1) medication was left by her bedside unattended by staff without a physician order for self-administration of medications,2: An undisclosed number of residents' medications were pre-prepared (a type of workaround, described as a delay between preparation and administration of a medication or the preparation of multiple medications for different residents) prior to administration, and;3: The Director of Nursing (DON) allowed the administration of pre-prepared medications to residents; fully aware they were unlabeled and had been pre-prepared. These failures increased the facility's potential for medication errors and for residents to experience a delay in care and treatment.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was protected from neglect when physician notification regarding her change of condition (COC, a significant shift in someone's physical, mental or functional state, requiring attention) was delayed. This failure resulted in Resident 1 to experience delays in care and required hospitalization for an unmanaged fever, altered level of consciousness (sudden changes in condition, awareness or consciousness (your subjective awareness to yourself and the world)) and sepsis (a life-threatening blood infection). Cross reference F761. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide one of five sampled residents (Resident 1) with nursing care in a manner that maintained his dignity and respect, when Registered Nurse 1 (RN 1):1. Did not cease performing a rectal (of, relating to, or situated near the rectum, which is the final section of the large intestine) treatment/procedure after Resident 1 complained of pain and asked RN 1 to stop.2. Did not ensure privacy during care/treatment which required Resident 1 to be partially unclothed from the waist down.3. Did not provide explanation of care/treatment to Resident 1 prior to performing an invasive (involving the introduction of instruments or other objects into the body or body cavities) rectal medication insertion. (See F552 for additional information). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) received care and services in accordance with professional standards of practice when:1. Registered Nurse 1(RN 1) performed a digital stool dis-impaction (a procedure to remove hardened, impacted stool from the rectum using a lubricated, gloved finger, which is inserted into the rectum to break up and extract the stool) procedure for Resident 1 without a physician's order.2. Facility did not provide licensed nursing staff (RN 1, Registered Nurse 2, Registered Nurse 3) sufficient education and training regarding rectal suppository (a small, solid medication plug designed to be inserted into the rectum. It melts and releases its medication into the bloodstream through the rectal wall) insertion and digital rectal stool dis-impaction (see F726 for additional information). [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse within two hours to the DEPARTMENT for one of five (5) sampled residents (Resident 1). This finding had the potential to result in inability for the DEPARTMENT to investigate and advocate for Resident 1's rights, and possible continuous abuse to Resident 1 and other residents of the facility. Record review of the facility Face Sheet (facility demographic) indicated Resident 1 was originally admitted to the facility on [DATE] with medical diagnoses which included post laminectomy syndrome (a condition, where part of the bone (lamina) covering the spinal cord is removed and causes persistent or recurring pain, tingling and numbness in the buttocks and legs) and constipation (a condition characterized by infrequent or difficult bowel movements). [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (Resident 1) of seven sampled residents from misappropriation of resident property when Resident 1 ' s debit card was used by Certified Nurse Assistant 1 (CNA 1). This failure resulted in Resident 1 feeling taken advantage of, and stupid.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was issued to 2 (Resident #244 and Resident #245) of 3 sampled residents reviewed for beneficiary notification.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to obtain a physician's orders for the use a respiration device for 1 (Resident #140) of 3 sampled residents reviewed for choices.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide adequate supervision and assistance to prevent a fall for one out of two sampled residents (Resident 1), when: 1. The facility's policy was not followed when Resident 1 was assisted by one staff only while using a mechanical lift to transfer Resident 1 from wheelchair to bed, and the policy indicated at least two nursing staff were needed to safely move a resident with a mechanical lift. 2. The staff completing the transfer for Resident 1 did not have a mechanical lift competency completed prior to Resident 1's fall incident on 3/21/24. These failures resulted in Resident 1 sustaining a fall on 3/21/24, resulting in a left femoral fracture (a break in the thigh bone).

Inspectors wroteBased on observations, interviews and records review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were free from accidents when: 1. The facility staff took more than five minutes to answer Resident 1 ' s call light (an alerting device for nurses or other nursing personnel to assist a patient when in need), when Resident 1 turned on his call light for assistance to use the toilet. This failure resulted in Resident 1 to fall on the floor twice while attempting to go to the toilet without staff assistance causing Resident 1 to sustain right arm fracture. 2. The facility staff did not ensure Resident 2 was supervised when smoking. This failure resulted in Resident 2 to sustain cigarette burns to his right thigh and right scrotum (The bag of skin that holds and helps to protect the testicles).

Inspectors wroteBased on interviews and records review, the facility failed to ensure one of three sampled residents (Resident 5) was free from pain and discomfort when Resident 5 who had left hip arthroplasty (also known as hip replacement - a surgical procedure to replace some or all of a joint) and Chronic Pain (pain that lasts for longer than 3 months) did not receive her ordered pain medication according to the scheduled administration time. This failure resulted in Resident 5 to experience excruciating pain to the point that she was in tears.

Inspectors wroteBased on observation, interviews and records review, the facility failed to ensure three of three sampled residents (Resident 6, Resident 5 and Resident 7) were given showers during their scheduled shower days. This failure to maintain Resident 6, Resident 5 and Resident7 ' s personal grooming and hygiene needs had the potential to raise the risk of unidentified skin issues, bacterial and fungal infections.

Inspectors wroteBased on observation, interviews and records review, the facility failed to ensure call lights (an alerting device for nurses or other nursing personnel to assist a patient when in need) were answered within five minutes per facility policy for two of three sampled residents (Resident 1 and Resident 3). This failure resulted in 1) Resident 1 to fall on the floor twice while attempting to go to the toilet without staff assistance causing Resident 1 to sustain right arm fracture; and 2) Resident 3 developed Moisture-associated skin damage (MASD - caused by prolonged exposure to various sources of moisture, including urine or stool) to his perirectal area from sitting on his poop for a long time. (Cross Reference F689)

Inspectors wroteBased on observations, interviews and records review, the facility failed to ensure call light was in good working condition for one of three sampled residents (Resident 8). This failure had the potential risk for Resident 8 ' s needs uncommunicated to the staff placing her at risk for neglect and harm.

Inspectors wroteBased on interviews and records review, the facility failed to ensure the Minimum Data Set (MDS - health status screening and assessment tool) was accurately completed for 1 of 3 sampled residents (Resident 1). This failure resulted in lack of complete information necessary to develop a resident centered care plan to meet Resident1 ' s health care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (Resident 1) was free from abuse by another resident (Resident 2) of the facility. This failure had the potential to cause physical harm, pain or mental anguish.

Inspectors wroteBased on interview and record review, the facility failed to report immediately or within two hours, an alleged resident-to-resident incident between Resident 1 and Resident 2. This failure had the likelihood for incidents of potential abuse between residents to not get reported, prevented, corrected, or investigated, and could result in physical, mental, or psychosocial harm to residents.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to one of two residents (Resident 1), when the facility did not administer three ordered medications to Resident 1. This failure prevented Resident 1 from receiving medications to treat her medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of two residents (Resident 1), when Resident 1 ' s Medication Administration Record (MAR) (where nurses document the administration of medications) for August 2023, lacked documentation of blood glucose monitoring and administration of insulin during four of 19 days. This failure resulted in Resident 1 having an incomplete and inaccurate MAR.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accident hazards and failed to provided supervision to each resident to prevent avoidable accidents, when: 1. One out of 15 residents who required extensive assistance when transferring (Resident 339) was transferred by [Staff E] only. [Staff E] (Certified Nursing Assistant (CNA) was the only staff named in the Intradepartmental Team notes, who operated the mechanical lift that required two staff for safe operation. This resulted in Resident 339 falling out of the lift and sustaining a right shoulder dislocation requiring surgical intervention; 2. One out of five residents at risk for elopement (an unauthorized departure of a patient from an around-the-clock care setting) (Resident 78), exited the facility through the main entrance, without triggering an alarm. [...]

Inspectors wroteBased on interview and record review, the facility failed to include the necessary information, such as Facility name, Total number of actual hours worked by Registered Nurse (RN), Licensed Vocational Nurse (LVN), and Resident census, on the Nursing Staff Data daily, for the month of November and December 2022. These failures had the potential to result in poor quality of care to residents, due to inaccuracy of total numbers of hours worked by the nursing staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light system, installed in the bathrooms used by residents, in 38 of 40 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40 and 41), were accessible to residents lying on the floor of the bathroom. This failure created the potential for residents who fell in the bathroom, not to be able to alert staff and summon help.

Inspectors wroteBased on observation, interview, and records review, the facility failed to provide an Activities program designed to meet the needs and interests of seven sampled residents (Resident 8, 21, 25, 33, 36, 53, and 59), who received 1:1 activity visits. This failure had the potential to result in deterioration of the residents' mental and physical health and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for two of two sampled residents, when it: a. Failed to monitor and revise interventions to provide adequate hydration to Resident 21 as recommended by the RD, and; b. Failed to accurately record two of Resident 6's meal intakes. These failures had the potential for: a. Resident 21 to continue losing weight and increased her risk to develop dehydration (a condition where the amount of water in your body is too low) which may lead to dry skin and mucosa, sleepiness or tiredness, headaches, constipation, minimal urine output, dizziness and, in severe cases, delirium, unconsciousness or even death. b. [...]

Inspectors wroteBased on interviews and records review, the facility failed to ensure sufficient nursing staff to provide safe and quality of care to all residents during night shift, when: 1) The Nursing Staff Data sheet, dated 11/25/22, from 10 p.m. - 6:30 a.m., revealed two (2) Licensed Nurse CNAs were providing care. A review of the Facility census was 86 residents; 2) The Nursing Staff Data sheet, dated 11/27/22, from 10 p.m. - 6:30 a.m., revealed (1) Licensed Nurse (LN) and three (3) Certified Nursing Assistants (CNAs) were providing care. A review of the Facility census was 83; and, 3) The Nursing Staff Data sheet, dated 11/28/22, from 10 p.m. - 6:30 a.m., revealed, one (1) Licensed Nurse (LN) and one (1) CNA were providing care to residents. A review of the facility census was 82. [...]

Inspectors wroteBased on observation, interview and record review, the facility: (1) failed to properly dispose of controlled drugs (medications with a high potential for abuse and dependency), when controlled drugs documented as disposed were not destroyed and were kept unsecured. These failures created the potential for diversion of controlled substances and for staff to work impaired, placing residents at risk of improper care. The facility further: (2) failed to ensure proper handling and administration of medications for one resident (Resident 185), when Resident 185's medications were left unattended at her bedside table. This failure placed Resident 185 at risk of not receiving her medications.

Inspectors wroteBased interview and record review, the facility failed ensure medications were administered as prescribed, to one of 20 sampled residents (Resident 58), when facility staff administered Isosorbide Dinitrate and Carvedilol (medications to treat high blood pressure and heart failure) and Insulin Glargine (a medication to treat high blood sugar) to Resident 58 outside of the parameters indicated by Resident 58's physician. These failures resulted in Resident 58 receiving 28 doses of unnecessary medications (7 doses of Isosorbide Dinitrate, 17 doses of Carvedilol and 4 doses of Insulin Glargine) over a period of 40 days.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the menu was followed for one day, when an incorrect portion of the seasoned sauce was served for lunch, and 42 of 42 residents on pureed/dysphagia mechanical diets (food altered in consistency for those with swallowing difficulties) did not receive the correct food items. These failures had the potential for residents to receive the wrong and/or inappropriate allocation of caloric intakes, which could further compromise their medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and store food in a sanitary manner, when a kitchen staff was not wearing appropriate hair restraints, and the kitchen pantry shelves contained multiple dented cans of food, and packages of English muffin kept past their storage date. These failures had the potential to place residents at risk for food-borne illness and the growth of microorganisms.

Inspectors wroteBased on Interview and record review, the facility failed to submit an accurate staffing information based on Payroll Based Journal (PBJ) to Federal Agency for the month of May, June, July, August, September, October, and November 2022. This failure had the potential to result in inaccuracy of numbers of Direct Care Staff needed to provide care to residents, based on PBJ report to the Federal Agency.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three licensed nurses (Licensed Nurse D) knew the minimum contact time (how long the product needs to stay wet on a surface to be effective) of the disinfectant used to sanitize the facility's reusable glucometers (portable devices which analyze resident blood samples for glucose levels). This failure created the potential for the use of contaminated glucometers, exposing residents to blood-borne diseases.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to prevent pressure ulcers to one of three residents (Resident 37) at risk for pressure ulcers. For Resident 37, after an assessment indicated Resident 37 was at risk for pressure ulcers and needed extensive staff assistance with bed mobility, the facility failed to create an individualized plan to frequently turn and reposition Resident 37 in bed in order to relieve pressure on bony prominences (a risk factor for the development of pressure ulcers). The facility also failed to have a system of accurately and comprehensively documenting the turning and repositioning of immobile residents at risk for developing pressure ulcers. These failures placed Resident 37 at risk for pressure ulcers. Resident 37 developed a pressure injury on his sacrum/coccyx area (bottom of spine area).