Monrovia Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices for four of eight sampled residents (Residents 1, 5, 6, and 7) by failing to:Ensure Resident 1's bedside dresser was clean. Ensure Residents 1, 5, 6, and 7's shared bathroom closet area was clean. These failures had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and/or the development and transmission of disease (an illness or sickness) and infections to Residents 1, 5, 6, and 7. A&B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Hoyer lift sling (a supportive fabric device that cradles an individual used with a Hoyer lift [a patient lift, a mechanical device with lifting mechanism] to safely transfer individuals with limited mobility between a bed, wheelchair, or toilet) was maintained in a safe and functional condition prior to a transfer for one of two sampled residents (Resident 2). As a result, on 6/4/2026, the Hoyer lift sling ripped while Resident 2 was lifted off the bed, suspending Resident 2 in the air. Resident 2 fell from the Hoyer lift to the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, safe, sanitary, and homelike environment when:a. There was black substance on the caulk (a flexible sealing material used to fill gaps, cracks, and joints to prevent air, water, dust, and contaminants from passing through) in two of two showers (Shower 1 and Shower 2) located inside one of two facility shower rooms.b. The cove base (a type of vinyl and or rubber trim that's applied to the edges of a floor to help create a smooth transition between the floor and the wall) in the shared bathrooms of three of three sampled resident rooms (Rooms 1, 31 and 35) and the wall close to the bathroom door inside room [ROOM NUMBER] was loose and had a gap from the wall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 3 and 14) received nursing care and services in accordance with professional standards of practice. For Resident 3 the facility failed to ensure the physician notification was completed and act upon a change in condition (CIC) when Resident 3 experienced the following: On 4/2/2026 Resident 3's sodium level (Normal sodium levels = 135 to 145 milliequivalent per liter (meq/L)) was 131 meq/L (low). Resident 3's level of consciousness was altered and Resident 3 was lethargic (consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and appropriate discharge for one of one sampled resident (Resident 80) who discharged against medical advice (AMA- when a resident chooses to leave the facility before the physician recommends discharge). This failure had the potential to result in Resident 80 being discharged without necessary instructions, services, or follow-up care, placing the resident at risk for adverse health outcomes, including worsening conditions, medication mismanagement, or rehospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate comprehensive assessment for one of one sampled resident (Resident 46) when Resident 46's Minimum Data Set (MDS - a resident assessment tool) did not indicate Resident 46 had loosely fitting dentures. This failure had the potential to result in Resident 46's individualized needs not being met and had the potential to result in an increased risk of weight loss or malnutrition.

Inspectors wroteBased on interview and record review, the facility failed to develop a specific and individualized smoking care plan for one of six sampled residents (Resident 73) to address safe storage and safety when Resident 73 kept their own smoking supplies. This deficient practice had the potential for unsafe smoking practices at the facility. During a review of Resident 73's admission Record (AR), the AR indicated the facility admitted Resident 73 on 5/20/2022, with diagnoses that included hemiplegia and hemiparesis (one-sided weakness and paralysis) affecting the left dominant side and depression (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities). During a review of 73's Annual Exam (Amended) History (H&P), dated 11/2/2025, the H&P indicated Resident 73 had the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services were provided to or one (1) of one (1) sampled resident (Resident 44) who was at risk for skin breakdown and pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) to prevent worsening skin integrity by failing to ensure the low Air Loss Mattress's (LALM- an air-filled mattress used to relieve pressure) setting was set according to Resident 44's weight. This failure had the potential to compromise pressure redistribution and increase the risk for skin breakdown and pressure injury development for Resident 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement adequate accident prevention interventions for one (1) of (2) sampled residents (Resident 71) by failing to:A. Ensure Resident 71's bed alarm was properly functioning at the time of the fall on [DATE]. B. Ensure adequate supervision was provided at the time of Resident 71's fall on [DATE]. These deficient practices resulted in Resident 71 sustaining a fall, placing the Resident 71 at increased risk for injury, including potential fractures, head injury, and decline in overall condition.

Inspectors wroteBased on interview and record review, the facility did not provide needed dental services for one of one sampled resident (Resident 46) when the Social Service Director (SSD) did not follow up with Resident 46's denture needs. This failure resulted in Resident 46 having feelings of abandonment and had the potential to result in Resident 46 experiencing nutritional deficits and psychosocial decline.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four kitchen staff (Dietary Supervisor and [NAME] 1) follow the International Dysphagia Diet Standardization Initiative (IDDSI - developed a standard that can be used to describe the characteristics of foods and drinks - from the point of view of a person with swallowing difficulties. To accompany this standard, IDDSI has also developed testing methods to determine if any food or drink conforms to the requirements of the IDDSI Standard) to test pureed food (A diet used in the dietary management of dysphagia with the food texture prepared lump-free, not firm or sticky and holds it shape on a plate. The diet requires no biting or chewing. Any liquids must not separate from the food and the food can fall off a spoon intact. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure thawed bacon inside one of two refrigerators (Refrigerator 2) was labeled with a thaw date for dietary staff to follow recommended maximum storage period. This deficient practice had the potential to cause food borne illness that could potentially affect the residents at the facility.

Inspectors wroteBased on interview and record review, the facility failed to immediately report an influenza (the flu, a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) outbreak (the occurrence of influenza cases greater than would normally be expected) to the Los Angeles County (LAC) Department of Public Health (DPH) when 3 of 6 sampled residents (Resident 1, Resident 2, and Resident 3) tested positive for influenza and as indicated in the Influenza and other Respiratory Virus Diseases Outbreak Toolkit. This deficiency had the potential to delay implementation of specific instructions from DPH to prevent the spread of influenza throughout the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dignity and privacy for two of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to affect Resident 2's and Resident 3's psychosocial wellbeing. a. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 5/27/2020, with diagnoses that included (a mental illness that is characterized by disturbances in thought) and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 1/14/2026, the MDS indicated Resident 2's cognitive status (the ability to think and process information) was moderately impaired. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Certified Nursing Assistant (CNA) 3 changed gloves after transferring Resident 4 back to bed and before preparing supplies and handling clean linens and diaper for Resident 4's diaper change on 2/4/2026. 2. CNA 1 and CNA 2 changed wash cloths and bath water prior to providing Resident 2 and Resident 3 perineal care on 2/5/2026. These deficient practices had the potential to spread bacteria that could lead to urinary tract infection.

Inspectors wroteBased on interview and record review, the facility failed to provide copies of requested medical records within two business days from written request as indicated by the facility's policy and procedure (P&P) titled, Access to Personal and Medical Records for one of three sampled resident (Resident 1). This deficient practice violated Resident 1's right to obtain copies of resident's medical records in a timely manner and had the potential to affect Resident 1's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs four of four sampled residents (Residents 1, 2, 3, and 4 ) in accordance with the facility's Policy and Procedure (P&P) by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was functioning during the power outage for 11 hours from 10/16/2025 at 9:30 PM to 10/17/2025 at 8:30 AM.These deficient practices had the potential for Residents 1, 2, 3, and 4 who were assessed as high risk of falls to not be able to call the facility staff for help or assistance and placed the residents at risk for harm/injury.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's Policy and Procedure (P&P) titled Medication Orders and Receipt Record to ensure three of three sampled residents (Residents 1, 6 and 7)'s medication delivered by the pharmacy were checked, signed, dated and timed by licensed staff upon receiving. This failure had the potential for missing medication or residents receiving wrong medication.

Inspectors wroteBased on interview and record review, the facility failed to notify Resident 1's doctor of Resident 1's refusals of accuchecks (sampling a drop of blood from the finger to determine the blood glucose [sugar] level) and insulin (a hormone that lowers the level of glucose [a type of sugar] or sugar in the blood) injection on 8/3/2025 and 8/4/2025. These failures had the potential to result in Resident 1 to not receive treatment to address Resident 1's risks for hypoglycemia (a condition where the level of glucose in the blood drops below a healthy range) or hyperglycemia (having too much glucose in the blood) which could negatively affect Resident 1's health and wellbeing.(Cross Reference F686 andF755)

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for one of two sampled residents (Resident 8) to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement, within two hours, in accordance with the facility's policy and procedure (P&P), titled Abuse Investigation and Reporting, dated 7/2017. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services to improve one of three (3) resident's (Resident 10) ability to carry out activities of daily living (ADL, basic activities such as eating, dressing, toileting) by failing to offer and assist Resident 10 out of bed into a chair for meals as ordered by the physician. This deficient practice placed Resident 10 at risk for a functional decline in physical functioning and mobility, decreased quality of life, pressure sore (injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) development, and feelings of low self-esteem and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 10) received treatment and care in accordance with professional standards of practice by failing to ensure Resident 10's Orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) consultation recommendations were implemented. This deficient practice resulted in a delay of care and had the potential for worsening pain and swelling in Resident 10's left hip and left knee and a decline in Resident 10's mobility, range of motion (ROM, full movement potential of a joint), physical comfort and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to document a weekly skin check for one of two sampled residents (Resident 1) from 7/5 - 7/18/2025. This failure had the potential for Resident 1's skin wounds to get worse and to not receive timely treatment for the worsening skin wounds.(Cross Reference F580 and F755)

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled resident's (Resident 1) supply of Morphine Sulfate (a medication used to treat pain) was restocked and readily available when the resident needed it. This failure had the potential to result in Resident 1 to experience unrelieved pain.(Cross Reference F580 and F685)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a Speech Therapy (ST, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) evaluation in accordance with the physician's orders for one of three sampled residents (Resident 10) who had swallowing, communication, and cognitive (mental action or process of acquiring knowledge and understanding) concerns. This deficient practice prevented Resident 10 from receiving ST services to potentially improve swallowing, cognitive, and communication abilities and maintain or achieve the highest practicable level of function.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records for one of three sampled residents (Resident 10) were readily accessible by failing to ensure Resident 10's Orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) consultation note, dated 3/20/2025, was readily accessible. This deficient practice had the potential to delay and negatively affect the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 sampled resident (Resident 1) was notified of a diagnostic test result that indicated Resident 1 had a mass (a lump) that measured 3.4-centimeter (cm, unit of measurement) on Resident 1's right kidney on 01/29/2025. Additionally, the facility failed to ensure appropriate follow-up was completed by Resident 1's physician (unidentified) to determine whether further interventions were necessary for Resident 1. This failure resulted in a delay in medical treatment and had the potential to result in a physical decline to Resident 1 due to the delayed treatment of a potentially serious medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- a resident assessment tool) related to active diagnoses was accurately documented for one of four sampled residents (Resident 2) when Resident 2's Parkinson's disease (a disorder of the central nervous system [a processing center that manages everything the body does] that affects movement, often including tremors) was not coded (recorded) in Resident 2's MDS. This deficient practice had the potential to negatively affect Resident 2's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan to address medication administration and side effects of Sinemet (a medication commonly used to manage Parkinson's disease [a disorder of the central nervous system (a processing center that manages everything the body does) that affects movement, often including tremors] symptoms, can cause a range of side effects, both mild and serious) for one of four sampled residents (Resident 2). This deficient practice had the potential to result in medication side effects not being identified and addressed for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's consultant pharmacist (PharmD) identified the irregularities (includes but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences) related to Sinemet use (medication used to manage the symptoms of Parkinson's disease [a disorder of the central nervous system (a processing center that manages everything the body does) that affects movement, often including tremors) during the monthly medication regimen review (MRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one of four sampled residents (Resident 2). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was receiving Sinemet (medication used to manage the symptoms of Parkinson's disease [a disorder of the central nervous system (a processing center that manages everything the body does) that affects movement, often including tremors]) was free from unnecessary medication for one of four sampled residents (Resident 2) by failing to: 1. Ensure there was a documented adequate indication for the use of Sinemet medication. 2. Ensure Resident 2 was monitored for effectiveness and/or any potential adverse side effects of Sinemet. These deficient practices had the potential to result in unnecessary use of Sinemet by not monitoring the effectiveness of Sinemet or potential adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed for one of four sampled residents (Resident 1) to assist Resident 1in finding her missing personal belongings. This failure had the potential for Resident 1 to feel unheard and/or disrespected. (Cross Reference F842)

Inspectors wroteBased on interview and record review, the facility failed to accurately document in one of four sampled residents (Resident 1) medical record the facility staff members who were present at Resident 1 ' s quarterly care conference (also known as a care plan meeting, is a scheduled meeting where staff, residents, and family members discuss the resident's care plan, progress, and any concerns) on 2/27/2025. This failure resulted in Resident 1 ' s medical records to contain inaccurate information. (Cross Reference F557)

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize, assess, and provide effective pain management to two of nine sampled residents (Resident 2 and Resident 3), according to the facility's policies and procedures (P&P) titled, Pain- Clinical Protocol, and Changes in Resident Condition, by failing to: 1. Ensure Resident 2's request to Licensed Vocational Nurse (LVN) 5 to have pain medications of ibuprofen (medication used to treat mild pain rated one to three out of 10) and Tylenol (acetaminophen- pain medication used to treat mild pain rated one to three out of 10) changed from as needed (medication taken when symptoms occur) to scheduled (medication taken at regular intervals) was reported to Resident 2's physician. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of nine sampled Residents (Resident 5) received prescribed (ordered by a physician) medications in accordance with the facility's policy and procedure (P&P) titled, Administering Medications, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 6 administered Resident 5's medications as ordered for the following medications: a. calcium (medication or mineral in nutritional supplements and multivitamins used to treat or prevent conditions associated with low calcium levels) 600+D3 (fat-soluble vitamin essential for bone health). b. Freshkote (medication used to relieve dry, irritated eyes) ophthalmic (eye) solution. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policies and procedures titled, Handwashing/Hand Hygiene (procedures that included the use of alcohol-based hand rubs (containing 60%-95% alcohol) and hand washing with soap and water), and Enhanced Barrier Precautions (EBP- set of infection control measures that use personal protective equipment [PPE- equipment worn to minimize exposure to hazards] to reduce the spread of multidrug-resistant organisms [MDRO- organism that is resistant to most antibiotics] by wearing a gown and gloves) by failing to: 1. Ensure Certified Nurse Assistant (CNA) 2 performed hand hygiene before and after providing care to Resident 8. 2. Ensure CNA 3 performed hand hygiene before and after providing care to Resident 10. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- a resident assessment tool) related to active diagnoses was accurately documented to reflect the resident's medical condition for one of nine resident (Resident 2). This failure had the potential to negatively affect Resident 2's plan of care and delivery of necessary care and services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation on the medication administration record (MAR- a report that serves as a legal record of the medications administered to a resident) for one of nine sampled residents (Resident 3), according to the facility's policy and procedure (P&P) titled, Charting and Documentation, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 4 accurately documented Resident 3's pain score (pain score indicating level of pain with zero being no pain and 10 being the worst pain) when LVN 4 gave Resident 3 Tylenol (acetaminophen- pain medication used to treat mild pain rated one to three out of 10). This failure had the potential to negatively affect Resident 3's plan of care and delivery of necessary care and services for uncontrolled pain management. Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to ensure a staff member treated one of one sampled resident (Resident 44) with respect and dignity. This deficient practice made Resident 44 feel singled out, embarrassed, emotionally distressed, angry, and belittled. Additionally, the deficient practice had the potential to cause psychosocial harm to Resident 44.

Inspectors wroteBased on observation and interview, the facility failed to ensure a homelike environment for one of one sampled resident (Resident 21) as evidenced by a cracked window in Resident 21's room. This failure resulted in Resident 21 feeling no one cared about the appearance of Resident 21's living space had a cracked window and was described by Resident 21 as ghetto and tacky.

Inspectors wroteBased on interview and record review the facility failed to develop a care plan (CP - document created that outlines the type of care a patient needs) for one of one sampled resident (Resident 3) for participating in the facility's bowel and bladder program. This failure had the potential to result in unmet bowel and bladder continence (ability to control movements of the bowel and bladder) needs for Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing sensory stimulating activities program designed to meet the interest of Resident 226. This deficient practice had the potential to result in psychosocial decline and a decreased quality of life to Resident 226 due to boredom and loneliness.

Inspectors wroteBased on interview and record review the facility failed to follow the steps outlined in the facility's policy and procedure (P&P), titled, Bladder and Bowel Program, for one of one sampled resident (Resident 3) who was placed in the bladder and bowel program. This failure had the potential to lead Resident 3 being unable to regain bowel and bladder continence.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a code status (an instruction from a patient of the medical team indicating what the medical team should do if the patient has a cardiac or respiratory arrest) was documented on the admission Record, Electronic Health Record (a digital version of a patient's medical history that can be accessed by authorized healthcare providers) dashboard banner, and the physical medical record for one of one sampled residents (Resident 27). This deficient practice had the potential to lead to negative outcomes with failing to honor resident's wishes and improper end-of-life care in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of three sampled residents (Resident 1) as indicated in the facility's policies and procedures (P&P) titled, Safety and Supervision of Residents, and Falls and Fall Risk, Managing, by failing to: 1. Ensure Certified Nursing Assistant 1 and/or Licensed Vocational Nurse 1 provided supervision/monitoring when Resident 1, who was assessed as being high risk for falls, had increased agitation and confusion, repeated episodes of getting out of bed, and ambulating in Resident 1's room unassisted. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise the plan of care and implement new interventions for one of three sampled residents (Resident 1) after Resident 1 first fell on 6/24/2024 at 1:20 AM to prevent Resident 1 from further falls and injuries. This deficient practice placed Resident 1 at risk for further falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 5) was free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to a resident's body, cannot be easily removed by a resident, and restricts the resident's freedom of movement or access to their body) for use of convenience (the result of any action that has the effect of altering a resident's behavior and requires a lesser amount of care or effort, and is not in a resident's best interest) by failing to ensure Certified Nurse Assistant (CNA) 1 did not tie the bedsheet/fitted sheet to the grab bar and keep Resident 5's arms under the fitted sheet to prevent Resident 5 from moving the resident's arms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a low air loss mattress (LAL mattress, a type of medical mattress designed to reduce pressure on the skin, which helps prevent pressure ulcers ([PU] localized damage to the skin and underlying soft tissue, usually over a bony prominence (areas where bones are close to the surface) or related to a medical or other device, resulting from sustained pressure) as per Physician's Order for one of three sampled residents (Resident 1 This deficient practice had the potential for Resident 1's PU to worsen.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 3 sampled residents (Residents 14, Resident 61, Resident 67) were made aware of the location of the most recent survey results conducted for resident's review. This failure resulted in violation of resident rights to access the facility's survey results and had the potential to result in the residents not being fully informed about the facility's overall performance and the potential for resident's not being able to make informed choices due to the lack of information.

Inspectors wroteBased on observation and interview the facility failed to ensure resident meals were palatable (refers to the taste and/or flavor of the food) for 3 of 3 sampled residents (Resident 47, 54 and 56) and the facility failed to taste the food prior to serving to the residents (in general) and as indicated in the facility's policy and procedure (P&P). This failure had the potential to result in unplanned weight loss due to poor food intake for Residents 47, 54 and 56.

Inspectors wroteBased on interview and record review, the facility failed to ensure the signed binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by an arbitrator [third party decision-maker] instead of a judge or jury in court) for three of 18 sampled residents (Residents 74, 130, and 56) was provided for the selection of a neutral arbitrator and a convenient venue (location to carry out arbitration proceedings agreed upon and suitable to both parties). This failure had a potential to result in a decline in the Resident 74, 130 and 56's physical and psychosocial condition due to possible hardships related to arbitration proceedings.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 56) was included in the resident's discharge planning. This failure resulted in Resident 56 not participating in Resident 56's discharge planning and had the potential to result in Resident 56's personal choices and preferences not included in Resident 56's discharge planning.

Inspectors wroteBased on interview and record review, the facility failed to ensure an abnormal urinalysis (urine test to detect and manage some disorders, such as urinary tract infections [UTI] or kidney problems) result of one of one sampled resident (Resident 132) was reported to the physician timely. This failure had the potential to result in a decline in Resident 132's condition due to a delay in the delivery of treatment and services.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services for one of one sampled resident (Resident 56) by failing to administer four liters per minute (4L/min, Liters, unit of volume, per minute) of continuous (constant, steady, and reliable oxygen flow) oxygen (O2, gas that the body needs to live) through a nasal cannula [NC, a device that gives you additional oxygen through your nose]) as indicated in the physician's order and the facility's policy and procedures (P&P). This failure had the potential to result in Resident 56 to experience shortness of breath, a delay in treatment, and the potential to result in respiratory distress (oxygen deprivation).

Inspectors wroteBased on interview and record review, the facility failed to ensure transportation was provided for a follow up eye (vision) appointment for one of one sampled resident (Resident 31), who needed eyeglasses. This failure resulted in a delay of necessary care and services for Residents 31 and had the potential to result in worsening eyesight for Resident 31.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 46) who was a smoker, was assessed quarterly on November 2023 for smoking risk factors and resident safety. This failure had the potential to result in Resident 46 to experience complications from smoking and sustain serious injuries.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the medical records of one of one sampled resident's administration of wound treatment was accurately documented (Resident 77). This failure had the potential to result in increased risk for inaccurate treatments being provided to Resident 77.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the infection prevention and control practices and implement interventions to prevent and control the spread of infections in the facility for one of 5 sampled residents (Resident 53), who had an indwelling medical device (device embedded in the body that provides a direct pathway for pathogens in the environment to enter the body and cause an infection), in accordance with the facility's policy and procedures (P&P) and national health guidelines. [...]