Monterey Healthcare & Wellness Centre, LP

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) on abuse for one of two sampled residents (Resident 4) when Certified Nursing Assistant (CNA) 1 failed to report an alleged resident-to-resident altercation between Residents 4 and 5 on 4/28/26. This deficient practice had the potential to place Resident 4 at risk for unrecognized abuse, delayed assessment of injuries, and failure to ensure resident safety, protection, and timely reporting in accordance with the facility's Abuse and Neglect policy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary medical social services to one of two sampled residents (Resident 3) when the Social Service Coordinator (SSC) did not follow up or encourage Resident 3 to participate in dental care services, and did not explain the potential risk and benefits of declining dental treatments as indicated in the Resident's care plan after Resident 3 reportedly refused dental treatments on 4/1/26. This deficient practice had the potential to result in unmet dental needs, delayed identification and treatment of oral health issues, and a possible decline in Resident 3's overall health and quality of life due to lack of appropriate follow-up and support from facility staff.

Inspectors wroteBased observation, interview, and record review, the facility failed to implement proper infection control for 66 of 66 sample residents per the facility's Water Management Plan for the Prevention of Waterborne Pathogens (bacteria, viruses, or parasites found in contaminated water) by failing to ensure: 1. The Water Heater 1's mercury temperature gauge (a glass tube filled with mercury that can be used to measure changes in temperature) was not broken and functional. 2. The Water Heater 2's mercury temperature gauge reading was maintained at 110 degrees Fahrenheit ( F, a unit of temperature), not at 145 F. 3. The water temperature reading at Nursing Station A ranged from 86 F - 105 F, which was below the 110 degrees Fahrenheit as indicated on the facility's Water Management Program. 4. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to develop and implement a comprehensive-person centered care plan for three of three sample residents (Resident 9, 35, and 5) by failing to ensure: 1. The care plan was not implemented for Resident 9 with a history of hemolytic anemia (a blood disorder where the red blood cells [RBC] are destroyed faster than the bone marrow can replace them, leading to fatigue, jaundice [yellowing of skin], and dark urine) to monitor the resident for signs and symptoms of anemia (a blood condition where there is not enough healthy RBC or hemoglobin [HGB, protein that carries blood to the tissues; normal range 11 - 16 grams per deciliter (g/dL)]). [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety for the facility's one of one kitchen used by 66 residents when the facility did not ensure the dishwasher machine thermometer was functioning properly. This deficient practice had the potential to spread foodborne illnesses throughout the facility through dishes that were not sanitized properly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff provided assistance with dining in a manner that promoted and maintained resident dignity for one of one sampled resident (Resident 69) when Certified Nursing Assistant (CNA) 1 was observed feeding Resident 69 while standing, rather than sitting at eye level. This deficient practice did not promote a dignified, person-centered dining experience and had the potential to make Resident 69 feel rushed, disrespected, or less engaged during meals.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 75) was provided with written information regarding Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) upon admission in accordance with federal requirements and facility policy. This deficient practice had the potential for Resident 75 not to be informed about their rights to make an informed decision regarding their medical care.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a resident exhibiting new behaviors of verbal threats for one of two sampled residents (Resident 35) when Licensed Vocational Nurse (LVN) 1 observed Resident 35 regularly saying, I want to hit you to staff but did not notify Resident 35's physician of this new behavior. On 3/24/26, Resident 35 was witnessed throwing coffee toward Resident 58 during activities and Resident 35 was transferred to a general acute care hospital (GACH) for medical and psychiatric evaluation. This failure to report Resident 35's new behavior of verbal threats toward others did not allow Resident 35's physician to evaluate Resident 35 and apply new interventions such as making changes to Resident 35's medications or ordering new nursing interventions. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise or update the care plan for one of one sampled residents (Resident 72) to address new interventions related to paranoid schizophrenia (chronic mental disorder characterized by intense, irrational paranoia, delusions [false beliefs], and auditory hallucinations [hearing voices]) due to increased hallucinations when readmitted to the facility on [DATE] after hospitalization. This deficient practice had the potential to result in Resident 72 not receiving appropriate interventions and treatment and/or services and negatively affect the resident's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of six residents (Resident 9 and Resident 16) was informed of the name and purpose of each medication at the time of administration. This deficient practice had the potential to limit Resident 9 and Resident 16's ability to make informed decisions and participate in their care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and monitor one of three sample residents (Resident 9 ), diagnosed with hemolytic anemia (a blood disorder where the red blood cells [RBC] are destroyed faster than the bone marrow can replace them, leading to fatigue, jaundice [yellowing of skin], and dark urine) with symptoms of blood loss in accordance with the care plan and professional standards of practice by failing to: 1. Monitor and assess Resident 9 for any signs and symptoms of hemolytic anemia such as skin pallor, shortness of breath upon activity, sore tongue, chest pain, tinnitus (ringing in ears), palpitations, and changes in condition. 2. Follow up with Resident 9's Clinic 1 (Hematology Clinic) regarding the after visit care regarding the plan of care for resident's management of hemolytic anemia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide interventions to one of three sample residents (Resident 54) with increased verbal aggression towards other staffs or residents and increased episodes of delusion (misconceptions or beliefs that are firmly held, contrary to reality) to ensure safety to other residents by implementing interventions to prevent Resident 54 from aggression towards residents and staffs. As a result, Resident 54 hit Resident 25 on the right cheek without major injury. In addition, Resident 54 had the potential to emotionally and physically harm other residents and staff due to aggression and delusional thoughts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the drugs and biologicals stored in Medication Cart A, for one of six sample residents (Resident 46) was properly labelled and reflected the correct dose and frequency as indicated on the active order's summary list. Resident 46's prescribed medication-Clozaril (Clozapine, an antipsychotic medication) Oral Tablet 25 milligrams (mg, unit of weight) medication label on the unit dose packaging (bubble pack or blister pack, an organization way to store and dispense pill medication). This failure had the potential to result in Resident 46 receiving the wrong dose and wrong frequency of Clozaril which may result in a medication error and compromise the safety of the resident.

Inspectors wroteBased on interview, and record review, the facility failed to accurately document the administration of medication for one of one sampled resident (Resident 4.)This failure had the potential to cause severe hypoglycemia (low blood sugar), unconsciousness, and death to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four (4) out of twenty-two (22) resident's rooms (room [ROOM NUMBER], 5, 20, and 26) accommodated no more than four residents in each room. The 4 resident rooms consisted of 2 (two) - twelve (12) bed capacity rooms, 1 (one), seven (7) bed capacity room, and 1 (one), six (6) bed capacity rooms. This deficient practice had the potential adversely affect the delivery of care, quality of life, safety and violate the resident's rights for privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident for twelve (12) out of twenty-two (22) resident rooms (room [ROOM NUMBER], 2, 3, 4, 6, 9, 21, 26, 27, 28, 30, and 31). The 12 resident rooms consisted of 1 (one), twelve (12) bed capacity room, 1 (one), seven (7) bed capacity room, 2 (two), four (4) bed capacity rooms, 2 (two), three (3) bed capacity rooms, and 6 (six), two (2) bed capacity rooms. This deficient practice had the potential to negatively impact the quality-of-care and the ability to of the nursing care to safely provide care and privacy to the residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to notify the physician (MD) of an accident involving a resident for one of two sampled residents (Resident 1) after Resident 1 was observed by staff walking head first into a door that resulted in a cut near his right eye during the nightshift on 3/7/26 around 3 AM. The facility's staff did not notify Resident 1's physician (MD) of the injury during the morning shift, on 3/7/26 at 9 AM, six (6) hours after the accident, when Resident 1 was sent to a general acute care hospital (GACH) for medical evaluation and treatment. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the licensed staff verified Resident 1 ' s admission orders from the facility, by reviewing Resident 1 ' s medical history and general acute care hospital (GACH 1) discharge orders upon readmission to the facility on 3/12/2025, for one of two sampled residents (Resident 1), when it failed to: As a result of this deficient practice, Resident 1 had the potential to not receive the care and services, and correct medications needed for the resident ' s diagnosis while in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate competencies in skills and techniques necessary to care for one of one resident (Resident 11) reviewed for competent nursing staff to care for resident with a diagnosis of Post-Trauma Stress Syndrome (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) that was identified through the resident assessments. This failure resulted in Resident 11 not receiving the appropriate skills related to his trauma and PTSD as identified through his resident assessments. This failure resulted in the staff not receiving the appropriate competencies and skill set needed to care for residents with trauma or PTSD to ensure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to post nurse staffing information daily in a prominent location that was readily accessible to residents and visitors for viewing in accordance with the facility's policy and procedure titled Nursing Department - Staffing, Scheduling & Postings. This deficient practice resulted in inaccessibility of the accurate daily number of clinical staff giving direct care to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility ' s proper sanitation and food handling practices by failing to ensure the Dietary Aide 1 (DA 1) adhere to properly securing hair with the hairnet without any hair exposed when assisting tray line ( process of preparing meals for the residents from the food preparation area to the meal trays) for 69 out of 69 residents residing in the facility. This deficient practice had the potential to result in foodborne illnesses (also called food poisoning caused by eating contaminated food (transfer of bacteria, viruses, toxins [poisons] from the environment to the food ingested).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper infection control practices for 69 of 69 sampled resident by failing to ensure the facility's Water Management Program followed the approved national, state, and local measures to prevent and monitor the growth of Legionella (water-borne opportunistic bacteria) These failures had the potential to contribute to poor infection control, improper cleaning and disinfection of the resident's clothing and linens, growth of Legionella within the facility's water system which can lead to Legionnaires' disease (a serious pneumonia [lung infection] that can be fatal) which would affect all the residents and staff within the facility, and potential to cause a facility fire by not tracking when lint screens were cleaned out from the clothes dryer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for 69 or 69 residents, staff and the public by failing to: 1. Ensure the facility's washing machine Lint Cleaning Log for 2/12/2025 and 2/13/2025 were completely filled out to indicate the facility's lint screens (lint trap, a device that catches lint and debris from laundry) were cleaned from the clothes dryer. These failures had the potential to cause a facility fire by not tracking when lint screens were cleaned out from the clothes dryer.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote respect and dignity to one of one resident reviewed for dignity (Resident 19) who was observed with jeans tied with elastic gloves on the belt loop and was falling off, exposing his buttocks and groin area. This deficient practice has the potential to affect the resident's self image, sense of self-worth/ self-esteem and negatively affect the psychosocial being of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be fully informed by the physician or other professional in a language that he can understand for one of three residents reviewed for resident's rights (Resident 56) who signed a consent to receive psychotropic medications ( medications that affects mood and behavior) when: 1. The Health & Physical (H&P) assessment by physician indicated Resident 56 does not have the mental capacity to make medical decisions. 2. Psychiatric notes indicated Resident 56 had cognitive impairments such as loose associations (a thought disorder characterized by a lack of logical connection between ideas or thoughts) and distractibility (the tendency to be easily distracted by external or internal stimuli). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs of one of three residents reviewed for resident's rights, (Resident 119) in accordance with the facility ' s policy and procedure by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was within reach of the resident in Shower room [ROOM NUMBER] in the west wing. This deficient practice had the potential for residents who shared Shower room [ROOM NUMBER] in the west wing not able to call the facility staff to ask for help or assistance specially during emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two residents reviewed for right to privacy (Resident 41 and 119) were provided with privacy when using the common restroom and common shower room by failing to ensure: The window in Shower room [ROOM NUMBER] in the [NAME] Wing had stained-glass window film peeling off which let other people in the patio look thorough the window and see the residents when in the shower room. The window in Restroom [ROOM NUMBER] in the East Wing ' s had stained-glass window film that were peeling off which let other residents, staffs and visitors from the patio see the residents when using the restroom. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive resident specific care plan for two of twelve residents reviewed (Resident 68 and 11) by failing to ensure: 1. Resident 68's care plan was developed to address discharge planning before discharged from the facility on 12/2/2024. These deficient practices had the potential to result in confusion of Resident 68 ' s care and discharge process and negatively affect the resident's psychosocial wellbeing. 2. Resident 11's care plan was developed to address management and triggers for the Post-Traumatic Stress Syndrome (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of four residents that was reviewed for trauma informed care, (Resident 11) who was diagnosed with Post-Traumatic Stress Syndrome (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) with culturally competent (cultural competence involves valuing diversity, conducting self-assessments, avoiding stereotypes, managing the dynamics of difference, acquiring and institutionalizing cultural knowledge, and adapting to diversity and cultural contexts in communities), trauma-informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) according to professional standards of practice and accounting for the resident ' s experience and preferences to eliminate or mitigate [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary behavioral health care and services for one of four residents reviewed (Resident 11) to attain or maintain the highest practicable physical, mental, and psychosocial well-being which encompassed the resident's whole emotional and mental well-being. This failure resulted in Resident 11's, who was diagnosed with Post-Traumatic Stress Syndrome (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), continued behavior of agitation, yelling, and attempts to hit staff members.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three residents (Resident 28) does not receive Bactrim (Sulfamethoxazole-Trimethoprim an antibiotics or medication used to treat infection) unnecessarily by indicating in the physician's order how long the medication should be administered. This deficient practice had the potential for Resident 28 to develop antibiotic resistance (medication not effective to treat infection) and results in adverse reaction (undesirable effect) health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four (4) out of twenty-two (22) resident's rooms (room [ROOM NUMBER], 5, 20, and 26) accommodated no more than four residents in each room. The 4 resident rooms consisted of 2 (two) - twelve (12) bed capacity rooms, 1 (one), seven (7) bed capacity room, and 1 (one), six (6) bed capacity rooms. This deficient practice had the potential adversely affect the delivery of care, quality of life, safety and violate the resident's rights for privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident for twelve (12) out of twenty-two (22) resident rooms (room [ROOM NUMBER], 2, 3, 4, 6, 9, 21, 26, 27, 28, 30, and 31). The 12 resident rooms consisted of 1 (one), twelve (12) bed capacity room, 1 (one), seven (7) bed capacity room, 2 (two), four (4) bed capacity rooms, 2 (two), three (3) bed capacity rooms, and 6 (six), two (2) bed capacity rooms. This deficient practice had the potential to negatively impact the quality-of-care and the ability to of the nursing care to safely provide care and privacy to the residents.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure on resident safety by failing to provide supervision to one of two sampled residents (Resident 1) who were at high risk for falls. This deficient practice resulted to Resident 1 having an acute subdural hematoma (a blood clot that forms between the brain's surface and its tough outer covering) after he had a fall when he attempted to stand up from a sitting position at the facility's patio without staff supervision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent two of two residents (Residents 1 and 2) who were assessed at high risk for elopement (an act of leaving a care facility or safe area independently without notifying anyone) from leaving the facility in accordance with the facility's policy for elopement and residents' plan of care by failing to: 1. Provide adequate monitoring and supervision to ensure Resident I, who had fluctuating capacity to understand and make decisions, and was assessed at risk for elopement with diagnoses of suicidal ideation (thinking about killing yourself) did not elope from the facility on 9/10/2024 during a change of shift [evening shift and night shift) at 11 PM from Patio I. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for one of two sampled Residents (Resident 1) that included specific interventions to monitor resident's behaviors who goes out on pass and with had a history of drug abuse. This deficient practice had the potential for residents to not receive appropriate care, treatment, and/or services.

Inspectors wroteBased on observation, interview and record review, the facility failed to investigate and attempt to locate one of two sampled residents, (Resident 1) who was assessed at risk for elopement, had a history of suicidal ideations, and had fluctuating capacity to understand and make decisions, upon receiving information on 7/13/2024, that Resident 1 was not admitted to the General Acute Care Hospital (GACH 2) on 7/11/2024. As a result, Resident 1 had not been located and currently still missing, after eloping from the ambulance transportation on the way to GACH 2 emergency room (ER). This deficient practice had the potential to result in Resident 1 ' s physical injuries and change in condition that may lead to hospitalization or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and supervise one of three sampled residents (Resident 1), who was identified and assessed at risk for elopement. As a result, Resident 1 eloped from the facility on 4/30/2024, and remained missing until 5/1/2024, when resident was found at a nearby school football field, next to the facility. This failure had the potential for Resident 1 to sustain injuries from being outside the facility with no access to scheduled medications and shelter needed for his condition which could lead to serious injury, serious harm, serious impairment and/or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods were handled, prepared, and stored in a manner that prevented foodborne illness (food poisoning) for 63 of 63 residents receiving food from the kitchen, by failing to ensure: a. Expired products were removed from kitchen pantry. b. Food items were dated, labeled, and sealed after opening in the food preparation area, walk in freezer and dry storage area. c. [NAME] 1 wore hair restraint to cover beard and mustache while in kitchen and food storage areas. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness for 63 of 63 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary environment and implement the facility ' s policy and procedure for infection control by ensuring resident ' s clothing and two clean linen carts were stored in the clean designed areas. These deficient practices had the potential to result in the spread of diseases and infection to the residents, the facility staffs, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to keep the copy of an Advance Directive (known as living will, personal directive, advance directive, medical directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity.) in the medical record for one of five sample residents (Resident 44). This deficient practice had the potential to cause harm and conflict in carrying out the resident 44's wishes for medical treatment and health care decisions leading to irreversible outcomes.

Inspectors wroteBased on observation, and interview, the facility failed to ensure one of one resident sample (Resident 20) was provided with privacy when showering in the common shower rooms. 1. Shower 1 (East Wing [EW]) did not have a privacy curtain in the shower room. 2. Shower 2 EW and Shower 3 EW and Shower 1 [NAME] Wing (WW) had no curtain in the shower room to provide privacy to the residents when dressing after shower. 3. Shower 2 WW had a large window without cover that could see through the shower room and the dressing area. This failure resulted in Resident 20 ' s not feeling safe, feeling exposed when showering or dressing after shower, and resident ' s refusal for shower for fear of somebody looking at him while he was naked. This deficient practice also had the potential for other residents ' privacy to be violated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment by ensuring the two restrooms had no foul odor for one of three sampled residents (Resident 47) that uses both restrooms. This failure resulted in Resident 47's reported not feeling to be in a homelike environment and had to wear mask when going to the restrooms because he could not breath due to terrible smell of the restroom.

Inspectors wrote2. A review of Resident 22 ' s admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included DM2 and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). A review of Resident 22 ' s history and physical, dated 2/23/2023, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 22 ' s Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 3/1/2024, indicated the resident has intact cognition. Resident 22 ' s MDS also indicated the resident is independent in doing activities of daily living (ADL ' s), including eating, toileting, bathing, dressing, and walking. A review of Resident 22 ' s Order Summary Report, dated 3/13/2024, indicated Resident 22 is prescribed medications for DM2: 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to meet the professional standards of quality care for one of four sample residents (Resident 5) by failing to clarify with the physician and review the pharmaceutical recommendation whether to administer Ziprasidone (a medication that affects mood and behavior) with food. This deficient practice has the potential to decrease bioavailability (drug become completely available to the body to produce a therapeutic effect) of the Ziprasidone and result in Resident 5 increased mood and behavioral concerns.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 20), maintains the ability to perform ADL (Activities of Daily Living) by failing to assess the reason for the refusal to take a shower and/or provide alternative measures to receive ADL assistance for a total of 47 days from 1/21/24 to 2/23/24 and 2/29/24 to 3/14/24. This failure had a potential to result in Resident 20 ' s decline to perform ADL, risk for body odor that could negatively affect the resident's self-image, skin break down, skin infections (occurs when germs enter the body and multiply, causing illnesses) and rashes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was posted and updated on a daily basis. to ensure sufficient staffs were maintained at the facility to provide care. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors to ensure the residents receives the care they needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services indicated in the facility policy by failing to ensure the Change of Shift Narcotics (drug that relief pain, cause state of stupor or sleep, and physical dependence) Reconciliation Records verified by two of wo Licensed Nurses. This deficient practice could lead to inaccurate record of narcotic medication use, loss or misuse of narcotic medication.

Inspectors wroteBased on observation, record review and interview, the facility failed to label drugs and medical device used in the facility that were stored in one of the two med carts and one of two medication room storage, in accordance with currently accepted professional principles by failing to: 1. Label a multi-dose Valproic Acid (a medication used to treat seizure disorder [a sudden, uncontrolled burst of electrical activity in the brain]) bottle without an opened date, stored in Medication Carts (Med Cart 1). 2. Remove three expired foley catheter insertion trays (medical device that helps drain urine from the bladder) stored in Medication Storage Room. This deficient practice had the potential to result in the loss of efficacy of the Valproic Acid and can increased risk of seizures and a potential to result in the use of ineffective medical device for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurately document in the Medication Administration Record (MAR) that insulin was given for one of five sampled residents (Resident 22) that indicated two doses of regular insulin (a medication prescribed to control blood sugar level) were not administered. This deficient practice had the potential for Resident 22 not to receive care and intervention in management of DM2 and lead to complications related to DM2 such as having high or low blood sugar.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents (Residents 10, 55, and 44) who had no mental capacity to understand the terms of the facility ' s binding arbitration agreement (an agreement that allows parties to resolve disputes and lawsuits privately rather than going to the court) does not sign the arbitration agreement. This failure had the potential for Resident 10, 55 and 44 to not understand their rights for a binding arbitration agreement.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a call light (device used to alert facility staff assistance as needed by residents) for one out of 11 sampled residents (Resident 10). This deficient practice had the potential for the resident facility ' s failure to provide resident 10 with a call light is a serious issue that has the potential to delay care, endanger their safety, and impact their overall well -being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four (4) out of twenty-two (22) resident's rooms (room [ROOM NUMBER], 5, 20, and 26) accommodated no more than four residents in each room. The 4 resident rooms consisted of 2 (two) - twelve (12) bed capacity rooms, 1 (one), seven (7) bed capacity room, and 1 (one), six (6) bed capacity rooms. This deficient practice had the potential adversely affect the delivery of care, quality of life, safety and violate the resident's rights for privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident for twelve (12) out of twenty-two (22) resident rooms (room [ROOM NUMBER], 2, 3, 4, 6, 9, 21, 26, 27, 28, 30, and 31). The 12 resident rooms consisted of 1 (one), twelve (12) bed capacity rooms, 1 (one), seven (7) bed capacity room, 2 (two), four (4) bed capacity rooms, 2 (two), three (3) bed capacity rooms, and 6 (six), two (2) bed capacity rooms. This deficient practice had the potential to negatively impact the quality-of-care and the ability to of the nursing care to safely provide care and privacy to the residents.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician for one out of four sampled residents (Resident 1) when Resident 1 refused to take Olanzapine and Divalproex, psychotropic medications (medications that affect brain activities associated with mental processes and behavior) on 2/19/2024. This deficient practice placed the resident and other residents at risk of harm when Resident 1 had a physical altercation with Resident 2 the following day.

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money) by failing to provide the trust fund (a legal arrangement that allows an individual to place assets in a special account to benefit another person or entity) to the resident or resident representative upon discharge from the facility, in accordance with the facility ' s policy and procedure on Discharge and Transfer of Residents for one of three sampled residents (Resident 1). These deficient practices resulted in Resident 1 ' s missing $5,091.46 Trust Fund from the date the resident was discharged from the facility on 5/2/23 up until 5/11/23 which caused an increased in Resident 1 ' s sadness and anxiety.

Inspectors wroteBased on interview, and record review, the facility failed to protect Resident 2 from physical abuse by one of three sampled residents (Resident 1), who had a known history of physical aggression toward staff and other residents by failing to: 1. Supervise Resident 1 to prevent Resident 1 from hitting Resident 2 on 8/27/2023, during the 3 PM to 11 PM shift, after Resident 1 had change of condition manifested by increased verbal/physical aggression and striking out during the 7 AM to 3 PM shift. 2. Ensure that a care plan was initiated when Resident 1 had a change of condition manifested by increased in verbal and physical aggression on 8/27/2023. 3. [...]