Mesa Glen Care Center

Inspectors wroteBased on interview and record review, the facility failed to provide one of three resident's (Resident 6's) medical records within two working days after receiving a valid medical request from the law firm representing Resident 6's legal representative (RP 1). This failure violated Resident 6's rights and resulted in RP 1 not receiving Resident 6's medical records within the required timeframe. During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 10/24/2025 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (a device used by residents to call for assistance from staff) was within reach (an arm's length) for two of two sampled residents (Residents 5 and 69). These deficient practices had the potential to result in delayed provision of care and services and placed the residents at risk for falls/injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents' (Residents 91 and 98) Minimum Data Set (MDS, a resident assessment tool) reflected an accurate assessment by failing to: a. Ensure Resident 91's diagnosis of anxiety disorder (mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry) was coded in MDS assessment dated [DATE]. b. Ensure Resident 98, who was discharged to home under the care of home health (wide range of health care services that could be given at home for an illness or injury) service was coded in the MDS assessment dated [DATE], accurately. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans (CP) to meet the residents' needs for three of three sampled residents (Residents 1, 85, and 91) by failing to: a. Develop an individualized CP to address the use of namenda (medication to improve memory, awareness, and daily functioning) for Resident 91. b. Follow the CP to maintain the appropriate setting for Resident 1's low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers/injuries [localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence]). c. Follow the CP for Resident 85's pressure ulcer treatment and LALM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to promote healing for residents with pressure ulcer/injury (PU/PI, localized damage to the skin and/or underlying tissue usually over a bony prominence) and skin maintenance for five of seven sampled residents (Residents 1, 85, 3, 50 and 58 ) by failing to:a. Ensure Resident 1's Low Air Loss Mattress (LAL, a specialized medical support surface designed to prevent and treat skin ulcers by combining alternating pressure with a steady low-volume airflow) was set consistent with Resident 1's weight.b. Ensure Resident 85's LAL mattress pressure was set consistent with Resident 85's weight and treatment for Resident 85's PU was provided in accordance with physician's order.c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for residents with indwelling catheter (including suprapubic catheter and nephrostomy tube, a flexible tube inserted into the body, usually the bladder through the urethra or through a small abdominal incision that remains in place for continuous, long-term urine drainage) for two of three sampled residents (Residents 50 and 104) by failing to:a. Ensure Resident 50's suprapubic catheter tubing was connected to a securement device on Resident 50's thigh.b. Ensure Resident 104's left and right nephrostomy catheter bags were positioned lower than the level of the bladder. These failures placed Residents 50 and 104 at risk for infection and injury related to the use of indwelling catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the integrity and proper labeling of peripherally inserted central catheter (PICC, a long, flexible tube inserted into a vein in the upper arm and guided into a large vein near the heart) line in accordance with professional standards of practice for two of five sampled residents (Resident 75 and Resident 106). These failures had the potential to result in infection and accidental PICC line dislodgement for Residents 75 and Resident 106.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for residents receiving respiratory therapy (a specialized healthcare field focused on assessing, treating, and managing patients with breathing or cardiopulmonary disorders) and oxygen therapy (a treatment that provides extra oxygen to breathe in) in accordance with professional standards of practice for two of four sampled residents (Residents 9 and 11) by failing to: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the actual nurse staffing information at the beginning of the shift in a prominent location, readily accessible to residents, visitors, and staff for viewing for one of four recertification survey days (5/5/2026). This failure had the potential to mislead the residents, visitors, and staff of the actual staffing in the facility that could affect the quality of nursing care provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage practices in one of one facility kitchen, by failing to: a. Discard a plate of chopped fresh fruit dated 4/28/2026 in the kitchen Refrigerator 1. b. Discard a plate of chopped fresh fruit dated 5/1/2026 in the kitchen Refrigerator 1. c. Discard an open loaf of white bread beyond its use-by-date (the last date the food was considered safe to eat) of 5/2/2026 in the kitchen bread storage area. d. Label two bags of frozen pie shells with the received date and expiration or discard date in the kitchen Freezer 1. e. Discard two unlabeled bags of frozen pie shells in the kitchen Freezer 1. These deficient practices had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the dumpster area free from litter and securely cover four of four large facility trash bins, as indicated in the facility's Policy and Procedure (P&P) on garbage and rubbish disposal. These deficient practices had the potential to attract vermin (animals that are harmful and carry diseases) and pests (any living thing that has a negative effect on humans) that could potentially enter the facility, affect the resident care areas, and expose the residents and staff to diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and treat one of one sampled resident (Resident 5) with respect, privacy and dignity in accordance with facility's policy titled Dignity and Respect. This deficient practice had the potential to cause psychosocial (mental and emotional well-being) decline and low self-esteem for Resident 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's bathroom sink was repaired for one of four sampled residents (Resident 23) when Resident 23's bathroom sink did not produce freely flowing hot water. This failure had the potential to increase Resident 23's risk of physical and emotional discomfort and distress due to a lack of access to hot water.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 46) was free from restraints. Resident 46 had a Wanderguard (a wearable security device used to manage and monitor residents prone to wandering or at risk of leaving the facility) without a physician's order. This failure placed Resident 46 at risk for psychological distress (an experience of emotional, mental, suffering that occurs when individuals are overwhelmed) related to the use of the Wanderguard alarm.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for one of three sampled residents (Resident 64) when her care plan indicated to provide her with two conflicting diets (meals that meet daily and special dietary needs of each resident). This failure had the potential to result in Resident 64 not receiving the appropriate diet, leading to malnutrition (a condition where the body does not get the right balance of nutrients to function correctly).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure non-English speaking (refers to individuals who cannot speak or understand or have difficulty speaking or understanding the English language) residents were provided with a communication device in a language that the resident understood for one of one sampled resident (Resident 105). This failure had the potential to affect Resident 105's communication with staff and had the potential for delay in the provision of care, treatment and service to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 64) was provided with bilateral quarter side rails on her bed for mobility and repositioning as ordered. This failure had the potential to cause a decline in Resident 64's mobility and independence.

Inspectors wroteBased on interview and record review, the facility failed to address the significant weight loss (the resident lost a large amount of weight in a short time) for one of five sampled residents (Resident 65) who had significant weight loss of 6.52 percentage (%) from 3/20/2026 to 3/29/2026. This deficient practice placed Resident 65 at risk for further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) an emergency kit (E-kit, contains the main items needed in an emergency) at the bedside for one of one sampled resident (Resident 2). This failure had the potential for Resident 2 not to receive emergency treatment from complications caused by unexpected bleeding from the hemodialysis access site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of bed rails/siderails (adjustable metal or rigid plastic bars attached to the bed) for one of one sampled resident (Resident 106). This failure placed Resident 106 at risk of entrapment and injury from the use of bed rails.

Inspectors wroteBased on interview and record review, the facility failed to conduct skills competencies upon hire for one of five sampled staff (Certified Nurse Assistant 2 [CNA 2]). This failure had the potential for the residents in the facility not to receive appropriate/safe nursing care and services from CNA 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacist's recommendation for Protonix (medication used to treat excessive stomach acid) oral tablet delayed release 40 milligrams (mg- unit of measurement) was acted upon for one of one sampled resident (Resident 69). This deficient practice had the potential for Resident 69 to receive unnecessary medication that could lead to adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent two medication errors out of 28 observed opportunities, yielding a facility medication error rate of 7.14 percent. The Licensed Vocational Nurse (LVN) crushed and administered two medications that should not be crushed for one out of eight sampled residents (Resident 9). These failures increased the risk for the medications to not work as intended, potentially leading to Resident 9 having uncontrolled seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent significant medication errors for one of eight sampled residents (Resident 9) when lamotrigine (a medication used to prevent seizures (a sudden, uncontrolled disturbance in the brain which can cause jerking, blank stares, and loss of consciousness)) extended release (ER) tablets were crushed prior to administration. These failures increased the risk for the medication to not work as intended, potentially leading to Resident 9 having uncontrolled seizures.

Inspectors wroteBased on interview and record review the facility failed to maintain clinical records in accordance with acceptable professional standards of practice for one of one sampled resident (Resident 5) by failing to accurately assess Resident 5's Fall Risk Evaluation (FRE- method of assessing a patient's likelihood of falling) upon admission. This deficient practice had the potential to negatively impact on Resident 5's delivery of services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and secure handrail located in one of one facility hallways at the North Station of the facility building. This deficient practice placed the residents at risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' room was free from pests (any living organism such as bugs or rodents that can transmit disease) for two of four sampled residents (Resident 23 and 64) when a bug was found in Resident 23 and 64's shared room. This failure had the potential to increase Resident 23 and 64's risk of infection and emotional distress.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 5's) medical record was complete when documentation regarding assisting Resident 5 with dinner and providing oral hygiene to Resident 5 on 2/2/2026 evening shift (3 PM to 11 PM) and providing Resident 5 oral hygiene on 2/3/2026 night shift (11 PM to 7 am) was not found in Resident 5's medical record. This failure resulted in incomplete documentation in Resident 5's medical record and had the potential for Resident 5 not to receive necessary services and adequate care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed to prevent the transmission of disease and infection for two of three sampled residents (Residents 1 and 2) when: a. Residents 1 and 2 took a shower in the shower room next to the facility's dining room while the shower drain was clogged.b. Facility staff failed to empty Resident 1's 3 full urinals hanging on the foot of Resident 1's bed. These failures had the potential to result in the spread of infections among the residents (in general) residing at the facility.(Cross reference F584)a1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow residents (in general) to call for staff assistance, when:One of three sampled residents (Resident 2) did not have a functioning call light (a device used by a resident to signal the need for assistance) when taking a shower in the shower room next to the facility's dining room. One of three of the facility's shower room (across from the South Nurses' Station) call light pull cord did not reach down to the ground. These failures had the potential for residents to experience harm if residents were unable to alert staff during an emergency. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed to prevent the transmission of disease and infection for two of three sampled residents (Residents 1 and 2) when: Residents 1 and 2 took a shower in the shower room next to the facility's dining room while the shower drain was clogged. Facility staff failed to empty Resident 1's 3 full urinals hanging on the foot of Resident 1's bed. These failures had the potential to result in the spread of infections among the residents (in general) residing at the facility.(Cross reference F584)a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer physician ordered medication to one of three sampled residents (Resident 1) on 3/13/2026 and 3/14/2026. This failure had the potential to result in Resident 1 experiencing itching and dryness to the face. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/5/2025 with diagnoses including anorexia nervosa (an eating disorder defined by restriction of energy intake relative to requirements), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of 35 sampled staff (Licensed Vocational Nurse [LVN] 1, LVN 3, Care Coordinator [CC] 1, Treatment Nurse [TN] 2, and the Hairdresser [HD]) followed state regulations by failing to wear identification name badges while on duty. This failure had the potential for residents (in general) not to know who was providing care for the residents (in general). a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that hot foods were maintained at a temperature greater than 140 Fahrenheit (Fahrenheit [F], a unit of temperature) during meal service for four of four food items that the residents receiving during mealtime at the facility. This deficient practice had the potential to result in rapid growth of bacteria that can cause foodborne illness and can lead to insufficient meal intake and wight loss due to cold or improperly heated food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to prevent accidents for two of two sampled residents (Resident 1 and 2) by failing to:a. Follow the physician's order for one to one (1:1 - an intervention where a dedicated staff member provides continuous direct monitoring of a resident) supervision for Residents 1 and 2.b. Not leave Residents 1 and 2 unattended in accordance with the residents' care plan. These deficient practices had the potential to result in harm that could lead to serious accidents/injury for Residents 1 and 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from physical restraints (any manual method, physical or mechanical device, equipment, or material attached or adjacent to the resident's body that cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to his/her body). Resident 1's bed was placed against the wall on the left side and a geriatric chair (Geri Chair, a large, padded and mobile reclining chair that prevents a resident from rising) was placed on the right side of Resident 1's bed. The facility did not have a physician's order for the use of Geri Chair for Resident 1. This deficient practice limited Resident 1's mobility, violated Resident 1's right and had the potential to cause physical and/or psychological (mental) harm to Resident 1. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) in accordance with the facility's Policy and Procedure (P&P) titled, Abuse Prevention/Prohibition, and Resident Rights for one of four sampled residents (Resident 4) when Resident 3 hit Resident 4 on the back of the head on 1/19/2026. This failure resulted in Resident 4 being subjected to physical abuse by Resident 3 while under the care of the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement timely and individualize the care plan interventions to address a resident's known history of aggressive behaviors for one of four sampled residents (Resident 3). This deficient practice placed the residents at risk for physical harm, psychological distress, and/or a decline in overall well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure current staffing information was posted in a prominent place readily accessible to residents, staff, and visitors on a daily basis at the beginning of each shift. This deficient practice resulted in posting inaccurate staffing information. During an observation on 1/2/26 at 12:08 PM, there was a posting titled Census and Direct Service Hours Per Patient Day in front of Nursing Station 1 near entrance lobby. The date on the posting was 12/31/25. During an interview on 1/2/26 at 12:10 PM, the Director of Nursing (DON) stated the posting was not current because the facility's Director of Staff Development had resigned and the facility staff who was responsible for posting the staffing information did not come to work due to personal circumstances. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to reevaluate and update care plan interventions to address resident's hoarding and the potential for accident hazards for one of five sampled residents (Resident 2). This deficient practice had the potential to place Resident 2 at increased risk for tripping and falling hazards, unsanitary environmental conditions, and fire safety violations. Cross Reference: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled resident's (Resident 2) environment/room remained free of accident hazards and clutter. This deficient practice placed Resident 2 at risk for falls, and injury due to excessive clutter surrounding Resident 2's bed. Cross Reference: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and sanitary ice and water handling practices to prevent contamination and the potential for waterborne illness for one of one ice machine serving the facility. This deficient practice had the potential to expose residents to unfiltered ice and water, which can harbor bacteria (Listeria, a bacterium), mold, and other contaminants, posing serious health risks and the potential for illness. During an observation on [DATE] at 1:05 p.m. in the facility kitchen with the Dietary Manager (DM), an expired water filter, dated [DATE], was observed connected to the icemaker. During an observation and concurrent interview with the Dietary Manager (DM) on [DATE] at 1:14 p.m. in the kitchen, DM stated he was new and was unsure when the water filter needed to be changed for the icemaker. [...]

Inspectors wroteBased on Interview and record review, the facility failed to ensure to develop and implement a care plan for one of three sampled residents (Resident 2) regarding the use of rollator walker (an assistive device designed to aid individual with walking difficulties that requires proper training and instruction for safe use to prevent falls and injuries). This deficient practice placed resident at risk for fall and injuries. On 11/27/2025, Resident 2 fell while attempting to get up from the rollator walker and sustained a left acute humeral neck fracture (a break in the humerus [the long bone in the upper arm, running from the shoulder to elbow] bone of the left arm). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to one of three sampled residents (Resident 1) when Resident 1 exited the building without the facility's knowledge on 10/22/2025. This failure placed Resident 1 at risk of an accidental injury while outside the facility's premises without staff supervision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly respond to call lights (a device used by a resident to signal his or her need for assistance from staff) and/or promptly respond to a resident's request for toileting assistance for three of five sampled residents (Residents 1, 4, and 6) according to the facility's Policy and Procedure (P&P) titled, Dignity, revised February 2021. This failure had the potential to result in residents (in general) feeling like their concerns were unheard and to feel frustrated.(Cross Reference F552)a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained by the ordering healthcare provider for one of five sampled resident (Resident 1). This failure had the potential to result in Resident 1 receiving medication against Resident 1's wishes. (Cross Reference F550)

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) when on 9/2/2025, Registered Nurse 1 (RN1) threw a cup of juice on Resident 1's face. This failure resulted in Resident 1 being subjected to physical abuse by RN 1 while under the care of the facility. Resident 1 cried and did not answer how Resident 1 felt when RN 1 threw water on Resident 1's face.

Inspectors wroteBased on interview and record review, the facility failed to report an incident of physical abuse for one of three sampled residents (Resident 1) within two hours to the California Department of Public Health in accordance with the facility's Policy and Procedure (P&P) titled, Abuse Reporting and Investigation. This failure violated Resident 1's right and had the potential for delay in abuse investigation and continued to expose Resident 1 to further physical abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat two of four sampled residents (Residents 8 and 14) with dignity by failing to:a. Ensure Staff did not stand over Resident 8 while assisting the resident to eat.b. Ensure Activity Assistant (AA) 1 did not refer to Resident 14 as a Feeder. These failures had the potential to result in Residents 8 and 14 to feel disrespected which could result in impairing Residents 8 and 14's sense of wellbeing and feelings of self-esteem.(Cross Reference F580, F689, and F755).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the environment remained free of accident hazards and/or provided adequate supervision for three of 11 sampled residents (Residents 6, 9, and 15) by failing to: a. Ensure Resident 15's assigned 1:1 sitter (S1) (1:1 Sitter, facility staff who provides constant, one-to-one observation for a resident who is at risk of falls, self-harm, or other dangers due to a medical or cognitive condition) S1 was not looking at S1's personal phone for four minutes instead of watching Resident 15. S1 was sitting inside the facility while Resident 15 was sitting outside in the facility patio. b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the nurse staff followed the facility's Administering Medications policy and procedure (P&P) by failing to:a. Administer medications in a timely manner for one of three sampled residents (Resident 6).b. Initial the resident's Medication Administration Record (MAR) after giving each medication and before administering the next ones for one of three sample residents (Resident 5).c. Ensure LVN 2 and LVN 5 documented that they administered Resident 4's medications before administering medications to another resident. Resident 4 did not receive Resident 4's scheduled medications on the evening of 8/12/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the doorknob and door of residents' room for three of three sampled residents (Residents 11, 16, and 17) was cleaned daily. This failure had the potential for residents to become sick by contacting germs (microscopic bacteria, viruses, fungi, and protozoa that can cause disease) from the dirty doorknob.

Inspectors wroteBased on interview and record review, the facility failed to follow their Change in a Resident's Condition or Status policy and procedure to notify one of three sampled residents (Resident 7's) doctor of Resident 7's weight loss on 7/1/2025. These failures had the potential to result in Resident 7 to not receive treatment to address Resident 7's weight loss which could negatively affect Resident 7's health and wellbeing. (Cross Reference F550, F689, and F755)

Inspectors wroteBased on observation, interview and record review, the facility failed to honor the privacy (a resident's right to be free from observation including the resident's private space) and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure) of one of one sampled resident (Resident 13) when a video recording (Video 1) of Resident 13's room was posted to TikTok (a social media app where people create and share short videos). This failure resulted in the violation of Resident 13's right to privacy and confidentiality and had the potential to result in Resident 13 experiencing emotional distress and feelings of decreased self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four Residents, Resident 22, was provided an accurate comprehensive admission assessment. This deficient practice resulted in delayed interventions for pain from a red and swollen right hand and forearm and services accommodating to Resident 22's cognitive state and blindness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of one sampled resident (Resident 1) with behavioral health care and services for the treatment of Resident 1's emotional, mental, and drug abuse (a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medication) by failing to: Identify goals and nursing interventions when Resident 1 had cannabis (marijuana, a mind-altering drug) abuse, anxiety (nervousness), and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) would leave the facility on out on pass (OOP, temporary permission of a resident to leave the facility in a specified time) unsupervised, without OOP orders from Resident 1's Physician (MD 1). [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly (quickly/timely) notify one of four sampled residents (Resident 1) Primary Care Physician/Medical Doctor (MD) 1 of Resident 1's unwitnessed fall (move downward, typically rapidly and freely without control, from a higher to a lower level) that occurred in Resident 1's in Resident 1's bathroom on 7/16/2025 at 11 pm, and of Resident 1's complaint of back pain after the fall, in accordance with the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by failing to ensure:1. Licensed Vocational Nurse (LVN) 1 notified MD 1 on 7/16/2025, when Certified Nurse Assistant (CNA) 1 notified LVN 1 of Resident 1's unwitnessed fall in the bathroom on 7/16/2025 at 11 pm.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Signing Residents Out, for one of four sampled residents (Resident 4) when Resident 4, who did not have a physician's order to leave the facility was allowed to leave the facility with Resident 4's responsible party (RP, a person who is responsible for guiding, informing, and assisting the resident regarding their care) on 6/15/2025 without Resident 4's medications. [...]

Inspectors wroteBased on interview and record review the facility failed to administer pain medication to one of four sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 did not administer any pain medication to Resident 1 on 7/17/2025 at 12:30 am, after Resident 1 complained of back pain after Resident 1 fell on 7/16/2025. This failure had the potential for Resident 1 to have unrelieved pain which could affect Resident 1's overall health and quality of life. During a review of Resident 1's Face Sheet (FS), the FS indicated, the facility admitted Resident 1 on 7/15/2024, with diagnoses which included arthritis (a condition characterized by joint pain, stiffness, and inflammation) on multiple areas of the body. [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly identify signs and symptoms (S/S, ways the body lets a person know that a person is sick) of a urinary tract infection (UTI- an infection in the bladder/urinary tract) for one (1) of three (3) sampled residents (Resident 1) when the facility did not monitor Resident 1's vital signs (VS, measurements of the body's basic functions, such as heart rate, breathing rate, blood pressure, and temperature) every shift according to Resident 1's care plan (CP) for UTI, dated 1/23/2025. This failure resulted in Resident 1 being transferred to General Acute Hospital (GACH) 1 and being admitted to GACH 1 with UTI and sepsis (a life-threatening blood infection). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents have the right to be free from verbal and mental abuse for one of three sample residents (Resident 8). These deficient practices resulted in residents being subject to neglect, verbal, mental and physical abuse.

Inspectors wroteBased on observations, interview and record review, the facility failed to report the resident- to- resident altercation to the State Survey Agency (SSA), the state Ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), within two (2) hours after the allegation of verbal abuse (the harmful use of language to control, intimidate or hurt someone. It can include behavior such as name-calling, belittling, or using controlling or threatening language) for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure [NAME], Abuse Reporting and Investigation. This deficient practice placed violated Resident 1's right and had the potential for delayed in abuse investigation and actual physical abuse (intentional bodily injury to a person, for example slapping, pinching, choking, kicking, shoving).

Inspectors wroteBased on interview and record review, the facility to provide an environment free from abuse for one of four sampled residents (Resident 2). This failure resulted in Resident 2 being subjected to physical abuse by Resident 1. Resident 2 sustained a laceration (a torn or jagged wound, a break in the skin or other tissue, often caused by blunt force or sharp objects) on the left eyebrow that required examination and cleaning at the General Acute Care Hospital (GACH 1).

Inspectors wroteBased on interview and record review, the facility failed to allow communication with persons outside the facility when Receptionist 1 did not notify Resident 1of incoming phone calls. This failure had the potential for Resident 1 to not receive important communication and worsen Resident 1's depression (a persistent mood disorder characterized by a pervasive feeling of sadness, loss of interest in activities, and difficulty with thinking, memory, and sleep).

Inspectors wroteBased on interview and record review the facility failed to ensure a care plan was developed and implemented for one of two sampled residents (Resident 1) who had a diagnosis of hypertensive heart disease without heart failure (refers to heart problems caused by high blood pressure, where the heart is working harder but not necessarily experiencing the symptoms of heart failure). This failure had the potential for Resident 1 to experience orthostatic hypotension (a condition where blood pressure drops significantly when a person stands up from a sitting or lying position) from not being monitoring for blood pressure (BP-the force exerted by blood against the walls of the arteries as it circulates throughout the body) as ordered by Resident 1's physician. Cross Reference:

Inspectors wroteBased on interview and record review the facility failed to ensure one of two sampled residents (Resident 1) was monitored for blood pressure (BP- the force exerted by blood against the walls of the arteries as it circulates throughout the body) on 3/8/2025 as ordered by Resident 1' s primary physician. This failure had the potential for Resident 1's BP to be low (hypotension [HTN]- a condition where the force of blood pushing against artery walls is too low). Cross Reference:

Inspectors wroteBased on interview and record review the facility failed to ensure Licensed Vocational Nurse (LVN) 4 and Registered Nurse (RNs) had the competency (the capability to apply or use the knowledge, skills, and abilities required to successfully perform tasks in the work setting) to follow through with one of two sampled residents (Resident 1) physician orders blood pressure assessment. This failure had the potential for Resident 1 BP to be low (hypotension [HTN]- a condition where the force of blood pushing against artery walls is too low). Cross Reference:

Inspectors wroteBased on observation, interview, and record review, Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1) failed to ensure one of five sampled residents (Resident 4) was not physically assaulted (attacked or harmed through physical violence) by another resident (Resident 5) on 3/20/2025. This deficient practice resulted in Resident 4 sustaining a closed head injury (type of traumatic brain injury where the skull remains intact) and mildly comminuted (bones break into pieces), minimally displaced (out of place) right nasal (nose) bone fracture (break in the bone) on 3/20/2025. Resident 4 was transferred to General Acute Care Hospital 1 (GACH 1) for evaluation of moderate head pain after a head injury from an assault.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment to prevent injuries for two of two sampled residents (Residents 37 and 294) by failing to: a. For Resident 37, the facility failed to: 1. Ensure Licensed Vocational Nurses (LVNs) implemented Resident 37's untitled Care Plan (CP), dated 2/26/2025, to provide interventions such as anticipating Resident 37's needs and providing opportunities for positive interaction/attention to Resident 37 to decrease or eliminate Resident 37's episodes of banging head on the walls/doors. 2. Ensure Certified Nursing Assistants (CNAs) provided hourly monitoring to Resident 37 who was assessed with aggressive behavior (any behavior or act aimed at harming a person or damaging physical property) as ordered by Resident 37's physician (Medical Doctor/MD 1) on 2/2/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents and/or responsible parties (RP) were provided information regarding the resident's right to formulate an Advance Directive (AD, a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated) and the resident's Physician Orders for Life-Sustaining Treatment (POLST- medical form that documents a patient's wishes regarding end-of-life care) was accurate and complete for seven of seven sampled residents (Residents 5, 6, 11, 35, 37, 41, and 75). This deficient practice had the potential to result in Residents 5, 6, 11, 35, 37, 41, 75 receiving unwanted care and treatment and/or unnecessary life-sustaining treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, clean, homelike environment for three of three sampled residents (Residents 11, 63, and 68) by failing to: a. Ensure Resident 11's personal wheelchair was reported as missing to the Social Services Director (SSD). b. Ensure Resident 63's toilet seat was fully attached to the toilet bowl. c. Ensure Resident 68's patio door was able to fully close. These failures had the potential to result in negatively impacting Resident 11, 63 and 68's quality of life and had the potential for an unsafe environment for the residents

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive plan of care for four of four sampled residents (Resident 5, Resident 47, Resident 68, and Resident 196). These failures resulted in Residents 5, 47, 68, and 196 not receiving individualized care and had the potential for Residents 5,47, 68, and 196 not able to maintain the residents' highest practical physical and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards of practice for two of three sampled residents (Residents 27 and 49) by failing to: a. Ensure Resident 27's Peripherally Inserted Central Catheter (PICC, thin flexible tube that is inserted into a view in the upper arm to give fluids and other medications) line and Midline (long, thin, flexible tube that is inserted into a large vein in the upper arm) were flushed (to fill with normal saline [NS, mixture of salt and water concentration] solution to prevent clotting when not in use) per the Medical Doctor (MD) order. b. Ensure Treatment Nurse (TN) 1 assessed Resident 49's skin condition. These failures had the potential to result in Residents 27 and 49 to develop complications from a delay in care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatments to prevent the development of pressure ulcer (PU- an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure) and promote healing for four of six sampled residents (Residents 1, 16, 20 and 36) by failing to: a. Ensure the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure injuries) for Resident 36 was set to alternating pressure. b. Ensure the low air loss mattress for Resident 20 was set to alternating pressure. c. Ensure Resident 1's heel boots for offloading purposes were applied. d. Ensure Resident 16's LALM was set at the correct weight setting. These failures had the potential to cause pressure ulcers, worsen and prevent healing for residents with skin and pressure injuries.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy titled, Pain Assessment and Management for two of two sampled residents (Resident 5 and 25) by failing to: a. Communicate the Pain Specialist (PS) recommendations to the Medical Doctor (MD) for Resident 25 on 1/28/2025 and 2/25/2025. b. Notify Resident 5's Physician when the current pain management was not working for Resident 5's pain. These failures had the potential to result in Resident 5 and 25 to experience unnecessary pain affecting their quality of life and well being

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff to provide care and services to meet the needs for three of four sampled residents (Resident 5, Resident 6, and Resident 41). These deficient practices had the potential to result in Residents 5, 6 and 41 did not receive adequate care to meet the residents' needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Zosyn (type of antibiotic) Intravenous (IV, route of administration that is directly inserted into the vein) and Daptomycin (type of antibiotic) IV were given per the physician's order for one of one sampled resident (Resident 27). These failures had the potential for Resident 27 to develop severe infections and complications from antibiotic use.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy titled, Psychotropic (medication that affects behavior, mood, thoughts, or perception) Medication Use for two of two sampled residents (Resident 5 and 197) by failing to: a. Ensure Resident 197's order for Ativan (medication used to treat anxiety) 0.5 milligrams (mg, unit of measurement) tablets every six hours as needed (PRN) for anxiety had an end date of 14 days. b. Obtain a signed informed consent for the use of Olanzapine (mediation used to treat schizophrenia [serious mental disorder in which people interpret reality abnormally] and bipolar disorder [mental illness that causes extreme mood swings]) and Lorazepam (medication used to treat anxiety) for Resident 5. These failures had the potential to result in unnecessary psychotropic medication use for Resident 5 and 197.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they had a medication error rate of five (5) percent (%) or lower for two of two sampled residents (Resident 13 and 26) during the medication administration on 3/6/2025. This failure resulted in three (3) medication errors out of 25 opportunities for errors, which resulted in a Medication Administration Error Rate of 12%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure significant medication error were prevented for two of two sampled resident (Resident 24 and 27) by failing to: a. Check the heart rate (HR) prior to administration of Metoprolol (medication used to lower blood pressure) and Amlodipine (medication used to lower blood pressure) to Resident 24. b. Administer Zosyn (type of antibiotic) intravenous (IV, route of administration that was directly inserted into the vein) and Daptomycin (type of antibiotic) IV as ordered by the Medical Doctor (MD) for Resident 27. These failures had the potential to result in discomfort or jeopardize the residents' health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled nutrition services staff member (Dishwasher 1 [DW 1]) was in-serviced monthly. These failures had the potential to result in resident injuries related to dietary needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner by failing to: a. Date apple sauces, mandarin oranges, fruit cocktail, and boxes of milk with the received date. b. Remove the vanilla extract from the dry storage when it was opened on 11/22/2024 and remove the chicken pozole from refrigerator 1 (Ref 1) when the use by date of 2/27/2025 had past. c. Ensure an opened date was listed on an opened muffin mix, powdered sugar, baking soda, peanut butter, cottage cheese, cream cheese, pepperoni, salad dressing, and liter of milk. d. Ensure the peanut butter was stored in a sanitary manner when the peanut butter canister was observed with crusted peanut butter and jelly on the outside of the canister and stored in the dry storage. e. Date a bag of grilled cheese sandwiches in Ref 1. f. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection prevention and control program for 58 out of 91 sampled residents (Resident 1, 5, 7, 9, 11, 12, 13, 15, 16, 17, 18, 21, 24, 25, 26, 27, 28, 30, 31, 32, 33, 34, 36, 37, 39, 40, 42, 44, 46, 47, 49, 50, 52, 53, 54, 55, 56, 57, 59, 62, 63, 64, 65, 67, 68, 69, 71, 72, 74, 77, 78, 80, 88, 89, 294, 295, 296, 298) by failing to: a. Initiate a line listing, contact tracing, monitoring, and isolation measures after Certified Nursing Assistant (CNA) 12 notified the facility that CNA 12 was diagnosed with scabies (a contagious skin infestation caused by the microscopic mite, Sarcoptes scabie) on 2/28/2025. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of 19 sampled residents (Resident 16) with respect and dignity by failing to ensure facility staff placed Resident 16's indwelling catheter (medical device that helps drain urine from your bladder) inside a privacy bag (a discreet cover designed to conceal a urine drainage bag) as indicated in the facility's policy and procedure titled, Quality of Life-Dignity. This failure resulted in a breach of the facility's standard protocol designed to preserve the resident's privacy and dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Psychoactive Medication Informed Consent, for the use of for Olanzapine (Zyprexa- antipsychotic medication that used to treat mental disorders) and Lorazepam (Ativan- medication to treat anxiety) for one of one sampled resident (Resident 5). This failure violated Resident 5's right and placed Resident 5 at risk for psychological distress due to unnecessary medication. Cross reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide for one of one sampled resident (Resident 20) reasonable accommodation to meet the resident's needs by failing to ensure the call light was within reach. This deficient practice had the potential to negatively impact the psychosocial well-being of the resident and result in delayed provision of care and services.

Inspectors wroteBased on interview and record review, the facility failed to report alleged abuse within two hours to the California Department of Public Health (CDPH) on 1/22/2025 for one of one sampled resident (Resident 51). This failure had the potential to expose Resident 10 to further abuse from Resident 51.

Inspectors wroteBased on interview and record review, the facility failed to transmit the Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) for one of one sampled resident (Resident 2) within 14 days of Resident 2's death. This failure had the potential to result in inaccurate resident information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy titled Catheter (thin flexible tube used to drain fluids from the body or deliver fluids into it) Care, Urinary for one of one sampled resident (Resident 27) by failing to perform foley catheter (FC, thin, flexible tube inserted into the bladder through the urethra to drain urine) care every shift per the physician's order for Resident 27. This failure had the potential to result in Resident 27 to experience complications from indwelling catheter use.

Inspectors wroteBased on interview and record review, the facility failed to notify the Medical Doctor and create a Change of Condition (COC) for one of one sampled resident (Resident 28), when Resident 28 lost 17 pounds (lbs., unit of measurement for weight) on 1/9/2025. This failure had the potential to result in Resident 28 to experience further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a precautionary signage indicating No Smoking/Oxygen in Use was placed on the door of the room and there was a physician's order for oxygen therapy for one of two sampled residents (Resident 293) who was on oxygen therapy. This deficient practice had the potential for unnecessary oxygen therapy use for Resident 293 and increased risk of harm to residents, staff, and visitors in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Hemodialysis (HD, use of machine to remove waste and extra fluids from the blood) Catheters (soft, flexible tube that is inserted into a large vein)-Access and Care of for one of one sampled resident (Resident 62) when the post dialysis (treatment to remove waste and excess fluid in the body) process assessment form was not completed on 3/1/2025. This failure had the potential to result in Resident 62 to experience complications after dialysis.

Inspectors wroteBased on interview and record review, the facility failed to provide trauma-informed care for one of one sampled resident (Resident 47) by not ensuring that Resident 47 received adequate care and services to address Resident 47's Post-Traumatic Stress Disorder (PTSD- a mental health condition that can develop after someone has experienced a deeply disturbing or frightening event). This deficient practice had the potential to result in inadequate attention to Resident 47's specific trauma-related needs.

Inspectors wroteBased on interview and record review, the facility failed to provide in-service training (a type of professional training or staff development that is given to staff while they are employed) on Post-Traumatic Stress Disorder (PTSD- a mental health condition that can develop after someone has experienced a deeply disturbing or frightening event) for 106 of 106 nursing staff to adequately care for one of one sampled resident (Resident 47) with diagnosis of PTSD. This deficient practice had the potential to result in inadequate attention to Resident 47's specific trauma-related needs that could affect Resident 47's well-being.

Inspectors wroteBased on interview and record review, the facility failed to post the actual nursing hours for the night shift (NOC, 11PM to 7:30 AM) from 3/2/2025 to 3/7/2025 in two of two sampled locations (Lobby and South Station). This failure had the potential to result in the residents and visitors to not know whether there is sufficient staff to provide quality care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide care and serves to prevent elopement for one of three sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Wandering (to walk around from place to place without any clear purpose) & Elopement, revised 1/11/2016, by failing to: a. Develop and implement a plan of care to address elopement risk for Resident 1, who was assessed as being at risk for elopement on 10/24/2024. b. Ensure Licensed Vocational Nurse (LVN) 4 and the Social Services Director (SSD) notified all staff caring for Resident 1 of Resident 1's history of elopement. c. Ensure facility staff provided Resident 1 with a wanderguard (monitoring device or system that helps keep residents at risk of wandering safe) as requested by Resident 1's responsible party (RP 1) on 11/8/2024. d. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the care plan to provide a sitter for monitoring for one of five sampled residents (Resident 1), who had a history of suicidal/homicidal ideations. This failure had the potential to result in serious injury and harm to Resident 1 and other residents.

Inspectors wroteBased on interview and record review, the facility failed to complete a Situation Background Assessment Recommendation Communication Form (SBAR) for one of five sampled residents (Resident 1) when Resident 1 engaged in a verbal altercation with Resident 5 on 12/31/2024. This failure had the potential to result in the delay of care for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility ' s policy titled Safety and Supervision of Residents and supervise one of five sampled residents (Resident 1) when Resident 1 verbalized having feelings of hurting Resident 5 on 12/31/2024 at 5 PM. This failure resulted in Resident 1 entering Resident 5 ' s room without permission, engaging in a verbal altercation with Resident 5, and attempting to throw items towards Resident 5 on 12/31/2024.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Abuse Reporting and Investigation, by failing to report an alleged physical abuse to the facility's Abuse Coordinator, California Department of Public Health (CDPH), the Ombudsman (an official appointed to investigate individual's complaints and assists in resolution of concerns), and the local law enforcement immediately and within 2 hours on 12/3/2024 for one of three sampled residents (Residents 2) when Resident 1 allegedly threw water at Resident 2. This failure had the potential to subject Resident 2 to potential further abuse from Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to apply Permethrin External Cream (a topical medication used to treat scabies [infestation of the skin caused by the human itch mite]) to one of six sampled residents (Resident 5) skin rash as ordered by Resident 5's physician on 11/23/2024. This failure had the potential for Resident 5 to not receive the necessary treatment for Resident 5's rash, which had the potential to result in Resident 5 experiencing pain and discomfort. (Cross Reference F755)

Inspectors wroteBased on interview and record review, the facility failed to supply ordered medication in a timely manner for one of six sampled residents (Resident 5), per the facility's policy and procedure (P&P), Ordering and Receiving Medications from Alliance Pharmacy, Inc, dated 04/2021. This failure had the potential to result in Resident 5 not receiving the necessary treatment for Resident 5's rash, which had the potential for Resident 5 to experience pain and discomfort. (Cross Reference F684)

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and orderly discharge for two of three sampled residents (Resident 1 and Resident 2) as indicated in the facility's policies and procedures (P&P) by failing to: 1. Ensure Resident 1 and Resident 2 were discharged to an appropriate facility that was able to provide the level of care Resident 1 and Resident 2 needed such as assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and medications, blood sugar checks, insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration, and wound care. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the discharge plan for two of three sampled residents (Resident 1 and Resident 2) by failing to: 1. Ensure Resident 1 and Resident 2 were discharged to an appropriate facility that was able to provide the level of care Resident 1 and Resident 2 needed such as assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and medications, blood sugar checks, insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration, and wound care. Resident 1 and Resident 2 were discharged to an Independent Living Facility (ILF- housing arrangement which does not provide care, supervision, or assistance with daily activities). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct daily skin checks for one of two sampled residents (Resident 2) who was at risk for skin breakdown as indicated in Resident 2's care plan titled, At Risk for Skin Breakdown. This failure had the potential for Resident 2 to experience skin breakdown and to not receive timely treatment for the skin breakdown. (Cross Reference F622, F623, and F842)

Inspectors wroteBased on interview and record review, the facility failed to maintain and implement its Infection Control Program to prevent the transmission of disease and infection by not assisting two of three sampled residents (Resident 1 and 6) in washing residents' hands before meals and after using the bathroom. This failure had the potential to result in the spread of infection to residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate information and specific resident needs were communicated to the receiving health care facility for one of one sampled resident (Resident 2), who was transferred to General Acute Care Hospital (GACH) 1 on 10/26/2024. This failure had the potential for Resident 2 to not receive the needed care and treatment at GACH 1 which could negatively impact Resident 2's health and well-being. (Cross Reference F623, F656, and F842)

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the notice of discharge/transfer for one of one sampled resident (Resident 2) to the Ombudsman (an official appointed to investigate individuals' complaints against maladministration) in a timely manner. This failure had the potential for the Ombudsman to not know of Resident 2's transfer/discharge from the facility and could violate Resident 2's right to be informed by the Ombudsman of Resident 2's options and transfer/discharge rights. (Cross Reference F622, F656, and F842)

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical record for one of one sampled resident (Resident 2) by failing to accurately document in Resident 2's medical record the correct date of treatment provided to Resident 2 and the correct date of Resident 2's discharge from the facility. These failures resulted in Resident 2's medical records to contain inaccurate information. (Cross Reference F622, F623, and F656)

Inspectors wroteBased on interview and record review, the facility failed to provide care and services for a change of condition to two of eight sampled residents (Resident 1 and Resident 2) in accordance with the facility's policies and procedures (P&P) titled, Change in a Resident's Condition or Status, and Charting and Documentation, by failing to ensure: 1. Resident 1's physician and Resident 2's physician was notified of Resident 1's and Resident 2's change of condition. 2. Resident 1's physician was not notified Resident 1 was transferred to the General Acute Care Hospital (GACH) 1. 3. Resident 1 and Resident 2 were monitored for any physical and/or psychosocial changes every shift for 72 hours after their altercation (a loud argument or disagreement) on 8/6/24. 4. An altercation between Resident 1 and Resident 2 which occurred on 8/6/24 was documented in Resident 2's medical record. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility had a Registered Nurse (RN) for at least 8 consecutive hours a day for 7 days a week for one (1) out of 18 days reviewed for nursing staffing assignments. This failure had the potential to result in a decline in residents' physical and/or psychosocial well-being due to insufficient monitoring and coordination of care and services by an RN.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for two of five sampled residents (Residents 3 and 6) when on 7/24/24 Resident 2 hit/punched Resident 3's face and on 7/28/24 Resident 5 hit Resident 6 in the head with a water pitcher. These failures resulted in Resident 3 being subjected to physical abuse by Resident 2 and Resident 6 being subjected to physical abuse by Resident 5 while under the care of the facility. Resident 3 sustained facial fractures (break in bones on the face) and facial contusions (bruises) on Resident 3's right eye. Resident 6 sustained a laceration (a cut or tear in the skin) on the left forehead that required suturing (stitch made to join the open parts of a wound) at General Acute Care Hospital 1 (GACH 1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, stain free, and homelike environment for the residents in one of two nursing stations (South Station). This failure had the potential to result in an unsanitary and non-homelike environment for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and assistance during ambulation for one of two sampled residents (Resident 1) as indicated in Resident 1's care plan titled, Patient Care Plan: Fall Risk. As a result, on 7/10/24 at 11:30 pm, Resident 1 walked backwards and fell to the floor. Resident 1 sustained right inferior (lower in position) pubic ramus (a group of bones in the lower pelvis [area of the body below the abdomen that contains the hip bones, bladder, and rectum]) fracture (a complete or partial break in a bone) and right sacral ala (fan-shaped bone located on the base of the sacrum [triangle-shaped bone in the lower spine]) fracture. Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 1 on 7/10/24 for further evaluation.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician for one of eight sampled residents (Resident 1) who was being discharged from the facility for a scheduled admission to General Acute Care Hospital (GACH) 3 on 4/22/2024 by failing to: 1. Ensure Social Services Assistant (SSA), Registered Nurse Supervisor (RNS) 1, and/or Licensed Vocational Nurse (LVN) 2 notified Resident 1's primary physician, Medical Doctor (MD) 1, and Nurse Practitioner (NP) 1 on 4/19/2024 when the SSA requested transportation to GACH 3 indicating a discharge order was needed for 4/22/2024, and on 4/22/2024, when RNS 1 and LVN 2 were caring for Resident 1, and NP 1 was in the facility to see Resident 1. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one of eight sampled residents (Resident 3) from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) as indicated in the facility's policies and procedures (P&P) titled, Resident Rights, and Abuse Prevention Program, when on 4/24/2024, Resident 4 punched (hit) Resident 3 in the face during a board game. As a result, Resident 3 was subjected to physical abuse by Resident 4. Resident 3 sustained blunt trauma (injury of the body by forceful impact, falls, or physical attack) to the face with edema (swelling) and ecchymosis (discoloration of the skin because of ruptured blood vessels below the skin surface) to the left eye. Resident 3 was transferred to General Acute Care Hospital (GACH) 2 on 4/24/2024 at 7:30 pm for further evaluation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a resident-centered comprehensive care plan to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of eight sampled residents (Resident 5) by failing to: Ensure facility staff placed bilateral (both sides) floor mats (padding placed on flooring intended to help prevent injury from falls) on each side of Resident 5's bed as indicated in Resident 5's Care Plan (CP) titled, Fall Risk. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of nine sampled residents (Resident 3) who was a high elopement (when a person who has been deemed too ill or impaired to make a reasoned decision leaves) risk was monitored as per the interventions outlined in Resident 3's Care Plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective], and an evaluation plan]) for elopement. This deficient practice had the potential to result in harm and injury to Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure readmission to the facility, for one of one sampled resident (Resident 1), after hospitalization. This deficient practice resulted in Resident 1 waiting for placement at the General Acute Care Hospital 1 (GACH 1) from 11/15/2024 to 11/23/2024 and had the potential to result in a decline in psychosocial well-being to Resident 1.

Inspectors wroteDuring an interview and record review, the facility failed to ensure Psychiatric Progress Notes were readily accessible on the resident's chart for two of two residents (Resident 1 and Resident 2). This deficient practice had the potential for inadequate, incomplete information among the interdisciplinary team for Resident 1 and Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policies and procedures titled, Investigating Injuries, Abuse Investigation and Reporting, and investigate an injury of unknown origin for one of two sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to sustain more injuries of unknown origin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate residents' physical limitations and ensure the call light was within reach for three of 22 sampled residents (Resident 7, 19, and 63) as indicated in the facility's policy and procedure (P&P) titled, Answering the Call Lights, and plan of care. This deficient practice had the potential for Resident 7, Resident 19, and Resident 63 to not be able to call the staff for assistance when needed and receive assistance in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy and procedure titled Advance Directive (a written statement of a person's wishes regarding medical treatment), for two of three sampled residents (Resident 7 and Resident 89). For Resident 89, the facility failed to offer Resident 89 to formulate an advance directive at the time when Resident 89 admitted to the facility. For Resident 7, the facility failed to obtain a copy of Resident 7's existing advance directive and placed the advance directive in Resident 7's medical record. These deficient practices had the potential for the staff to violate Resident 7 and Resident 89's right to refuse treatment and implement the resident's preferred medical treatment.

Inspectors wroteBased on interview and record review, Residents 28 and 86's notice of Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) of non-coverage did not have documented evidence of informed decision from the residents or resident representatives to pay for non-covered services after they were discharged from Medicare Part A for two of two sampled residents (Residents 28 and 86). These deficient practices placed Residents 28 and 86 at risk for payment of out-of-pocket costs from non-coverage services while in the facility.

Inspectors wroteBased on interview and record review, the facility failed ensure a timely comprehensive (annual) assessment was completed for two of 5 sampled residents (Resident 20 and Resident 25). These deficient practices had the potential to result in inappropriate care for Residents 20 and 25.

Inspectors wroteBased on interview and record review, the facility failed ensure a timely quarterly assessment was completed for two (Resident 31 and Resident 54) of 5 sampled residents. These deficient practices had the potential to result to an inappropriate care for these residents.

Inspectors wroteBased on interview and record review the facility failed to develop and implement an individualized person-centered plan of care for two of 22 sampled residents (Resident 7 and 45) as indicated in the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive. a. For Resident 7, the facility failed to develop and implement a care plan to address Resident 7's diagnosis of atrial fibrillation (Afib- an irregular and often very rapid heart rhythm) and use of Xarelto (a medication used to prevent blood clots). b. For Resident 45, the facility failed to develop and implement a care plan for Resident 45's suprapubic catheter (a hollow flexible tube inserted into the bladder used to drain urine from the bladder). These deficient practices had the potential for Resident 7 and Resident 45 to not receive consistent and appropriate care, treatment, and/or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: A. Provide care and services to prevent the development of Deep Tissue Injury (DTI- intact skin with localized area of persistent non-blanchable deep red maroon, purple discoloration due to damage of underlying soft tissue)/pressure ulcer/injury (PU/PI- refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for two of four sampled residents (Residents 31 and 49 ), who were assessed as high risk for developing pressure ulcers and to prevent worsening of pressure ulcer for one of four sampled residents (Resident 40), by failing to : 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all nursing staff possessed the competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needed to perform work roles or occupational functions successfully) and skill sets necessary to meet the residents' needs safely by failing to: a. Perform a performance evaluation and skills competency evaluation for one of four sampled facility staff. b. Ensure the current competency skills evaluation included staff communication/reporting regarding changes in resident condition. c. Ensure the training schedule and in-services training included staff communication/reporting regarding changes in resident condition.

Inspectors wroteBased on interview and record review, the facility failed to prevent unnecessary use of medication for two of five sampled residents (Resident 7 and Resident 13). Resident 7 and Resident 13 were not assessed and monitored for complications related to anticoagulant (commonly known as a blood thinner, medication that decrease the blood's ability to clot) therapy such as bleeding and bruising as indicated in the facility's policy and procedure (P&P) titled, Anticoagulation - Clinical Protocol, and Resident 13's plan of care. This deficient practice placed Resident 7 and Resident 13 at risk for undetected bruising and bleeding which could result in blood loss and bleeding in the brain and other major organs without immediate interventions and had the potential to cause a decline in Resident 7's and Resident 13's well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Resident 53 and 70) on psychotropic drugs (any drug capable of affecting mood, emotions, and behavior) were free from unnecessary medication. a. For Resident 70, licensed staff failed to monitor Resident 70's target behavior related to the use of Effexor (medication used to treat depression [a feeling of severe sadness or hopelessness]) as indicated in the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, and Resident 70's care plan. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policies and procedures titled, Acute Condition Changes, Prevention of Pressure Injuries (PU/PI- refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence,) Prevention of Pressure Ulcers, and the Care Plans titled, Risk for Skin Breakdown, and High Risk for Pressure Ulcer Secondary to Hypertension, for two of four sampled residents (Residents 31 and 49), who were assessed as at risk for developing pressure ulcers, by failing to ensure: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures (P&P) that indicated prohibition and prevention of abuse, neglect, and exploitation of residents for one of eight sampled resident (Resident 87). On 1/11/2024, the facility failed to investigate and report Resident 87's purple discoloration located on the right orbital (space within the skull that contains the eye including its nerves and muscles). This failure had the potential to result in compromised safety and psychosocial decline to Resident 87.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin for one of eight sampled resident (Resident 87). On 1/11/2024, the facility failed to report Resident 87's purple discoloration located on the right orbital (space within the skull that contains the eye including its nerves and muscles) as indicated in the facility's Policy and Procedure (P&P) titled, Abuse Investigation and Reporting. This failure resulted in a delayed investigation of an injury of unknown origin and had the potential to result in compromised safety and psychosocial declines to Resident 87 and the residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer and discharge to the responsible party (RP 1) of one of three sampled residents (Resident 34) in accordance with the facility's policy and procedure (P&P) titled, Transfer or Discharge, Facility Initiated. This deficient practice placed Resident 34 and RP 1 at risk to not be fully informed of their appeal rights and options, which had the potential to result in inappropriate discharge/transfer from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide in-room activities based on the resident's activity assessment for one of two sampled residents (Resident 45). This deficient practice had the potential to lead to low stimulation, boredom, or loneliness which could affect the physical, emotional, and psychosocial well-being of Resident 45.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate care to prevent urinary tract infection ([UTI] an infection in any part of the urinary system [kidneys, bladder, ureters, and urethra]) for one of two residents (Resident 1) while Resident 1 was having an indwelling catheter (collects urine by attaching to a drainage bag) by failing to: Ensure Certified Nurse Assistant (CNA) 2 positioned Resident 1's urine bag below the level of resident's bladder while Resident 1 was lying in bed. This deficient practice placed Resident 1 at risk for UTI when the urine flows back into the resident's bladder from the tubing and urine bag.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label the enteral (a method of delivering nutrition through a tube into the stomach) tube feeding bag with the start date and start time for one of one sampled resident (Resident 45) on tube feeding. This deficient practice had the potential to result in inconsistencies and errors in calculating the volume of the tube feeding administered hourly to Resident 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nasal cannula tubing (a device that delivers extra oxygen through a tube and into the nose) was stored in a plastic bag when not in use for one of 22 sampled residents (Resident 13) in accordance with the facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy) - Prevention of Infection. This deficient practice placed Resident 13 at risk for respiratory infection and had the potential to spread infection to other residents, staff, and visitors in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily. The staffing information included the actual worked hours of the Minimum Data Set (MDS) nurse that was not directly responsible for resident care was not posted in a prominent location readily accessible to residents and visitors for viewing for one of one day (first day of the survey). This deficient practice mislead the residents and visitors and had the potential to affect the quality of nursing care provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 11 sampled residents (Resident 2) was free from verbal abuse as indicated on the facility ' s Policy and Procedure (P&P) titled, Abuse Prevention Program. This failure resulted in verbal abuse to Resident 2 and Resident 2 feeling bad and worthless. In addition, the failure had the potential to result in psychosocial decline to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report a verbal abuse incident for one of 11 sampled residents (Resident 2) within two hours of occurrence and as indicated in the facility ' s Policy and Procedure (P&P) titled, Abuse Investigation and Reporting. This failure resulted in compromised safety to Resident 2 and had the potential to result in a psychosocial decline to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure palatable food was served for three of 11 sampled residents (Residents 5, 3, and 11). This failure had the potential to result in a physical decline and unmet nutritional needs for the residents.

Inspectors wroteBased on interview and and record review, the facility failed to ensure two staff assisted one of 11 sampled resident (Resident 3) with the use of the hoyer lift (mobility tool to assist staff with transfers of residents that have mobility challenges) during transfers, as indicated by the physician ' s order. This deficient practice had the potential to result in injury to Resident 3.