Montebello Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three (3) of 3 sampled residents (Residents 3, 23 and 71) reviewed for dignity were treated with respect and dignity in accordance with the facility's policy and procedure (P&P) when: Resident 3's indwelling catheter (a hollow tube inserted into the bladder [a hollow, balloon-shaped muscular organ located in your lower pelvis. Its primary job is to collect and store urine made by your kidneys until it is ready to be released from the body] to drain or collect urine) collection bag (ICCB) was not fully covered with a dignity bag. The dignity bag was covering the top half of the ICCB exposing the urine at the bottom of the ICCB. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately measure the shredded Monterey [NAME] Cheese used to prepare Quesadilla served for lunch on 5/14/2026. This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake, and weight loss for the six (6) of 6 sampled residents who received the Quesadilla on 5/14/2026.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling procedures and to maintain the food service area in a clean and sanitary manner in accordance with the facility's policy and procedure (P&P) by failing to ensure: The can opener was free of rust, peeling metal, and food residue. Containers of ground white pepper, oregano, ground black pepper, and onion powder were properly closed or sealed. The Brand 1 blender pitcher did not have a crack and did not have a whitish to yellowish color buildup. The Brand 2 food processor cover was not cracked and did not have a yellowish to whitish calcification buildup. The clear container of food thickener was properly closed. The microwave top and bottom interior was not rusted; the lining was peeled off, chipped and had dry food residue. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a coordination of care between the facility and hospice (care designed to give supportive care to people in the final phase if a terminal illness and focus on comfort and quality of life, rather than cure) staff for two of two sampled residents (Residents 6 and 40) by failing to ensure:Resident 6's hospice medications were reflected on the physician's orders. Resident 40's care plan reflected hospice care and interventions with hospice 1(HSP1). These deficient practices have the potential for Residents 6 and 40 to not receive the hospice care and services necessary to promote comfort and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device (a device used by a resident to signal his or her need for assistance) for one (1) of four (4) sampled residents (Resident 8) reviewed for environment was within reach in accordance with the facility's policy and care plan. This deficient practice had the potential to result in delayed provision of care and services for Resident 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean and homelike environment for one (1) of 23 sampled residents (Resident 102) by failing to ensure that the trashcan used for disposal of soiled (used) personal protective equipment (PPE-including protective clothing, helmets, gloves, face shields, goggles, face masks, respirators, or other equipment designed to protect the wearer from injury or the spread of infection or illness) in the resident's room(Room A) was not overflowing. This deficient practice created an unsanitary and unsafe environment and had the potential to place residents at risk of infection and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of five (5) sampled residents (Resident 4 and 55) were free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) by failing to ensure:Resident 4 had the correct indication for the use of buspirone (a prescription medication primarily used to treat generalized anxiety disorder [GAD, a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday issues]) as indicated on the facility's policy and procedures (P&P). Resident 55's Ativan (lorazepam, medication used to treat anxiety [persistent and excessive worry that interferes with daily activities) as needed (PRN) order had a documented rationale for extended use, beyond 14 days, in accordance with the facility's P&P.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate assessment of the Minimum Data Set (MDS, a resident assessment tool) to only reflect the resident's active diagnosis for one (1) of 23 sampled residents (Resident 32) in accordance with the facility policy. This deficient practice had the potential for the facility not to develop and implement an individualized care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, and mental psychosocial needs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) for one (1) of 23 sampled resident (Resident 40) when Resident was discharged from Hospice 2 (hospice, care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) on 6/27/2025. This deficient practice had the potential to prevent Resident 40 from receiving care that addressed the resident's specific needs, which could negatively affect the residents' overall wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming services, in accordance with the care plan and facility policy, for one (1) of three sampled residents (Resident 83) when Resident 83 was observed to have long, jagged fingernails and with a yellowish to light brown substance observed on the resident's right palm, left wrist, and fingernails. This deficient practice had the potential for Resident 83 to have injuries and harbor infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) for one (1) of three (3) sampled residents (Resident 3) reviewed for pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was at the correct settings in accordance with the facility's policy and procedure (P&P) and the resident's care plan (CP). Resident 3 weighed 152 pounds (lbs, unit of measurement for weight) but the LALM was set to 180 lbs. This deficient practice has placed Resident 3 at risk for deterioration of the resident's current pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment by not properly disposing of a used insulin syringe (specialized, single-use medical device used to inject insulin directly into the fatty tissue just beneath the skin) when one used insulin syringe was observed protruding halfway out of one of four sharps container (a specialized, puncture-resistant, and leak-proof bin used to safely dispose of medical instruments that can cut or puncture the skin). This deficient practice resulted in accident hazard and exposed staff and residents to the risk of needle stick injuries and potential bloodborne pathogen transmission (infectious microorganisms present in human blood that can cause disease in humans).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care services for one (1) of 1 sampled resident (Resident 6) reviewed for oxygen, by failing to ensure Resident 6 who was on oxygen therapy had her head of bed (HOB) elevated in accordance with the physician's order. This deficient practice had the potential to result in respiratory distress and had the potential to negatively impact Resident 6's health and well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 5) reviewed for dialysis (a lifesaving treatment for residents with a kidney failure), who was receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment was provided dialysis care according to the resident's care plan by failing to ensure post dialysis weight was obtained on 4/23/2026. This deficient practice had the potential for complications such as blood pressure drop for unnoticed excessive fluid removed during dialysis and/or fluid overload (occurs when the body retains too much water) if fluid is not properly removed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one (1) of six (6) sampled residents (Resident 38) when Licensed Vocational Nurse 2 (LVN 2) failed to administer Resident 38's potassium tablet (medication to treat or prevent hypokalemia [low blood potassium levels]) with food or full glass of water on 5/14/2026 as indicated on the facility policy and physician's order. This deficient practice had the potential to result in damaging the esophagus (muscular tube that connects the throat to the stomach) and irritating the stomach lining which may cause nausea, cramps, vomiting, or diarrhea (condition of having loose, watery stool at least three or more times in a single day, or more frequently) to Resident 38.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate and complete record for two (2) of 23 sampled residents (Residents 32 and 72) as indicated in the facility's policy and procedure when: Resident 32's memantine (Namenda, medication used to treat moderate to severe dementia [progressive state of decline in mental abilities] was incorrectly ordered for supplement instead of for dementia. Resident 72's 24-hour intake and output (I&O- the measurement of all fluids that enter and leave the body) was not tallied as ordered by the physician. This deficient practice had the potential to result in miscommunication, improper delivery of care, and inaccurate information of the care provided to Residents 32 and 72.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Resident 102's gastrostomy tube (G-tube a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) tip was not placed inside Resident 102's bedside drawer wrapped in tissue paper. This deficient practice had the potential to result in contamination of Resident 102's G-tube and increase the risk for infection.

Inspectors wroteBased on interview and record review the facility failed to provide supervision, safety measures and monitoring when one (1) of two sampled residents (Resident 1) eloped (exited the facility without the knowledge of facility staff) from the facility on 3/16/2026 around 8 PM and was not returned until 3/16/2026 around 8:45 PM by the police. This failure had the potential to lead to endangerment, accident and injury while outside the facility's premises without supervision from staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 6) received treatment and care in accordance with professional standards of practice (guidelines and expectations that define competent and ethical conduct within specific profession) by failing to complete medication reconciliation (the process of verifying and updating a patient's medication list during the transition from hospital to home or another care setting) of Resident 6's Discharge Medication List from General Acute Care Hospital (GACH 2) to administer the resident's Terazosin (a medication used in men to treat symptoms of benign prostatic hyperplasia [BPH-also known as an enlarged prostate], which include difficulty urinating, painful urination, and urinary frequency and urgency) once a day to start on 1/28/2025 at 9 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent accidents to one of four (Resident 1) sampled residents who was identified at risk for falls and had a history of falls in accordance with the facility's policy and procedure (P&P) titled, Fall Management by failing to:1. Ensure adequate supervision of Resident 1 was provided to prevent accidents and injury on 7/16/2025.2. Create a comprehensive resident - centered care plan (a care plan developed and implemented to meet his or her preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs) for Resident 1's long term care plan with focus on Resident 1's risk for fall/injury which includes intervention to supervise the resident every hour from 4/1/2025 to 7/16/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 2 sampled residents (Resident 1) who was unable to carry out Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily) was provided care and services to maintain good grooming and personal hygiene. This deficient practice resulted in Resident 1's fingernails being untrimmed with sharp edges which potentially resulted in the pea size bruise on the inner corner of the resident's left eye and scratches measuring 1/4 to 1 inch to the resident's right forehead.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop/implement comprehensive care plan for Resident 1's Foley catheter care which was order physician on [DATE]. This failure had the potential to negatively affect the provisions of care and services for Residents 1 and had the potential to place Resident 1 at risk for left buttock pressure ulcer wound become worse, cause urine blockage, and risk of urinary tract infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure concise, and accurate document what happened on 4/17/2025 on Weekly Summary Documentation for one (1) of two (2) sampled residents (Resident 1). This deficient practice had the potential to cause delay of precaution and care for pressure ulcer and potentially cause worsening of wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the appropriate care and services for one (1) of two (2) sampled residents (Resident 1) who was admitted with indwelling catheter (a tube that helps drain urine from the bladder [organ inside the body that stores urine] through a drainage tube [indwelling catheter tube] into a drainage collection bag) by failing to monitor Resident 1 for signs and symptoms of urinary tract infection (UTI, an infection in the bladder/urinary tract) in accordance with the care plan and facility policy on catheter care. This deficient practice had the potential to result in the delay of treatment and care in the event Resident 1 develops a catheter associated urinary tract infection (germs enter the urinary tract through the urinary catheter and cause infection) which could result in harm, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced dignity and respect in full recognition of the individuality for two (2) of three (3) sampled Residents (Residents 70 and 198) by failing to ensure the residents' urinary collection bag (a medical device used to collect urine that is drained from the bladder, typically via a urinary catheter [a thin, flexible tube {usually made of silicone or plastic} inserted into the bladder to drain urine]) was covered with a privacy bag. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accident (any unexpected or unintentional incident, which results or may result in injury or illness to a resident) hazards for two of two sampled residents (Residents 81 and 198) when: 1. A razor blade was found on the floor in Resident 81's room. This failure had the potential to cause injury to Resident 81. 2. Medication was observed left unattended at Resident 198's bedside table. This deficient practice had the potential for Resident 198 or other residents to get hold of the medication and if ingested (swallowed), had the potential for complications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe provision of pharmaceutical services as indicated in the facility policy by failing to: 1. Remove and discard one expired insulin (medication used to regulate blood sugar levels) Humulin R (short-acting insulin) vial, three expired suppositories (medications inserted into the rectum), one expired topical ointment (medication or cream applied directly to the skin), and two expired enemas (liquid to help relieve constipation [infrequent or difficult bowel movements]) from the medication cart. 2. Remove and discard eye drops according to label 3. Store insulin Lispro (short-acting insulin) and insulin Lantus (long-acting insulin) in the refrigerator. 4. Remove and discard three expired Vitamin D bottles from the medication storage room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide menus and nutritional adequacy for three (3) of 3 sampled residents (Residents 198, 84, and 35) in the food care area by failing to: 1. Provide Residents 198, Resident 84 and Resident 35 with a facility meal menu in advance 2. Follow the menu as written for Resident 198 on large and double portion (A large portion refers to a quantity that is bigger than average or standard, while double portion implies a quantity that is twice as large as the original or a standard amount) diets and were served incorrect amounts of food. These deficient practices had the potential to result in weight loss due to inadequate calories in residents who did not receive the correct amount or food items of their choices of their preference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) by failing to label and discard expired food items stored in the facility's kitchen refrigerators, freezers, and dry storage by failing to ensure: 1. 17 pre-filled orange juice cups and two (2) orange juice pitchers inside refrigerator 3 were labeled with a use by or expiration date. 2. Conventional oven temperature was accurate since its oven knobs have no temperature settings. 3. 18 Large metal baking trays were free of grease build-up 4. Two (2) large food pans were free from dents. 5. [...]

Inspectors wrote4. During a review of Resident 248's admission Record, the admission record indicated Resident 248 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD, a progressive lung disease characterized by persistent airflow limitation and difficulty breathing due to narrowed or damaged airways). During a review of the MDS, dated [DATE], indicated Resident 248 had modified independence (some difficulty in new situations) for cognitive skills for daily decision making. Resident 284 need partial or moderate assistance with the eating, oral hygiene and personal hygiene. Resident 284 was dependent with the toilet, upper and lower body dressing, change of position, and transfer. During a review of Resident 284's Physician Orders, dated 3/14/2025, the physician's orders indicated the following: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of one (1) of 21 sampled residents (Resident 9) in accordance with the facility policy by failing to ensure: 1. Resident 9's call light (device used by residents to call staff for assistance) was within reach. 2. Resident 9 was provided a touch pad call light (device used by residents to call staff for assistance with a gentle touch) appropriate for the resident's condition/needs. This deficient practice has the potential to delay in the provision of Resident 9's necessary care and services, which could negatively affect the overall condition of the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate assessment of resident's functional ability for personal hygiene on the Minimum Data Set (MDS, a resident assessment tool) for one (1) of 1 sampled resident (Resident 9) as indicated on the facility policy. This deficient practice had the potential for the facility to not develop and implement a resident centered care plan for Resident 9 to receive care and services to maximize or improve Resident 9's functional ability in personal hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan for two of 21 sampled residents (Residents 28 and 86) in accordance with the facility policy by failing to ensure a care plan reflected: 1. Resident 28's smoking and refusal to wear a smoker's apron (prevents burns in clothing and keep hot ashes from burning the skin) while smoking. This deficient practice had the potential to place Resident 28 at risk for injury, accidents, and harm. 2. Resident 86's fluid restriction as indicated on the physician's order, dated 3/1/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to set the low air loss mattress (LALM, pressure relieving mattress that operates using a blower based pump that is designed to circulate a constant flow of air through the mattress, commonly used to heal pressure ulcers [wound that occurs as a result of prolonged pressure on a specific area of the body]) at the correct setting for one (1) of six (6) sampled resident's (Resident 51) in accordance with the facility's policy and procedure (P&P) titled, Skin Integrity Management and physician's order. This deficient practice had the potential to result in Resident 51's pressure ulcers to worsen.

Inspectors wroteBased on observation, interview and record review the facility failed to label the enteral feeding (form of nutrition that is directly delivered into the digestive system (a group of organs that work together to digest and absorb nutrients from the food eaten) as a liquid) for one (1) of two (2) sampled resident's (Resident 80) in compliance with the facility's Enteral Feeding policy and procedure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately monitor the fluid intake for one of one sampled resident (Resident 86) who was on fluid restrictions, as indicated on the physician's order. This deficient practice had the potential to place Resident 86 at risk for fluid overload (too much fluid in the body which can raise the blood pressure and force the heart to work harder), edema (swelling caused by too much fluid trapped in the body's tissues), and dehydration (a dangerously loss of body fluid caused by illness, sweating, or inadequate intake).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure administering of all drugs and biologicals to meet the needs of one (1) of five (5) sampled residents (Resident 149) in accordance with the facility's policy and procedure (P&P) by failing to completely administer two (2) medications mixed in water to Resident 149. This deficient practice resulted to Resident 149 not receiving the full amount of 2 medications as prescribed by the physician, which could affect the resident's well-being.

Inspectors wroteBased on interview and record review the facility failed to conduct a monthly Medication/Drug Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) in the month of 2/2025 for one (1) of five (5) sampled residents (Resident 47) in accordance with the facility's Medication Regimen Reviews policy and procedure (P&P). This deficient practice had the potential to cause Resident 47 to receive unnecessary medication and to potentially have adverse reactions (harmful effects) from medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). There were two (2) medications errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error, which yielded a facility medication rate of eight (8) % for one of five (5) sampled residents (Resident 149) observed during medication administration. This deficient practice had the potential for harm to Resident 149 due to the resident not receiving the full amount of each medication as prescribed by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly contain waste and cover two (2) of 2 large trash bins with lids as indicated on the facility policy. This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) that could potentially infiltrate the facility, affect the resident care areas, and pose a disease threat to the residents and staff of the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide nutritional care services for one of two sampled residents (Resident 1) who is experiencing impaired nutrition by: a. Failing to ensure Resident 1's primary physician and Registered Dietician (RD) were notified regarding Resident 1's change of condition (COC, a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, of functional domains) of weight loss of six (6) pounds (lbs., unit of measurement) noted on 7/3/2024. b. Failing to ensure Resident 1's primary physician and RD were notified regarding Resident 1's meal intake of 50% or less noted on 7/3/2024, 7/5/2024, 7/6/2024, 7/7/2024, 7/8/2024 and 7/9/2024 (total of 6 days). c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary environment by failing to prevent the accumulation of dust and lint, and dispose dead cockroaches found in the facility's laundry room. This deficient practice had a high potential to encourage pest activity and infection.

Inspectors wroteBased an observation, interview, and record review, the facility staff failed to ensure one of four sampled residents (Resident 4) was free of accident hazards by leaving an unattended bottle of cleaning solution in the shower and failing to supervise Resident 4 who had a history of wandering (when a resident roams around and becomes lost or confused about his/her location). This deficient practice resulted in Resident 4 to gain access to the bottle of cleaning solution on 5/2/24 and was observed holding the bottle tilted towards the resident's mouth. This failure also had the potential for other residents to have access to the bottle of cleaning solution and risk for ingesting the cleaning solution, which could lead to harm and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures as indicated on the facility policy when facility staff failed to: 1. Wear Personal Protective Equipment (PPE, protective clothing such as gown, gloves, goggles, mask) when entering an Enhanced Standard Precaution (reducing transmission of organisms through health provider with the use of gown and gloves when caring for the resident) room. This deficient practice has the potential to spread infection to other residents. 2. Ensure the Legionella (a type of bacteria spread through small droplets of water that can cause legionellosis [Legionnaires' Disease, a serious and potentially deadly lung infection]) Water Management Program policy and procedure was fully implemented. [...]

Inspectors wroteFindings: 1.b. A review of Resident 24's admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included history of fall, history of transient ischemic attack (a temporary disruption in the blood supply to part of the brain), generalized muscle weakness, and other lack of coordination. During a review of Resident 24's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 2/20/2024, the MDS indicated Resident 24 was unable to follow commands, and required maximum assistance with the toilet, personal hygiene, change of position and transfer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment and care screening tool) accurately reflected the status of two (2) of 2 sampled residents (Residents 77 and 31) by failing to: 1. Resident 77 did not have an accurate assessment for falls. 2. Resident 31 did not have an accurate assessment for restorative nursing program (a program that helps residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) received. This deficient practice had the potential for the facility to not develop and implement an individualized care plan, which could negatively affect Resident 77 and 31's overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide the necessary care and services for (two) 2 of (three) 3 residents (Residents 77 and 82) who were at risk for falls by failing to: 1. Modify the fall/injury care plan for Resident 77 after episodes of multiple falls. Facility also failed to provide supervision to Resident 77. 2. Ensure Resident 82's floor mat was placed on the floor as indicated on the care plan. This deficient practice had the potential for injury to Resident 82 in an event of a fall. This deficient practice has the potential for Resident 77 and 82 to have further falls which could result to harm, hospitalization, and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of seven (7) sampled residents (Resident 16 and 48) as indicated on the facility policy by: a. During a Medication Pass observation, Licensed Vocational Nurse 7 (LVN 7) failed to administer Resident 16's medications within 60 minutes of scheduled time of 9 AM on 4/24/2024. This deficient practice had the potential for Resident 16's health and well-being to be negatively impacted due to unintended consequences, such as decreased effectiveness of the medications and adverse reactions (an unwanted effect caused by the administration of a drug) from the medications. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). 10 medication errors out of 33 total opportunities for error, to yield an overall medication error rate of 30.3 % for two (2) of seven (7) residents observed for medication administration (Residents 16 and 48). The medication errors were as follows: 1. During a Medication Pass observation, Licensed Vocational Nurse 7 (LVN 7) failed to administer Resident 16's medications within 60 minutes of scheduled time of 9 AM on 4/24/2024. 2. During a Medication Pass observation, LVN 7 failed to check Resident 48's blood glucose (blood sugar, main sugar found in the blood) and administer insulin (medicine to lower the level of glucose [type of sugar] in the body) before lunch meal on 4/24/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label foods in the kitchen with item name, 'use by' date (the last date recommended for the use of the product) and failed to discard expired food as indicated in the facility's policy and procedure. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe environment by failing to fix the broken tile around two uncovered sewer drains on the floor, in the hallway, causing the floor to be uneven. This deficient practice had the potential for residents, visitors, and staff to be placed at risk for fall and injury.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure one (1) of 22 sampled residents (Resident 18) was cared for in a dignified way by failing to sit and be at eye level while feeding Resident 18 on 4/22/2024. This failure had the potential to negatively affect Resident 18's dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five (5) sampled Residents (Resident 107) was given information to formulate an advance directive (written statement of a resident's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the resident be unable to communicate them to the doctor). This deficient practice had the potential to cause conflict in carrying out the Resident 107's wishes for medical treatment and health care decisions.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician/ medical doctor (MD) when there was a delay in discharging one (1) of 22 sampled residents (Resident 108) to home from 3/8/2024 to 3/9/2024. This deficient practice had the potential to result in an unsafe discharge.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for (one) 1 of 22 residents (Resident 77) who had multiple falls. This deficient practice has the potential for Resident 77 to have further falls, which could result in harm, hospitalization, and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to clean one of one sampled resident (Resident 36) face and gown after having breakfast. This deficient practice resulted in not meeting the resident ' s needs and had the potential for compromised dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan to insert an indwelling foley catheter (a hollow tube inserted though the urethra [a tube through which urine leaves the body] into the urinary bladder to collect and drain urine) for wound management for one of 22 sampled Residents (Resident 39). This deficient practice had the potential for Resident 39's wound to get worse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one (1) of 1 sampled resident (Resident 17) for respiratory care area by failing to ensure Resident 17's nasal cannula (NC, device used to deliver supplemental oxygen placed directly on a resident's nostril) tubing was changed weekly per facility's policy. This deficient practice had the potential for Resident 17 to develop a respiratory infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure for one of seven sampled residents (Residents 48) was free from significant medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications [not recommendations] regarding the preparation and administration of the medication or biological; or accepted professional standards and principles) by failing to check blood sugar and administer insulin (medicine to lower the level of glucose [type of sugar] in the body) before meals in accordance with the physician's order. On 4/24/2024, Resident 48's blood sugar was checked after the insulin was administered and after the resident already consumed a portion of his lunch meal. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for three out of 22 sampled residents (Resident 18, 41 and 78) by failing to accurately document the administration of antibiotic (medicine to treat infection) and narcotics (drug or controlled substance that affects the mood or behavior and if consumed for nonmedical purposes or not prescribed by the doctor can cause serious harm) count in the narcotic drug record (narcotic count sheet is a document used to document and track the administration of controlled substance to ensure accurate dispensing and administration of medications, as well as to provide a record of how much of a controlled substance has been used and when). This deficient practice had the potential to negatively impact the delivery of services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 22 sampled resident's (Resident 80) call light was within reach. This failure had the potential to result in Resident 80's not receiving assistance when needed from facility staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information (list of total number of staff and the actual hours worked by the staff) was posted and placed in a visible and prominent place on 4/22/2024. As a result, the total number of staff was not readily accessible to residents and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe and functional environment for residents, staff, and the public, due to an unapproved repair project, and non-compliance with the State building codes. This deficient practice of has the potential to have negative effects to the safety, welfare and health of the residents, staff, and the public.