Miracle Mile Healthcare Center, LLC

Inspectors wroteBased on interview and record review, facility failed to ensure one of three sampled residents (Resident 1) care plan was updated quarterly per facility policy. This deficient practice resulted in Resident 1 not having up to date goals and interventions to reflect his current care and needs and negatively affect his care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, safe, comfortable, and well-kept environment for one of three sampled residents (Resident 4) as evidenced by excessive clutter and hoarding behaviors in the resident's room. This deficient practice created a fire hazard and impeded safe mobility for both Resident 4 and facility staff. During a review of Resident 4's admission record indicated that Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Major Depressive Disorder (MDD - a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry), and Chronic Obstructive Pulmonary Disorder (COPD-a chronic lung disease causing difficulty in breathing). [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a licensed nursing staff were competent in identifying and safe management of a portable oxygen cylinder. One registered nurse supervisor (RN) was unable to identify whether a portable oxygen cylinder pressure gauge (an indicator for amount of oxygen remaining in the cylinder) was full or empty. This deficient practice had the potential to place residents requiring portable oxygen therapy by interrupting and delaying oxygen delivery during respiratory and cardiac arrest. During a facility tour observation on [DATE] at 11:11 AM, an empty portable oxygen cylinder was placed on a crash cart (a mobile set of drawers on wheels containing airway equipment such as oxygen mask, nasal and oral airway, oxygen cylinder, suction machine) used to treat life threatening emergencies. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately calculate the Direct Care Services Hours Per Patient Day (DHPPD) for Certified Nursing Assistants (CNA) for five of five sampled days ([DATE], [DATE], [DATE], [DATE] and [DATE]). This deficient practice resulted in inaccurate DHPPD hours being reported and posted and had the potential to affect the quality of care and services given to the residents because of a decrease in direct nurse care hours. During a telephone interview on [DATE] at 9:59 am with CNA 5, she stated her CNA certification expired in September of 2023 and she was assigned as hall monitor, sitter or caregiver depending on the need at the facility (which were all non-CNA roles). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the required Interdisciplinary Team (IDT, a group of people from different jobs or specialties who work together to help take care of a resident in a healthcare facility) members-specifically the attending physician-participated in the development of the resident's comprehensive care plan, and failed to document the physician's participation or any attempt to obtain input, for one of three sampled residents (Resident 2)These deficient practices had the potential to result in Resident 2's needs and care not been met.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2)'s physician order dated 3/16/2026 was being placed and implemented. This deficient practice had the potential to negatively affect Resident 2's care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2)'s History and Physical (H&P) was completed within 72 hours per the facility policy. This deficient practice had potential to result in Resident 2's needs not been met.

Inspectors wroteBased on interview and record review the facility failed to ensure medication left at resident's bedside was taken by one of four sampled residents (Resident 2). This failure resulted in Resident 2 not receiving the morning doses of their blood pressure, heart, and cancer medications, and had the potential to negatively affect her health. During a review of Resident 2's admission Record dated 5/1/26 indicated the resident was admitted to the facility on [DATE] with diagnoses including; [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS - resident assessment tool) for one of seven sampled residents (Resident 2). This failure resulted in an inaccurate assessment for Resident 2 and had the potential to affect the delivery of care and services. During a review of Resident 2's admission Record, dated 4/16/26, indicated Resident 2 was admitted to the facility on [DATE], with a diagnoses including; bradycardia (slow heart rate), hypertensive heart disease with heart failure (occurs when chronic high blood pressure causes the heart to work harder, resulting in thickened (hypertrophied) or weakened heart muscle), cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood), and hemiplegia (muscle weakness on one side of the body) of the left nondominant side. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure interventions performed during a change of condition incident were documented in the medical record for one of seven sampled residents (Resident 1)This failure resulted in an incomplete medical record for Resident 1 and had the potential to affect the delivery of care and services. During a review of Resident 1's admission Record, dated 4/16/26, indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses including; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remained free from accidents and hazards for ambulatory cognitively impaired residents, by failing to provide adequate supervision and monitoring for two out of three sampled residents, (Resident 1 and Resident 2) according to the facility's policy and procedures (P&P) titled, Safety and Supervision of residents with a review date of 1/20/2026. This deficient practice resulted in an unexpected and unintentional resident altercation that had the potential to result in significant physical injury and burns.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure five of 10 sampled residents (Residents 15, 55, 3, 11, and 46) received appropriate services to prevent a decline or maintain joint range of motion (ROM, full movement potential in a joint) and mobility by failing to:1a. For Resident 55, provide Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) as ordered for both upper extremities (UE, shoulder, elbow, wrist/hand) active range of motion (AROM, movement at a given joint when the person moves voluntarily) three times a week from 3/2/26 to 3/17/26. 1b. Indicate objective range of motion measurements for impaired joints on Resident 55's Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) evaluation dated 2/3/2026.2. [...]

Inspectors wrotea. Based on interview and record review, the facility failed to ensure that a physician was notified and documentation pertaining to the resident's refusal of medication was done for one of three sampled residents (Resident 89) according to the facility's policy and procedures (P&P) titled Requesting, Refusing, and/or Discontinuing Care or Treatment, reviewed 1/20/2026, when Resident 89 frequently refused the following medications;1. Antiseizure (calm overactive electrical signals in the brain to prevent or stop seizures) medications, 18 times in January 2026, 27 times in February 2026, and 22 times from 3/1/2026 to 3/19/2026.2. Antipsychotic (used to treat serious mental health conditions by managing symptoms such as hallucinations, delusions, or severe loss of touch with reality) medications 20 times in January 2026, 27 times in February 2026, and 17 times from 3/1/2026 to 3/19/2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 3/17/2026 by failing to:1. Ensure minced and moist texture bread and cabbage was prepared according to the IDDSI- Level Five minced and moist foods- (All foods prepared for this diet must be soft, moist with all excess fluid drained, and minced to size no larger than 4mm fits through the gaps of fork prongs) when 5 residents received bread and cabbage with carrots that was not small (minced) did not fit through the fork prongs.2. Ensure cooks followed the food production recipe for 28 residents on the soft and bite size diet (food particle are soft and chopped into 1/2 inch pieces) who received minced (ground beef consistency) corned beef instead of chopped into 1/2 inch pieces. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when:1. Two open packages of hot dog with dates 3/10/26-3/13/26 expired and stored in the walk-in refrigerator. Fully cooked Corned beef was stored on the bottom shelf below raw ground beef. One box containing 70 single serve containers of juice with a thaw date of 3/5/26 expired exceeding storage period for frozen juice and stored in the walk-in refrigerator. 2. There was water accumulation around the grease trap (A kitchen grease trap (or interceptor) is a plumbing device designed to capture fats, oils, and grease (FOGs) from wastewater/dish machine before they enter drainage systems, preventing clogs, backups, and odors.), oil-like substance was floating over the water build up. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner. Three of four trash bins were overfilled, lids kept open and flies were present inside the dumpster room. There was trash (plastic cups, food containers, plastic utensils, gloves and paper) scattered on the ground, and under the trash bins. This deficient practice had the potential for harborage and feeding of pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection control practices for one of one residents (Resident 115) and for three of three sampled staff by failing to: Change Resident 115's Peripherally Inserted Central Catheter (PICC-a long, thin, flexible tube inserted into a peripheral vein in the arm and advanced to the heart used to deliver medication intravenously (IV-into a vein) access for weeks or months) dressing within 7 days according to the facility's P&P titled, Central Venous Catheter Dressing Changes. [...]

Inspectors wroteBased on observation, interview and record review, the facility's staff and practitioner failed to assess one (1) out of 1 sampled resident (Resident 115's) mental and physical abilities to determine whether self-administering medications are clinically appropriate for the Resident prior to leaving medications at Resident 115's bedside. This deficient practice paused the risk of improper use/ingestion, and accidents with the potential for adverse reactions, unnecessary hospitalization and possible poor outcomes for Resident 115 and for residents with wandering behavior.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent employing a staff member who had been found guilty of abuse or mistreatment by a court of law when one of 10 contracted therapy staff (Physical Therapy Assistant [PTA] 1) continued to work at the facility after PTA 1 was cited by the Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) Board of California (PTBC) on 2/5/2025 for a conviction of a misdemeanor (criminal offense) violation of inflict corporal injury (willful, direct application of physical force) and failure to notify the PTBC. This deficient practice had the potential for PTA 1 to abuse or mistreat any resident residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident or their representative were notified timely in writing of resident transfer and bed hold provision according to the facility's policy & procedures (P&P) titled Bed-Holds and Returns with review date 1/20/2026 for one of five sampled residents (Resident 110). This deficient practice resulted in Resident 110 and/or their representative not being aware of the facility's bed hold policy upon transfer to the hospital from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide s speech and language pathology (SLP, profession that identifies, assesses, and treats speech, language, cognitive communication and swallowing disorders) services to improve communication for one of 25 sampled residents (Resident 92) who had difficulty with speech and communication. This deficient practice had the potential to prevent Resident 92 from communicating effectively with other residents, staff, healthcare providers, and the community.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the environment remained free of accident hazards for one of seven sampled residents (Resident 38) by failing to provide Resident 38 with a wheelchair with two hand brakes. This deficient practice has the potential to result in Resident 38 falling or sustaining an injury.

Inspectors wroteBased on interview and record review, the facility failed to effectively manage a resident's pain by not making a pain consultation appointment as ordered by the physician for one of one residents (Resident 16) sampled residents for pain management. This deficient practiced had the potential to negatively affect the residents' physical comfort and psychosocial well-being and had the potential to increase the resident's pain level.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 13), who had diagnosis of paranoid schizophrenia (type of schizophrenia associated with feelings of being persecuted or plotted against) was provided with the necessary behavioral health care as indicated in the plan of care and per physician order when the facility failed to monitor and document the targeted behaviors of Resident 13's psychotropic medications (drug that affects behavior, mood, thoughts, or perception). This deficient practice had the potential for Resident 13 to not receive the correct medication dosage or psychiatric care.

Inspectors wroteBased on interview and record review, the facility and consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) failed to identify irregularities during medication regimen review/ drug regimen review (MRR or DRR a comprehensive evaluation of a patient's current medication list to identify potential drug interactions, adverse effects, and other medication-related issues) related to administration of Keppra (generic name - levetiracetam, a medication used to treat or prevent seizures (a sudden, temporary surge of uncontrolled electrical activity in the brain that causes temporary changes in behavior, movement, feelings, or consciousness) when one of three residents (Resident 81) reviewed during medication pass observation, refused antiseizure medication, Keppra, 126 times between 12/2025 through 3/19/2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow doctor's orders to administer pain medication for severe pain at or above a pain score of eight out of ten (8/10- a numerical pain assessment tool where zero [0] is no pain and 10 is severe pain)for severe pain, per doctor's orders. This deficient practice did not provide treatment and care in accordance with professional standards of practice and physician's order for Resident 48.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage, labeling, and/or disposal of medications by failing to ensure: 1. An open box of Assure Prism Blood Glucose (BG; amount of sugar in the blood) Control Solution (used to check blood glucose monitors) included an open date (the date the medication was first opened) to prevent the potential use of blood glucose control solution after expiration for residents with diabetes (a condition where the body has trouble controlling blood sugar) receiving diabetic treatment from Medication Cart 4 (MedCart) 4, in accordance with the manufacturer's specification for Assure Prism Blood Glucose Monitoring System, dated 12/2025. 2. Resident 12, who was no longer in the facility's medications were removed from MedCart 2 and not stored with active residents' medications. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a bed grab bar (a medical device designed to assist with mobility, allowing users to reposition, turn, and safely transfer in and out of bed) was maintained and in good working order for one out of one sampled Resident (Resident 76). This deficient practice had the potential to create severe safety risks, such as entrapment, asphyxiation and falls with injury.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) of useable living space for 30 out of the 38 resident rooms per regulation requirement. This deficient practice had the potential to result in crowded living conditions, increased physical injury and lack of privacy from inadequate useable living space for the residents and working space for the health caregivers.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents' (Resident 2) was free from abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) and neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) by failing to ensure staff checked on Resident 2 every 2 hours to assist the resident with toileting as needed and to provide care on 1/9/2026 on the 11PM to 7AM shift on 1/9/2026 on the 11 PM to 7 AM shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the Low Air Loss mattress (LAL- a bed that alternates pressure to help heal and prevent pressure injuries) was set at the correct pressure for one of four sampled residents (Resident 1) according to the manufacturer's guide titled Dynarex LAL mattress manual. Resident 1's weight was 106 pounds (lbs-unit of weight measurement) and the LAL mattress was set for someone who weighed 350 lbs on 2/3/2026. This failure placed Resident 1 at increased risk for skin breakdown and compromised dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents' (Resident 2) did not suffer an unwitnessed fall on 1/9/2026 on the 11 PM to 7 AM shift as evidenced by failing to: Ensure that staff checked on Resident 2 every 2 hours to assist the resident with toileting as needed and to provide care on 1/9/2026 on the 11Pm to 7AM shift as stated in Resident 2's Care Plan (CP-a personalized document that outlines a resident's needs, goals, and the specific services required to achieve them, ensuring consistent and holistic care) titled Resident is at Risk for falls . initiated on 3/6/2025. 2Place floor mats on the floor for safety on 2/3/2026 as ordered by physician. This failure resulted in Resident 2 being found in her room on the floor (unknown length of time) sitting in feces on 1/10/2026 at approximately 5 AM. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide incontinent (lack of control over urination or defecation) care and appropriate pressure injury (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure) prevention interventions for one of four residents (Resident 1) as evidenced by Resident 1 wearing the same incontinent (the involuntary loss of bladder control (urine) or bowel control (feces/stool) brief (designed for managing moderate to heavy bladder or bowel incontinence) that Certified Nursing Assistant (CNA) 1 applied on the resident on 1/6/2026 at 5:30 AM through 1/10/2026 at 1AM (approximately three days). CNA1 wrote his initials, time, and date when he applied the incontinent brief on Resident 1. This failure placed Resident 1 at risk for skin breakdown and compromised dignity. Findings; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the safety of one of the three residents (Resident 1) by failing to: 1. Complete the Wandering Risk and Elopement (a patient, often cognitively impaired, leaves a healthcare facility or safe area unsupervised and unnoticed, posing serious risks of injury or death) Screening Assessment on 9/26/2025 (initial admission) on 10/20/2025.2. Update Wandering and Elopement Risk Assessment as Resident one is known to have observed displaying exit seeking behavior and trying to leave the facility on 10/11/2025 and 11/4/2025.3. Develop a comprehensive care plan for elopement to prevent injuries. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately provide necessary and appropriate behavioral health care and services to one of three sampled residents (Resident 1) who was experiencing mental health crisis on 11/4/2025 during the 3pm to 11pm shift. As a result on 11/4/2025, Resident 1 broke a window with the metal object. Resident 1 stood on top of a nightstand in her room l on the floor. Resident 1 suffered swelling and severe pain to the right leg. On 11/4/2025 at . Resident 1 was transferred to a general acute care hospital (GACH) 1 for further evaluation and management. Resident 3 was afraid to sleep and be in the same room with Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable environment for one of three sampled residents (Resident 2), by failing to ensure:1. Resident 2 was not admitted and remained in a cold room with a broken window on 11/4/2025 2. Repaired broken window in a timely manner.3. Checked and logged the resident's room temperature to ensure the room temperature was comfortable and not cold.4. Provide Resident 2 with extra blankets to keep the resident warm.5. Move resident 2 to another room with no broken window. These failures:1. Resulted in Resident 2 stating he was very angry and suffered/endured the from extreme cold temperature for two days and nights placing Resident 1 at increased risk to suffer hypothermia (a condition that occurs when core body temperature drops below 95 degrees Fahrenheit). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain window screens in good repair for one of six sampled resident rooms (Room A). During observation on 9/16/25, the window in Room A was observed open and the window screen had a big hole in the lower corner. This deficient practice had the potential for insects to enter through the hole in the window screen and potentially cause diseases to residents, staff and visitors. During observation inside Room A and concurrent interview on 9/16/25 at 11:23 a.m., the certified nursing assistant (CNA 1) stated the window in Room A was slightly open. CNA 1 stated the window was open for ventilation. CNA 1 further added the window screen had a hole and .insects such as flies and mosquitoes can get inside the room and go to the residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to keep the call light (the primary method of patient-nurse communication in a hospital setting, often used as a measure of nurse responsiveness) within reach for one of three random selected residents (Resident 3). This deficient practice had the potential to result in staff delay in meeting resident's needs for hydration, toileting, and activities of daily living as well as a delay in provision of assistance which may lead to falls and accidents. [...]

Inspectors wroteBased on interview and record review, the facility failed to promote dignity and respect for one of three sampled residents (Resident 3) by failing to: 1. Provide clean clothings and linen. 2. Provide an incontinence (Inability to control the flow of urine from the bladder [urinary incontinence] or the escape of stool from the rectum [fecal incontinence] diaper. This deficient practice placed Resident 3 to feel uncared for and embarrassed.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe and orderly discharge from the facility to Residential Care Facility for the Elderly (RCFE) for one of three sampled residents (Resident 1) by failing to: 1. to have resident's physician document the reason for discharge in the medical record. 2. have documentation of communication with the receiving facility about Resident 1's discharge and follow up call to the facility on how the resident was adjusting to the new facility. These failures had the potential to result in ineffective discharge planning, with disruption in continuity of care, and complications in the resident's recovery. Cross reference with F712.

Inspectors wroteBased on interview and record review the facility failed to provide one of six sampled residents (Resident 1) the Notice of Transfer Discharge form 30 days before non-emergency discharge. This failure resulted in the resident not being able to appeal his discharge thus infringing on his rights to do so.

Inspectors wroteBased on interview and record review the facility failed to ensure a safe and orderly discharge for one of six sampled residents (Resident 1). This failure resulted in the resident not being involved in selecting the facility he would be discharged to.

Inspectors wroteBased on interview and record review the facility failed to develop a care plan for history of memory problems for one of six sampled residents (Resident 1). This failure resulted in no plan of care for Resident 1's memory problems during his time at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physicians came in to visit the resident as outlined in the regulation for one of five sampled residents (Resident 1). This failure had the potential to effect the residents plan of care and delivery of services.

Inspectors wroteBased on interview and record review, the facility failed to honor one of the four sampled residents (Resident 3) rights to be seen by a physician by failing to arrange reliable transportation for Resident 3. This deficient practice resulted in Resident 3 missing his appointment on 3/4/2025.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of the four sampled residents (Resident 4) who was cognitively impaired was provided at least 80 square feet (sq. ft. -unit of measurement for space) per resident in multiple resident bedrooms. This deficient practice had the potential to negatively impact Resident 4 ' s well-being by reducing privacy and dignity.

Inspectors wroteBased on interview, observation and record review, the facility failed to maintain a safe, functional and comfortable environment for residents, staff and public by failing to ensure the ceiling was free from water leaks for two of five sampled residents (Resident 2 and Resident 3). This failure had the potential to place Resident 2 and 3 at risk for falls or injury from fracture (break in bone).

Inspectors wroteBased on interview, observation and record review, the facility failed to maintain a safe, functional and comfortable environment for residents, staff and public by failing to: i. Ensure the ceiling was free from water leaks for two of five sampled residents, Resident 2 and Resident 3. ii. Ensure the one of the 13 thermostats in the facility were free from mechanical and electrical failure and were in safe operating condition These deficient practices have a potential to cause incidental accidents and had the potential for the resident ' s physical discomfort. Cross Reference F689.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the elevator was in safe working condition. This failure had the potential to cause harm to the residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 25 residents (Resident 48, Resident 97, and Resident 105) had the Advance Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) or Advanced Directives Acknowledgement forms (a signed acknowledgment indicating the resident and/or resident representative were provided with information regarding creating an Advanced Directive) documented in the residents' active medical record. This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the facility staff stored and discard controlled (s (medications that the use and possession of are controlled by the federal government), and non-controlled medications properly as indicated in the facility's policy and procedures (P&P) titled Controlled Medication Disposal. This failure had the potential to result in lack of accountability for these medications, and presented a potential for the diversion of the controlled substances

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. [NAME] 1's cell phone and speaker were placed on the preparation sink (prep sink: area where food is prepared). 2. Opened bags of hashbrowns in the kitchen's chest freezer were not labeled with an open date. 3. Dietary Aide (DA1) loaded dirty pots and pans into the dish machine and then removed cleaned and sanitized dishes to air dry without washing hands between the two actions. These deficiencies had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could place the residents at risk for food borne illness or contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the industrial washing machine used to wash facility linen for residents was in operating condition to provide clean linen daily and as needed for all facility residents. This deficient practice had the potential to result in a significant delay in providing clean and sanitary linen for all 111 medically compromised residents. Cross reference:

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment for 2 out of 30 sampled Resident's (Resident 50 and Resident 84). The deficient practice of failing to obtain informed consent prior to initiating treatment with psychotropic medications (medications that affect brain activities associated with mental processes and behavior) could have prevented Resident 50 and 84 from exercising his right to decline to take psychotropic medications.

Inspectors wroteBased on observation, and interview, the facility failed to ensure a comfortable, homelike environment for one out of five residents (Resident 3). This failure resulted in Resident 3 feeling uncomfortably cold while resting in her bed without bed covering such as, a top sheet and blankets, in addition resident had no pillowcase for her pillow. Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to provide activities of daily living (ADL-such as bathing, showering, toileting, and mobility) for one of seven sampled residents (Residents 96). This failure resulted in Resident 96 feeling angry and had the potential to develop skin infections, skin irritation, and foul odor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent skin surrounding the ostomy free of excoriation (abrasion, breakdown) to the colostomy ( (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) site for one of seven sampled residents (Resident 114). This failure resulted in Resident 114's colostomy site and surrounding site to become excoriated and at risk for infection.

Inspectors wroteBased on interviews and record reviews the facility failed to complete a post-hemodialysis (dialysis is the removing of waste, salt, and extra water to prevent build up in the body for residents who have loss of kidney function) assessment for one of 18 sampled residents (Resident 47). This deficient practice placed the resident at risk for a delay in detecting if the resident had a non-functioning arteriovenous shunt (AV- a connection or passageway between an artery and a vein used for hemodialysis) and a delay in detecting complications including infections and bleeding.

Inspectors wroteBased on interview and record review, the facility failed to ensure the social service designee follow up with the sending facility (F2) the resident's personal belonging for one out of 30 sampled Residents (Resident 48) This deficient practice had the potential for personal property misplaced and or lost.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to observe infection control measures by: 1. Storing a clean bedside table, clean linen and a wheelchair in the bathroom for one out of nine bathrooms (room [ROOM NUMBER]'s bathroom). 2. Failing to doff used gloves after applying topical medication to a resident in room and then went out in the hallway for one out of five Licensed Vocational Nurse (LVN 5). These deficient practices had the potential to cause cross contamination and spread infections to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 68) did not have a broken trim on the wall near his bed, missing knobs to his closet door, and a exposed wire that ran from his television to the window in room [ROOM NUMBER]. This failure had the potential to put Resident 68 at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff receive required abuse training for one of five employees (Sitter 1 [STR 1]), who did not receive abuse training upon hire on 6/18/24. This failure has the potential to delay identification or protection of residents from possible abuse, neglect, and exploitation.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sample residents (Resident 2) was free from medication errors. By failing to ensure Resident 2 received the prescribed clonidine oral tablet 0.1 milligram (mg -metric unit of measure) give 1 tablet by mouth every six hours as need for hypertension for SBP more than 160 or diastolic blood pressure (DBP - blood pressure during the phase between heartbeats) more than 100 as ordered on 12/6/24, 12/7/24, and 12/15/24. This failure resulted in Resident 2 not receiving the prescribed medication as needed for systolic blood pressure (SBP - blood pressure in your arteries when your heart beats and pumps blood out) over 160. Placing Resident 2 at risk for uncontrolled blood pressure and stroke.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide protection from abuse by a facility staff, for one of the three sampled residents (Resident 1). By failing to ensure CNA3 did not slap Resident 1 on 12/5/2024. This deficient placed all facility residents at risk for further abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident, who had periods of confusion, did not elope (the act of leaving a facility unsupervised and without prior authorization) from the facility for one of nine sampled residents (Resident 1). The facility failed to: 1. Implement the care plan to Monitor/document/report PRN (whenever necessary) any changes in cognitive (of, relating to, being, or involving conscious intellectual activity (such as thinking, reasoning, or remembering) function when Resident 1 exhibited periods of confusion on [DATE]. 2. Monitor and supervise Resident 1 when Certified Nursing Assistant (CNA 3) observed Resident 1 on [DATE] at around 1 pm close to the elevator. Resident 1 was wearing a double gown (one on front and one on the back) with a sweater and had a black bag with some belongings. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to have a Director of Nursing (DON) employed at the facility consistently over the past two months. This failure had the potential to affect resident care, clinical outcomes, and assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a , well-kept environment for two of three sample residents (Resident 3 and 4), by failing to maintain a comfortable, warm room overnight, and a neutral odor environment. This deficient practice resulted in Residents 3 and 4 feeling cold at during the night and the unit having offensive odors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) who is continent (the inability to control the flow of urine or stool) of bladder (is a hollow, stretchy organ in the lower part of your abdomen that stores urine before it leaves your body through your urethra) and bowel (a long, tube-shaped organ in the abdomen that is part of the digestive system and is responsible for digesting food and expelling waste) received services and assistance to maintain continence. This failure had the potential to result in skin problems such as pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), skin irritation, rashes, redness, and peeling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two-person assist with Activities of Daily Living (ADL, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care for one of three sampled residents (Resident 1). These deficient practices resulted in Resident 1 falling to the floor during ADL care, was transferred to a general acute care hospital (GACH) sustaining a sprain to her left ankle.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food consistent with the preferences of one of three sampled residents (Resident 2) who was noted to be allegic (occurs when a person's immune system reacts to substances in the environment that are harmless to most people) to coconut, when staff served Resident 2's food tray was noted with a piece of chocolate cake noted with coconut on it. This failure resulted to Resident 1's getting a piece of chocolate cake noted with coconut on it which was listed as food allergy.

Inspectors wroteBased on interview and record review the facility failed to implement fall prevention measures by monitoring for the effectiveness of the interventions and modify the interventions based on the needs of the resident to prevent recurrent falls and injury for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 having multiple falls on 10/10/23, 11/20/23, 2/25/24, 5/24/24, 7/5/24, and 8/21/24. [...]

Inspectors wroteBased on interview and record review, the facility failed ensure medical record for two of four sampled residents (Resident 1 and 3) was accurate and compete for: 1. Resident 1's Medication Administration Record (MAR), 2. Resident 1 and 3's informed consent (resident's authorization to receive treatments or medications after risks and benefits are discussed by physician, physician's assistant, or nurse practitioner) form. These failures resulted in an inaccurate and incomplete medical record and informed consent forms. for Resident 1 and 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 8 [R8]) was provided care and services to main good grooming, personal hygiene, and clean and organized environment. This deficient practice resulted in R8 being left unattended in bed with a blanket, linen, gown, and trash on the floor.

Inspectors wroteBased on interview and record review, the facility failed to provide care, services, and advocacy for eight of 21 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, and 8 ) as per professional standards of practice, when the resident had a change in condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) by failing to: 1. Failing to check blood sugar levels (FS) before meals and/ checking dinner and bedtime within minutes of each other. 2. Failing to administer insulin (a naturally occurring hormone your pancreas makes that's essential for allowing your body to use sugar (glucose) for energy. If your pancreas doesn't make enough insulin or your body doesn't use insulin properly, it leads to high blood sugar levels (hyperglycemia). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate competencies to provide nursing and related services to assure resident safety by failing to: 1. Maintain and update basic life support/ Cardiopulmonary Resuscitation (BLS/CPR) certification to one of six sampled facility staff (Minimum Data Set Nurse 1[MDS1]). 2. Ensure two of six sampled facility staff (Licensed Vocational Nurse 2 [LVN2], and Licensed Vocational Nurse 9[LVN9]) had the specific competencies and skill sets necessary to care for the residents in the facility. These deficient practices had the potential to place resident at risk of not getting proper immediate care during a life-threatening situation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician when there is a significant change in resident's health condition for one of five sampled residents (Resident 1) by failing to: 1. Notify the attending physician and/or the Psychiatrist (PSYCH 1) when Resident 1 (R1) had increased paranoia (the unwarranted or delusional belief that one is being persecuted, harassed, or betrayed by others, occurring as part of a mental condition) episodes. Resident 1 stating, I was being poisoned, and refusing to take prescribed Risperdal (used to treat certain mental/mood disorders such as schizophrenia) and Keppra (used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain]). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 1[R1]) received Risperdal (medication used to treat certain mental and or/mood disorders such as schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly]) as prescribed by the attending physician (MD1). Resident 1's diagnoses included schizophrenia. 2. Ensure the MD1 were made aware that one of five sampled residents (R1) was refusing to take Risperdal as ordered and was exhibiting increased paranoia episodes manifested by (m/b) R1 stating, I was being poisoned, and hearing voices. 3. Ensure the Pharmacist (Pharm1) conducted a monthly medication regimen review (MRR - an important component of the overall management and monitoring of a resident's medication regimen) for one of five sampled residents' (R1) used of Risperdal. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality of care to ensure documentation were completed after administration of medications to each resident for four of eight sampled residents (Resident 1, 3, 4, 5). This deficient practice had the potential to result in medication error, which could negatively impact residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. One of three sampled residents (Resident 8 [R8]) received Risperdal (medication used to treat certain mental illnesses and or/mood disorders such as schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly]) as prescribed by the attending physician (MD1). 2. MD 1 was made aware R8 was refusing to take Risperdal as ordered and was exhibiting psychosis (a mental disorder characterized by a disconnection from reality) episodes manifested by (m/b) R8 refusing to treatments, sitting on the floor, and refusing to get back into bed while yelling and threatening staff when asked to into bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures to ensure the indwelling catheter (or known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag was not touching the floor for one of one sampled resident (Resident 8). This deficient practice had the potential for cross contamination and placed the residents at risk for infection.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to notify a physician of changes for one of three Residents (Resident 1). This deficient practice resulted Resident 1 not assessed by psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) after altercation with Resident 2.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to protect resident's right from physical and verbal abuse for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 2 slapping Resident 1 on the face.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were administered as ordered by the physician for one of two sampled residents (Resident 1). For Resident 1, the facility failed to document medications were administered as soon as given and failed to document the reasons why the medications were not administered. These deficient practices resulted in the facility failing to determine if the medications were administered to Resident 1, prevent the potential for medication errors, medication duplication and delay in care and treatment to meet the needs of Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure belongings were itemized for three of four sampled residents (Resident 1, Resident 2, and Resident 3). For Resident 1, Resident 2, and Resident 3, the facility failed to itemize their belongings upon admission and as new belongings were added during their stay at the facility. This deficient practice had the potential for Resident 1, Resident 2, and Resident 3 to lose their belongings without the facility knowing what belongings were missing. Findings. 1. A review of the admission Record indicated the facility admitted Resident 1 on 2/21/24 with diagnoses including cerebral palsy (a group of disorders that affect a person ' s ability to move and maintain balance and posture) and anxiety disorder. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the primary physician was notified promptly when there was a change of condition for one of four sampled residents (Resident 1). For Resident 1 who had diarrhea on 3/4/24 at 8:46 a.m., the facility failed to notify Resident 1 ' s primary physician (MD) promptly on 3/4/24 and ensure the physician orders for the blood test were carried out timely. The primary physician gave order on 3/5/24 for blood test and the blood test was not done until 3/8/24. These deficient practices had the potential for Resident 1 to have dehydration due to the diarrhea and potentially delay the necessary treatment.

Inspectors wroteBased on observation, interview, and record review, the facility's staff failed to revise a care plan for one of two sampled residents (Resident 2). This deficient practice had the potential to place Resident 2 at risk for altercations with other residents by wondering into other resident ' s rooms or coming onto the roommate ' s side of the room.

Inspectors wroteBased on observation and interview, the facility failed to provide an odor free and home like environment by failing: 1. Ensure the second-floor unit where residents resided was free from a strong ammonia smell which smelled like urine. This deficient practice had the potential to exacerbate (to make something that is already bad even worse) allergic reactions in residents who have respiratory issues such as asthma (is a condition in which your airways narrow and swell and may produce extra mucus. This can make breathing difficult and trigger coughing, a whistling sound (wheezing) when you breathe out and shortness of breath). 2. Provide a comfortable sound level for one of six sampled resident (Resident 1) per facility ' s policy. This deficient practice placed residents exposed to loud noise in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one out of one sampled resident (Resident 3) by failing to: 1. Ensure Resident 1 ' s nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) was changed per facility ' s policy. 2. Ensure there is a current physician ' s order for oxygen supplement therapy for Resident 1. These deficient practices had the potential for the residents to develop respiratory infection.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure one of six sampled resident, Resident 1 ' s medication was properly stored and secured per facility policy. This deficient practice increased the risk for accidents and unintended complications from receiving more or less than the required medications dose for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s(s ' ) right to be free from physical abuse by a Certified Nurse Assistant (CNA) for one of two sampled residents (Resident 1). This deficient practices placed Resident 1 at further risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to report immediately not later than two hours an allegation of abuse to the facility administrator, and to other officials (including to California Department of public Health [CDPH] and adult protective services where state law provides for jurisdiction in long-term care facilities) for one of two sampled residents (Resident 1). This deficient practice placed the residents in the facility at risks of abuse and a delay in a timely investigation.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Notice of Proposed Transfer and Discharge was provided to the resident as soon as practicable. The facility also failed to provide documentation to show that the State Long Term Care Ombudsman (public advocate) was notified of the transfer and discharge from the facility for one out of the three sampled residents (Resident 1). This deficient practice denied the residents additional protections from being inappropriately discharged and caused Resident 1to have increased depression and anxiety which required and increase in Lamotrigine (a medicine used to treat seizures which are bursts of electrical activity in the brain that temporarily affect how it works. It also helps prevent low mood [depression] in adults with bipolar disorder).

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of medical records for one of one sampled residents (Resident 1) by documenting a 30-day notice (notice to vacate/be discharged from the facility required to be provided to residents 30 days in advance) as served on 11/28/2023 instead of the actual date of 12/20/2023 (discharge date [DATE]) for one of the sampled residents (Resident 1). The deficient practice of falsifying the status of treatment records in such a way that the record does not accurately reflect information delivered to the residents had the potential to cause Residents 1 to experience anxiety and depression. Cross Reference:

Inspectors wroteBased on observation, interview, and record review the facility failed to respect the residents ' rights to dignity and respect for 1 out of 3 sampled residents (Resident 3). by failing to provide the resident clothing and by not utilizing privacy curtains or closing the door while resident was undressed. This deficient practice left Resident 3 exposed to facility staff, residents, and visitors leaving the resident vulnerable to exploitation, humiliation, and safety concerns.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of three sampled residents (Resident 3 ' s) medical records had accurately documented assessment and treatment reflective of the resident ' s status during a cardiac arrest (when the heart suddenly and unexpectedly stops pumping). This deficient practice resulted in Resident 1 ' s medical records being inaccurate and missing vital information of treatment and services provided while attempting to revive the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 113 out of 113 residents were provided a safe, clean, homelike environment by having peeling paint throughout the facility including residents' rooms, hallways, handrails and dinning room. This deficient practice had the potential to negatively affect residents' psychosocial (mental, emotional, social, and spiritual health) well-being and affect the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Maintain required accurate counts and documentation of controlled substances (a drug or medication that is monitored by the government) for one out of four medications carts (medication cart 3). 2. Maintain required accurate records and documentation of the use of drugs retrieved and administered from the emergency drug supply (e-kit) which included controlled substances. This deficient practice had the potential of drug diversion (used for a purpose or on a person not prescribed for) and/or medication errors.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 35 sampled residents (Resident 70) were free from significant medication errors (an error in medication administration or omission [withholding] that jeopardizes a resident's health and/or safety). By failing to: Administer Resident 70's furosemide (generic for Lasix, a medication to treat high blood pressure, HTN), losartan (medication to treat high blood pressure) nifedipine (medication to treat high blood pressure) and Flomax (medication used to treat benign prostatic hyperplasia, a noncancerous enlargement of the prostate gland) on 11/5/23 and on 11/8/23 as per physician's orders. This deficient practice had the potential to cause harm to Resident 70 by causing uncontrolled blood pressure which could in turn cause cardiac arrest, stroke, and death. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance. This deficient practice placed ninety-one (91) of one hundred thirteen (113) facility residents, who received food from the kitchen, at risk of not consuming adequate fiber, water soluble vitamins and unplanned weight loss, a consequence of poor food intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Dented (hallow or dip in a surface caused by pressure or blow) cans were found in the kitchen dry storage along with other cans not dented. b. Staff was not wearing a beard guard (a latex-free net use to prevent hair from falling to food). c. Six (6) clean carts used to deliver meal trays for lunch had dust residue on the racks. d. Refrigerator 1 door and gaskets (a rubber attached to outer edge of the refrigerator use for airtight seal) had dirt and dust build up. e. Walk in-freezer and chest freezer had ice buildups and ice crystals. f. Countertops and pots and pans storage areas were dusty to touch. g. Pots and pans were stacked wet and not air dried. h. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the assessment entries on the Minimum Data Set (MDS-a standardized assessment and care screening tool) related to accurate diagnoses for one of three sampled residents (Resident 55) were correct. This deficient practice had the potential to negatively affect the plan of care and delivery of necessary care and services for Resident 55.

Inspectors wroteBased on interview and record review the facility failed to ensure preadmissions screening and annual resident review (PASRR-mental health assessment used to identify a need for active treatment due to a mental illness) assessment screening was completed to determine the facility's ability to provide care for the special needs for one of four sampled residents (Resident 42). This deficient practice placed Resident 42 at risk of not receiving necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to revise a care plan titled Noncompliance with restorative nursing assistant (RNA-assist the resident in performing tasks that restore or maintain physical function as directed by the established care plan) for one of three sampled residents (Resident 102), who continued to refuse RNA services. This deficient practice had the potential for Resident 102 to have decreased strength, mobility, increased weight gain, depression (feeling sad or within drawn for normal activities of daily life), and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge summary included a final summary of the resident status, including reconciliation of all pre and post discharge medications and a post-discharge plan of care for one of three sampled residents (Resident 127). This deficient practice had the potential to delay assistance to Resident 127 for adjustment to a new living environment after discharge.

Inspectors wroteBased on observation, interview and record review the facility failed to implement its policy and procedures (P&P) titled Repositioning for one of three sample residents (Resident 64), by not repositioning Resident 64 every 2 hours. This deficient practice had the potential to negatively affect the resident's physical comfort, psychosocial well-being and had the potential for formation of pressure sores (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) to Resident 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its residents with or without limited range of motion (ROM - movement of the joints) received appropriate treatment and services to increase, prevent, or maintain the ROM mobility for one of six residents (Resident 113) with physician's orders for Restorative Nursing Assistant (RNA) exercises. This failure resulted in or had the potential to delay treatment and services for Resident 113 and placed the resident at higher risk for further decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess, document, and provide care and services consistent with professional standards of practice for the care of a hemodialysis (a machine that filters waste, salts, and fluids from your blood when your kidneys are no longer health enough to do this work adequately) AV Shunt (arteriovenous shunt-abnormal connections between coronary arteries and a compartment of the venous side of the heart for dialysis access) post dialysis for one of one sampled residents (Resident 70). This deficient practice had the potential to allow for unidentified malfunctioning AV shunt, infections and bleeding from the AV shunt site which could all lead to serious harm and/or death.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure one out of 35 sampled residents (Resident 70's) physician signed and dated physician's orders for the month of September 2023. This deficient practice had the potential for inaccurate orders and/or medication errors. Cross Reference:

Inspectors wroteBased on interview and record review, the facility's rehabilitation department failed to follow the facility's policy and procedure (P&P) to initiate a maintenance program with either nursing or restorative aids (certified nursing assistants primarily assigned to perform therapeutic exercises and activities to maintain or re- establish a resident's optimum physical function and abilities) following the completion of physical therapy (care that aims to ease pain and help you function, move, and live better) treatment for one (1) of three (3) sampled residents (Resident 67). This deficient practice resulted in the delay of treatment and services for Resident 67 and placed Resident 67 at risk for possible decrease in strength, mobility, and overall quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2), who was identified as exhibiting aggressive behavior, had a 1:1 sitter (provide residents with supervision, companionship, and care) monitoring the resident while smoking on the patio. As a result, on 10/18/2023, Resident 2 punched Resident 1 in the face while on the smoking patio. Resident 2 fell on the floor and Resident 1 continued to punch Resident 2. Resident 1 sustained an abrasion (a superficial rub or wearing off on the skin) on the left cheek.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) who had episodes of aggressive behavior was provided with adequate supervision. As a result, on 10/18/2023, Resident 2 physically attacked Resident 1. Resident 2 punched Resident 1 in the face. Resident 1 fell on the floor and Resident 2 continued punching Resident 1.

Inspectors wroteBased on interview and record review the facility failed to provide services in compliance with applicable state regulation that require facilities licensed for 100 beds or more shall always have at least one registered nurse (RN) on duty in the facility, day, and night, in addition to the director of nursing services (DON). The facility failed to ensure that an RN was always on duty during the 7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift and 11 p.m. to 7 a.m. shift for the month of 9/2023. This deficient practice failed to ensure supervision were given to licensed vocational nurses, (LVN ' s), certified nursing assistants (CNAs) and oversee the care of the residents in the facility.