Mountain View Conv Hosp

Inspectors wroteBased on observation, interview, and review, the facility failed to ensure the licensed staff develop a baseline care plan addressing the smoking needs for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 not to receive the care and services related to his smoking while under the care of the facility.

Inspectors wroteBased on observation, interview, and record review, facility failed to follow the Smoking Policy plan for two of five sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 not receiving appropriate care and smoking safety instructions specific to the residents smoking need.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: a. Two (2) dumpsters (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts) were not completely closed and was propped open by a piece of wood when not actively in use. b. There were gloves, trash, and liquid drippings in the dumpster surroundings. c. The trash can did not have a cover in the dishwashing area. These failures had potential to attract birds, flies, insects, pests and possibly spread infection to 77 of 77 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the pad call light (a specialty alerting device that have ultra-sensitive touch surface for residents with limited mobility for nurses or other nursing personnel to assist a resident when in need) or call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for five of seven sampled residents (Residents 66, 40, 90, 31, and 37) reviewed under the environment task. This deficient practice had the potential to result in a delay of care and services and possible injury when Residents 66, 40, 90, 31, and 37 were unable to call for staff assistance.

Inspectors wroteBased on interview and record review, the facility failed to inform and provide a written information to all adult residents concerning the right to accept and refuse medical surgical treatment and, at the resident's option, formulate an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) to three of nine sampled residents (Residents 9, 17, and 3) by the Social Services Director (SSD) failing to provide written information to residents on advanced directive formulation reviewed for Advanced Directives. These deficient practices violated the resident's rights and/or representative's right to be fully informed of the option to formulate their advanced directives.

Inspectors wroteBased on interview and record review, the facility failed the facility failed to ensure residents are screened using the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long-term care) for a mental disorder (MD - a person's mind makes it hard to think, feel, or act normally in daily living) or intellectual disability (ID - a person has trouble learning, understanding, or solving problems like most people their age) prior to admission and that individuals identified with serious mental illness (SMI) and/or ID/developmental disability (DD)/related conditions (RC) receive the care and services in maintaining his/her highest practicable level in the most appropriate setting for three (3) of 3 sampled residents (Resident 4, 10, and 74), by failing to submit a new Level I PASRR for [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for three (3) of three sampled residents (Residents 11, 4) by failing to ensure: 1. Resident 11 had a care plan addressing the schizophrenia (a mental illness that is characterized by disturbances in thought) upon admission from another long-term care facility. 2. Resident 4 had a care plan addressing the bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). These deficient practices had the potential for a delay in the delivery of the necessary care and services the residents need.

Inspectors wroteBased on interview, and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards of care for two of two sampled residents (Residents 7 and 90) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide appropriate treatment and services for care of one (1) of three (3) sampled residents (Residents 111) reviewed for urinary tract infection (UTI, a common infection that occurs when bacteria enters and multiplies in the urinary system, which includes the kidneys, bladder, and urethra) by failing to ensure Resident 111's suprapubic catheters (a thin, flexible tube used to drain urine (pee) from the bladder when a person cannot urinate normally) did not have loops on the catheter tubing. The deficient practice had the potential for the resident to develop urinary tract infection. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two of three sampled residents (Residents 7 and 90) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when:1. Cook 1 was unable to verbalize final minimum internal temperature of foods when cooking and did not check if the blender was completely dry before preparing puree foods. 2. Dietary Aide 1 (DA 1) did not submerge the blender appropriately in the sanitizer. 3. Dietary Aide 2 (DA 2) was unable to use the right test strips when checking for chlorine concentration. These failures had potential to result in harmful bacterial growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food and drinks that are contaminated with germs or chemicals) in 71 of 77 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents' meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 3/23/2026. This deficient practice had the potential to result in hunger and frustration for 71 of 77 residents getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Thawed ground beef was placed back in the freezer and was at 31 degrees Fahrenheit ( F, a scale of temperature). 2. Walk-in refrigerator's gasket (a rubber placed between two solid and flat surfaces to create a tight leak-proof seal) was torn, it had dust and dirt buildup. 3. Two (2) dented (a hallow, dip, or depression on a surface, caused by blow, impact or pressure) cans were stored with non-dented cans. 4. [NAME] 1 did not take the temperature of the vegetables during cooking using a food thermometer. (Cross Reference Ftag 802) 5. Dietary Aide 1 (DA 1) did not wash kitchen equipment correctly in the three-compartment sink when: a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the binding arbitration agreement (a resident waives the right to pursue legal action against the nursing home in court, and instead agrees to have any future disputes handled by a private arbitrator [an independent person or body officially appointed to settle a dispute]) indicated the resident or anyone else (e.g., resident's representative) were allowed to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman (a resident advocate) for three of three sampled residents (Residents 33, 75, and 93) reviewed for Arbitration Facility Task. The deficient practice had the potential for residents to be unaware of their rights pertaining to Arbitration Agreement.

Inspectors wroteBased on interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure: 1. Certified Nurse Assistant (CNA) 3 washed hands after removing gloves from changing Resident 26's diaper and proceeded to leave the room, observed during infection control tasks. 2. Linen carts for resident's personal clothing were not covered with a loosely woven/permeable (having pores or openings that permit liquids or gases to pass through) material to protect the linens inside the cart, observed during infection control tasks. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when there were five (5) flies (a type of insect) observed in the dishroom. This failure had the potential to result in 71 of 77 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.

Inspectors wroteBased on interview and record review, the facility failed to honor the resident's right to be informed in advance by the physician or other practitioner or professional, of the risks and benefits of proposed care, treatment, and treatment alternative or option for one of one sampled resident (Resident 73) reviewed for informed consents (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to complete Resident 73's informed consent on the use of bolsters and matched the physician's order. This deficient practice violated the resident's/resident representative's right to make an informed decision regarding the use of the bolsters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely for one of seven sampled residents (Resident 84) reviewed under environment facility task by failing to ensure Resident 84 did not have a dilapidated (in very bad condition because of age or lack of care) bedside drawer on the resident's room. The deficient practice had violated the resident's right to a safe, clean, comfortable, and homelike environment that can potentially lead to the resident`s depression and not feeling welcomed.

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of staff to resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) immediately, but no later than two (2) hours after the allegation was made to the State Survey Agency (CDPH, California Department of Public Health), the Ombudsman (a resident advocate), and local law enforcement (LLE) in accordance with federal and state law for one (1) of one (1) sampled resident (Resident 20) reviewed under the abuse care area. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from harm from abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) regarding transfers and discharge by failing to ensure that necessary medical information was communicated to the receiving long term care facility for one (1) of three (3) sampled residents (Resident 118) during a review of closed records. This deficient practice placed Resident 118 at risk for a delay in the continuity of care and receiving the services and treatment the resident needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident`s environment was free of accident hazards for one of three sampled residents (Resident 90) reviewed for accidents by failing to ensure Resident 90 did not have medications or biologicals (medicines derived from living organisms-such as humans, animals, or microorganisms-rather than being created from chemicals) left at the bedside. These deficient practices increase the risk of accidents such as ingestion poisoning on residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (EF-also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of enteral feeding for two (2) of two sampled residents (Residents 119 and 43) reviewed for tube feeding when the water flush bag was not changed according to the manufacturer's recommendations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for two of three sampled residents (Residents 111 and 90) reviewed for respiratory care by failing to ensure: 1. Resident 111's oxygen via nasal cannula (a lightweight, flexible plastic tube used to deliver supplemental oxygen directly into a person's nostrils), dated 3/12/2026, was discarded and replaced with a new setup. 2. Resident 90's bottle of sterile water for inhalation 1000 milliliters (ml - a unit of volume) with a date opened on 3/1/2026 was discarded. These deficient practices had the potential for residents to develop complications such as shortness of breath and desaturation (low levels of oxygen in the blood) and respiratory infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed timely identification and removal (from current medication supply) of medications for disposition for: 1. One (1) of three (3) Medication Storage Room (Medication Storage for Station 1) observed during Medication Storage and Labeling facility task by failing to ensure there were no expired medications in the Medication Storage for Station 1. On 3/25/2026 found an expired Major Co q-10 soft gels (a vitamin-like nutrient naturally produced by the body and found in every cell) with expiration date of 1/2026. 2. [...]

Inspectors wroteDuring an observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for two of six Medication Carts (Station 1 Medication Cart 1 and Station 1 Medication Cart 2), by failing to: 1. Place the name of the resident, a readable room number, and an open date on a bottle of eye drop (Refreshe, over-the-counter artificial tears used to instantly moisturize, lubricate, and soothe dry, gritty, burning, or irritated eyes) in Medication Cart 1 in Station 1. 2. Plan an open date on Resident 87's bottle of Potassium Citrate-Citric Acid (also known as Potassium CIT-CITRIC ACID, medication that reduces acid in urine in Medication Cart 2 in Station 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in long-term care facilities to ensure that antibiotics are used only when necessary and appropriate [means prescribing the right drug at the right dose at the right time for the right duration]) program and infection prevention and control program for one (1) of 1 sampled resident (Resident 119 ) by failing to clarify with the physician the appropriate indication for the continued use of antibiotic from the hospital. This deficient practice had the potential to increase antibiotic resistance (when bacteria develop the ability to withstand the effects of antibiotics, making it difficult or impossible to treat infections) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview, and record review, the facility failed to implement its Pneumonia Immunization (vaccine for an infection/inflammation in the lungs) policy and procedure (P&P) for one of three sampled residents (Resident 3) investigated under infection control facility task by failing to administer pneumonia vaccine to Resident 3. This deficient practice had the potential to place Resident 3 at risk for respiratory infection including pneumonia (a lung infection).

Inspectors wroteBased on interview and record review, the facility failed to inform the attending physician (MD) and the responsible party (RP) for one of three sampled residents (Resident 1) regarding a change in treatment, when on 2/9/2026 Resident 1's Low Air Loss (LAL-a specialized therapeutic bed surface featuring air-filled chambers with microscopic holes that slowly release air with the design creating a constant, gentle airflow that keeps the user's skin cool, dry, and reduces moisture, which helps prevent and heal pressure ulcers [bed sores- localized damage to the skin and underlying tissue caused by constant, unrelieved pressure, often against a bony area that restricts blood flow]) was discontinued. This deficient practice resulted in the violation of the RP's right to be informed and make decisions and had the potential for a delay in Resident 1's care.

Inspectors wroteBased on interview and record review, the facility failed to follow physician's order for one of three sampled residents (Resident 1) when Licensed Vocational Nurse 1 (LVN 1) administered atenolol (medication used to treat high blood pressure) at 9 a.m. on 12/25/2025, and 12/28/2025 and losartan (medication used to treat high blood pressure) at 9 a.m., on 12/25/2025, 12/26/2025, 12/27/2025 and 12/28/2025, to Resident 1 who had a systolic blood pressure (sbp- pressure in the arteries when the heart beats) below of 110 millimeter of mercury (mmHg-unit for measuring pressure) despite physician's order to hold (suspend the medication) the atenolol and losartan for blood pressure below 110 mmHg. These failures had the potential to result in Resident 1's uncontrolled hypotension (low blood pressure).

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) to address Resident 1's use of cephalexin (medication used to treat infection) and ciprofloxacin (medication used to treat infection). This failure had the potential for Resident 1's delays in the delivery of necessary care and services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 1) by failing to timely notify the Wound Care Physician of Resident 1's pressure ulcers. This failure had the potential for the development and worsening of pressure ulcers.

Inspectors wroteBased on interview, and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration), surveillance of infections (the systematic, ongoing collection, analysis, and distribution of data on disease occurrence) and administering medications for one of three sampled residents (Resident 1) by:Failing to monitor Resident 1 for the side effects (any reaction to a treatment or medicine that is not the main reason a person was taking it) or adverse effects (undesired or harmful effects) of cephalexin (antibiotic medication used to treat infection) on the following dates and [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain privacy of confidential information when Licensed Vocational Nurse (LVN) 1 left electronic health record (EHR- a digital version of a patient's paper chart) open and unattended for one of three sampled residents (Resident 2). This deficient practice violated Resident 2's right to privacy and confidentiality of medical records.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (permission granted in the knowledge of the possible consequences, typically that which is given by a resident and or Responsible Party [RP] to a doctor for treatment with full knowledge of the possible risks and benefits) from one of three sampled resident (Resident 2)'s RP for the use of a bed alarm (a safety device that makes a sound or alerts a caregiver when a person gets out of bed, sits up, or moves suddenly). This deficient practice had the potential to violate Resident 2 and their RP's rights to an informed consent.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records for one of three sampled residents (Resident 2) when Resident 2 had two active orders that contradicted (two seemingly opposite ideas are both true) each other. This deficient practice had the potential to negatively impact the delivery of services to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was provided with correct information regarding the specific location where Resident 1 was being discharged in the Notice of Transfer or Discharge the facility provided to Resident 1. This deficient practice had the potential to result in confusion and affect the delivery of care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Resident 1's intermittent catheterization (a procedure where a hollow tube is temporarily inserted into the bladder to drain urine and then removed) procedure was documented. This deficient practice had the potential to result to inaccurate medical interventions for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 2) concerns were reported to the licensed nurses, investigated, and documented in the grievance form. This deficient practice had the potential to violate residents' rights to have grievances addressed.

Inspectors wroteBased on interview and record review, the facility failed to provide copy of medical records upon written request for two of three sampled residents (Resident 1 and Resident 2). On 5/9/2025 at 10:32 a.m., Resident 1 requested for medical records and the medical records were sent electronically on 5/27/2027 at 3:57 p.m. (18 days). On 5/27/2025 at 12:01 p.m., Family Member (FM) 1 requested for Resident 2's medical records and the medical records were not received as of 6/2/2025. This deficient practice violated the rights of Resident 1 and Resident 2 to obtain a copy of their medical records.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1) when Resident 1's Dialysis Communication Records binder went missing on 2/20/2025 with Resident 1's Dialysis Communication Records. This deficient practice had the potential to negatively impact the delivery of services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to inform the attending physician (MD) and resident representative on one of four sampled residents (Resident 2) when Resident 2 had a significant change in condition (COC - a change in the resident's physical, mental, or psychosocial status that causes either life-threatening conditions or clinical complications) on 1/22/2025 when Resident 2 was noted with hematuria (blood in the urine). This deficient practice had the potential for the delay in the care of Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a form that summarizes a person ' s health conditions and current treatments for their care) for one of four sampled residents (Resident 2), when Resident 2 had a Change in Condition (COC- a major decline in a resident ' s status), on 1/22/2025 of hematuria (blood in the urine). This deficient practice had the potential to negatively affect Resident 2 ' s physical and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report an injury of unknown origin for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for more injury.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline individualized care plan for one of three sampled residents (Resident 1). Resident 1 had no care plan to address safety precautions related to history of epilepsy (repeatedly uncontrolled electrical activity in the brain, which may produce a jerking movement of a part or the entire body. This deficient practice had the potential for Resident 1 to not receive appropriate care and treatment specific to their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for four of four sampled residents (Resident 22, 71, 95, and 17) investigated under Environmental Task by: 1. Failing to maintain the cleanliness of Resident 22's electric fan. 2. Failing to ensure Residents 71, 95, and 17's rooms were not below 71 degrees Fahrenheit (a unit of measure). These deficient practices had the potential to negatively affect the residents' quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement a comprehensive person-centered Care Plan (CP - a document outlining a detailed approach to care customized to an individual resident's need) by failing to: 1. Develop and implement a CP for supplemental oxygen (O2) use for one of three sampled residents (Resident 94) investigated under the Respiratory Care area. 2. Develop and implement a CP for diabetes mellites (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) for one of three sampled residents (Resident 94) investigated under the Respiratory Care area. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of eight sampled residents (Residents 75, 63, and 61) received appropriate services to prevent a decline in range of motion range of motion (ROM, full movement potential of a joint) and mobility by failing to: 1a. Provide Resident 75 with passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to both knees during the 12/4/2024 Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment session as ordered by a physician. 1b. Provide appropriate monitoring of Resident 75's range of motion by therapy staff on a quarterly basis to determine any changes in ROM. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for six of eight sampled residents (Residents 16, 22, 6, 74, 405, and 354) investigated under accidents by failing to ensure: 1. Residents 16 and 22's fall mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have a side table on top of them. 2. Resident 6's bed pad alarm (a device that alerts caregivers when a patient or resident attempts to leave their bed or chair without assistance) was working when the resident went to the bathroom. 3. Resident 74's bed did not have frayed wires on the bed remote control. 4. Resident 405's bed was not left in an elevated/high position while unattended by staff. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (EF or tube feeding, a form of nutrition that is delivered into the digestive system as a liquid) for two of three sampled residents (Resident 94, 60, and 68) reviewed under the Tube Feeding care area by failing to: 1. Ensure Licensed Vocational Nurse 4 (LVN 4) checked for residual (the amount of liquid or food that remains in the stomach after a tube feeding) prior to administering the gastrostomy tube (G-tube or GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding for Resident 94. 2. Label the water flush bag with the rate to be infused for Resident 60. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure to dispose of medications in a manner that was not retrievable, in one (1) of two (2) inspected Medication Rooms (Medication Room Station 1.) 2. Include the verifying signatures of two licensed nurses on the Medication Disposition Record/Pass Log for six (6) of six (6) logged records. As a result, control and accountability of discontinued medications and medications awaiting final disposition (process of returning and/or destroying unused medications) did not follow state and federal regulations and facility policy and procedures. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Residents 17 and 353) reviewed for unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) medications were free from the use of unnecessary psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure by: 1. Failing to monitor side effects (also known as adverse effects - unwanted, uncomfortable, or dangerous effects that a drug may have) of Trazadone (a psychotropic medication used for depression [also referred to as antidepressant] and insomnia [inability to sleep]) for Resident 17. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than 5 percent (%) due to five (5) errors observed out of 28 total opportunities resulting in an error rate of 17.86%. The medication errors were as follows: 1. Resident 57 received a dose Omega-3 Fatty Acid (a medication used as a dietary supplement to protect eye health) that was different than the one ordered by Resident 57's physician. 2. Resident 404 did not receive metformin (a medication used to treat diabetes mellitus 2 ([DM 2] - a condition where there is high blood sugar levels) and pioglitazone (a medication that treats DM 2) as ordered by Resident 404's physician, and received a form of multivitamin that was different than the one ordered by Resident 404's physician. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet/level four (4) (food that are soft and pudding-like consistency) received puree beans that could not hold it shape and puree cabbage that was weeping liquid on the resident's plate. This deficient practice had the potential to cause coughing, choking (to keep from breathing the normal way) and death for 11 of 76 residents on puree/level 4 diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. There were chipped, cracked, and rusted kitchen utensils and equipment. 1. Two (2) of five (5) shelves in the walk-in refrigerator had cracks and rusts. 2. Green chopping board had food stains, cracks, and scratches. b. Food preparation surfaces and kitchen equipment were not cleaned and sanitized. 1. Reach-in refrigerator had food debris, dirt and dust build up around the gasket (a piece of rubber in between surfaces). 2. Dry storage racks with dust build up and food debris and dirt on the floor in the dry storage room. 3. Coffee machine spout (a tube or lip projecting from a container, through which liquid can be poured) had dried up coffee and waterspout had mineral water buildup. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for one of two residents (Resident 94) reviewed under the Advance Directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate) care area by failing to ensure a resident with full code status (primary goal of prolonging life by all medically effective means) did not have an active physician's order indicating do not resuscitate / do not intubate (DNR/DNI - a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation [CPR] or intubation [a procedure that can assist with breathing] if breathing stops or the heart stops beating). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify one of six sampled resident's (Resident 75) physician (MD 1) for a change in condition (COC) for inability to complete passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises for both knees during Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment. This deficient practice had the potential for Resident 75 to have delay in assessment and intervention and further decline of both knee ROM.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for one of one sampled resident (Resident 353) that identified resident-centered interventions regarding Resident 353's use of a psychotropic (medications that affect the mind, emotions, and behaviors) medication, lorazepam (medication used to manage anxiety [feelings of fear, dread, uneasiness, and worried thoughts]). This deficient practice had the potential to result in a delay in care or lack of delivery of care and services for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for personal hygiene for one of one sampled resident (Resident 77) investigated under the activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) care area when Resident 77, a female resident, was not offered shaving equipment or offered by the facility staff to be groomed for facial hair. This deficient practice had the potential to negatively affect the resident's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with necessary respiratory care and services that is in accordance with professional standards of practice to one (1) out of 1 sampled resident (Resident 97) investigated respiratory care area by failing to ensure the oxygen humidifier (a medical device that adds moisture to supplemental oxygen to help relieve respiratory problems and irritation) indicated the date it was last changed. This deficient practice placed the resident at risk for acquiring infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident was assessed for the use of grab bars/bed rails (a metal or plastic bars positioned along the side of a bed), which includes a review of risks including entrapment (when a resident is trapped in the spaces in between or around the bed rails, mattress, or bed frame); and informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained from the resident or if applicable, the resident representative for one of one sampled resident (Resident 89) investigated under bedrails by failing to obtain a physician's order on the use of grab bars/side rails, obtain an informed consent, assess the resident on the safe use, and develop and implement a care plan on the use of grab bars/side rails. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperatures when breakfast food temperatures in Station Three (3) had the following temperatures: - Fried eggs 114 degrees Fahrenheit (°F, a degree of temperature) - Oatmeal 94°F - Milk 51°F - Juice 69°F This deficient practice placed 34 of 77 facility residents in Station 3, including Resident 6, on regular consistency texture (texture with no restriction) and texture modified diets at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to document the resident's condition and treatments administered when the resident was found unresponsive for one of one sampled resident (Resident 100) reviewed under death care area. This deficient practice had the potential to result in inaccurate documentation in the medical record regarding Residents 100's condition and response to care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure the nasal cannula (NC - tubing connected to a device that gives additional oxygen [O2] through the nose) was labeled with the date last changed to ensure the NC was changed weekly per the facility policy and procedure for one of three sampled residents (Resident 405) reviewed under the Respiratory Care area. 2. Ensure to label the urinal bottle (a container for collecting urine that is used by people who are unable to use a bathroom toilet) with the name and room number of the resident for one of one sampled resident (Resident 89) investigated during random resident screening. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's Antibiotic Stewardship Program (ASP- a set of commitments and actions designed to improve the use of antibiotics [a medication used to treat bacterial infections]) for one of one sampled resident (Resident 3) investigated under the infection control care area by failing to monitor and complete the infection surveillance evaluation for Resident 3's metronidazole (a type of antibiotic) order. This deficient practice had the potential to place the resident at risk for microbial resistance and reduced resident outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment was conducted by failing to ensure the Minimum Data Set (MDS - resident assessment tool) was coded correctly to indicate a resident was discharged home for one of one sampled resident (Resident 102) reviewed during the Hospitalization Closed Record Review care area. This deficient practice had the potential to result in negatively affecting Resident 102's delivery of care and services.

Inspectors wroteBased an interview and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcers (PU-a localized injury to the skin and or underlying tissue usually over a bony prominences as a result of pressure or pressure in combination with shear) for one of three sampled residents (Resident 1) by failing to assess Resident 1's skin and wound weekly. This deficient practice placed Resident 1 at risk for development of pressure ulcers and worsening of wound.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was receiving heparin (an anticoagulant medication that helps prevent the formation of blood clots) was monitored for its side effects of bleeding. This deficient practice had the potential to place Resident 1 at increased risk for side effects including bleeding.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1). This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation and can result in the delay of delivery of care.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (is harsh and insulting language directed at a person) by another resident for one of three sampled residents (Resident 1). On 10/16/2024 at 10:30 a.m., Resident 1 reported the incident of alleged verbal abuse of Resident 2 towards Resident 1 to Social Service Assistant 1 (SSA1). This deficient practice resulted in Resident 1 feeling anxious (feeling of worry, nervousness, or uneasiness) and verbalizing feeling depressed (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities) and stressed in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to report the allegation of a resident-to-resident verbal abuse ((is harsh and insulting language directed at a person) to the State Survey Agency (SSA) for one of three sampled residents (Resident 1). On 10/16/2024, Resident 1 reported an allegation of abuse by Resident 2 to Social Service Assistant 1 (SSA 1). The Abuse Coordinator reported the allegation to the SSA on 10/29/2024, 13 days after the allegation of abuse was made. This deficient practice had the potential to result in unidentified abuse and failure to protect other residents from abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure clinical records were complete and accurately documented for one of three sampled residents (Resident 1). On 10/16/2024 at 10:30 a.m., Resident 1 reported the incident of alleged verbal abuse (is harsh and insulting language directed at a person) of Resident 2 towards Resident 1 to Social Service Assistant 1 (SSA 1). SSA 1 did not document the conversation with Resident 1 in Resident 1's clinical record. This deficient practice resulted in inaccurate information in Resident 1's clinical record.

Inspectors wroteBased on interview and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (an injury that breaks down the skin and underlying tissue) to one out of three sampled residents (Resident 1) by failing to develop and implement a resident-centered care plan addressing and assessing the resident's pressure injury risk assessment weekly for the first four weeks for Resident 1 who was admitted with a deep tissue injury (serious condition that affects the underlying layers of skin, muscle, and other soft tissues) in the sacral region (area at the base of the spine, near the hips). The deficient practices had the potential for development and worsening of pressure ulcers/injuries to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 1) by failing to ensure Certified Occupational Therapist Assistant 1 (COTA 1) wore a protective gown while assisting Resident 1, who was placed on enhanced barrier precaution (EBP-expand the use of personal protective equipment and refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms [MDRO- are germs that are difficult to treat because they are resistant to many antibiotics) get out of the bed for rehabilitation therapy. This deficient practice had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminant from one surface to another) of infection among residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident received care consistent with professional standards of practice to prevent pressure ulcer (a localized injury to the skin and or underlying tissue usually over a bone prominence as a result of pressure or pressure in combination with shear [occur between the internal body structures and skin tissues typically moving in opposite directions and may lead to deep tissue injury]) for one of three sampled residents (Resident 1) by failing to ensure only one sheet of linen was placed over the low air loss mattress (LALM-a mattress designed to distribute the patient's body weight over a broad surface area to prevent skin breakdown and treat pressure ulcers) as indicated in the manufacturer's guidelines. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident ' s dignity for one of three sampled residents (Resident 1) by failing to ensure the residents urinary collection bag was covered with privacy bag. This deficient practive had the potenttial to affect the self esteem and self -worth of Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) peripheral intravenous (IV-needle inserted within the vein) site was labeled with date and time it was inserted. This deficient practice had the potential for Resident 1 to not receive the necessary care to the IV site.

Inspectors wroteBased on interview and record review, the facility failed to ensure an ongoing weekly weight assessment was performed for one of three sampled residents (Resident 1) who was assessed as at nutritional risk by: 1. Failing to follow Registered Dietitian's (RD) recommendation to weekly weight Resident 1. 2. Failing to follow facility's policy to recheck Resident 1's weight after a weight loss was determined. These deficient practices had the potential to put Resident 1 at risk for unplanned weight loss. Findings. a. [...]

Inspectors wroteF573 Resident Rights/Exercise of Rights §483.10(g)(2) The resident has the right to access personal and medical records pertaining to him or herself. (i) The facility must provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically), or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate resident needs and preferences for five (5) out of five 5 sampled residents (Residents 54, 87, 257, 28, and 52) investigated under the call lights care area by failing to: 1. Ensure the call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for Residents 54, 87, 28, and 52. 2. Ensure Resident 257's call light was answered promptly by facility staff. These deficient practices had the potential to result in the residents not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the resident's comfort and well-being.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for five out of 26 sampled residents (Residents 81, 62, 72, 63, and 84) by failing to ensure: 1. Resident 81 had a care plan on the use of insulin (Glargine and Lispro, medications used to lower blood sugar levels). 2. Resident 62 had a care plan on the use of psychotropic medications (Aripiprazole and Sertraline, medications that affect the mind, emotions, and behavior). 3. Resident 72 had a care plan on the use of an anticoagulant (Eliquis, a drug to treat and prevent dangerous blood clots). 4. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to three out of ten sampled residents (Residents 74, 46, and 33) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident receives care and services for the provision of parenteral fluids (formulated liquids that are injected into a vein to prevent or treat dehydration [a condition caused by the loss of too much fluid from the body]) consistent with professional standards of practice for two out of two sampled residents (Residents 63 and 257) by: 1. Failing to indicate the date and time of when Resident 257's total parenteral nutrition (TPN - a special formula given through a vein that provides most of the nutrients the body needs when someone cannot receive feedings or fluids by mouth) infusion (to introduce a solution into the body through a vein) was started. 2. [...]

Inspectors wroted. A review of Resident 66's admission Record indicated the facility admitted Resident 66 to the facility on 4/11/2022 and readmitted the resident on 5/23/2022 with diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, type two diabetes mellitus (condition that affects the way the body processes blood sugar), aphasia (a language disorder that affects a person's ability to communicate), and dysphagia (difficulty or discomfort in swallowing). A review of Resident 66's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/23/2023, indicated Resident 66 was rarely or never understood, has adequate hearing, no speech pattern, and was dependent on staff for activities of daily living. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. A cup containing prepared pineapple chunks inside the walk-in refrigerator was labeled without the preparation date. 2. The ice cream freezer's thermometer was not inside the freezer. These deficient practices had the potential to result in cross-contamination (unintentional transfer of bacteria/germs or other contaminants from one surface or substance to another) and foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) for 76 of 100 residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility's interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together) failed to ensure that the self-administration of medication assessment was completed for one of one sampled resident (Resident 304), who was self-administering medications obtained outside of the facility. This deficient practice had the potential to result in unsafe medication administration or omission.

Inspectors wroteBased on interview and record review, the facility failed to provide a notice of bed-hold (when a nursing home holds a bed when the residents go to the hospital) policy and return form for one of three residents investigated under closed record (Resident 101), when Resident 101 was transferred to General Acute Care Hospital 1 (GACH 1, health care facility where the resident receives active but short-term treatment for a severe injury or episode of illness, an urgent medical condition, or during recovery from surgery). This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility not of the resident's or responsible party's preference.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan (initial written guide that organizes information about the resident's care) within 48 hours of admission for one out of six sampled residents (Resident 257). This deficient practice had the potential for Resident 257 not to receive the appropriate care and treatment specific to her needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living (ADL) do not diminish for one of 26 sampled residents (Resident 66) when the facility failed to provide Resident 66 a communication board (a device that displays symbols, photos, or illustrations to help individuals with limited or no language skills communicate more easily) at the bedside. This deficient practice had the potential for Resident 66 to not communicate her specific needs with the facility staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to one out of ten sampled residents (Resident 30) by failing to ensure Resident 30's low air-loss mattress (LALM, an air mattress covered with tiny holes) was set according to the resident's weight. The deficient practice had the potential for the development and worsening of the resident's pressure ulcer.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of ten sampled residents (Resident 46), who was assessed to be at high risk for fall with injury, was provided an environment that is free from accident hazards by failing to keep the resident's bed at its lowest possible position. The deficient practice had the potential for repeated accidents and falls that could lead to fractures (a partial or complete break in bone) and even death.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the facility had sufficient staff to provide care and respond to each resident's basic and individual needs, by failing to ensure a Registered Nurse (RN) was staffed according to the Facility Assessment. Resident 257's peripherally inserted central catheter (PICC, a long, flexible catheter (thin tube) that is placed into a vein in the upper arm) was not flushed (a procedure to ensure the lines stay clean and prevents blockage) by a registered nurse as ordered by the physician on 11/23/2023, 11/24/2023, 11/25/2023, and 11/26/2023. This deficient practice had the potential place the residents requiring parenteral services and treatment at risk for complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident diagnosed with dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one of 26 sampled residents (Resident 84) when Resident 84's care plans (a written or electronic record containing all the information the resident needs to effectively manage their own health) did not include and support Resident 84's dementia care needs. This deficient practice had the potential to affect Resident 84's safety and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist's recommendations regarding the use of heparin (a medication used to prevent blood clots from forming or keep existing clots from getting worse) was acted upon for one of five sampled residents (Resident 24) investigated under the care area of unnecessary medications. This deficient practice had the potential to increase the risk for bleeding for Resident 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to two out of ten sampled residents (Resident 21 and 46) by failing to ensure: 1. Resident 21's urinal bottle (a container used to collect urine) was labeled with the name of the resident. 2. Certified Nursing Assistant 1 (CNA 1) wore a gown (disposable hospital gown) while performing direct nursing care (care performed involving contact with resident and the resident's surroundings) to Resident 46 who was on enhanced standard precautions (an infection control intervention designed to reduce transmission of resistant organisms). These deficient practices had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of infection among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functioning call light system (device used to alert facility staff assistance as needed by residents) was provided for two of seven sampled residents (Residents 38 and 257) investigated under the accommodation of needs care area when their call light was not functioning at the call light panel after pressing the call light button to activate the call light system for ten (10) minutes. This deficient practice placed the residents at risk for a delay of necessary care and services the residents need.

Inspectors wroteBased on interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS-a standardized assessment and care screening tool) Assessment for two of three sampled residents (Residents 83 and 101) investigated under closed records by failing to: 1. Ensure Resident 83's assessment indicated the resident was discharged to the community (refers to private home/apt., board/care, assisted living, or group home). The MDS indicated the resident was discharged to an acute hospital (a health care facility where patient receives active but short-term treatment for a severe injury or episode of illness, an urgent medical condition, or during recovery from surgery 2. Ensure Resident 101's assessment indicated the resident was discharged to an acute hospital. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of all staff and resident ' s on 10/20/2023 by failing to: 1. Ensure Family Member 1 (FM 1) was not able to open the locked facility back door from the inside for Evaluator to come in at 7:59 p.m. 2. Ensure FM 3 was not able to open the locked facility back door secured with a keypad that needed a code number, from the outside without anybody letting him in at 8:10 p.m., after visiting hours. These deficient practices placed all the residents and staff ' s safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to timely issue a refund to the resident representative for one of three sampled residents (Resident 3). This deficient practice resulted in delayed issuance of the resident's refund.

Inspectors wroteBased on observation, interview, and record review, the facility failed the following for one of three sampled residents (Resident 1): 1. Failed to label Resident 1's intravenous (IV - within a vein) fluid (liquids given to replace water, sugar, and salt that you might need if you are ill) bag with resident ' s name, rate (number of drops per minute), date and time started. 2. Failed to label intravenous tubing with date and time opened. These deficient practices had the potential to cause medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from sexual abuse inflicted by Registered Nurse 1 (RN 1). On 5/20/2023 starting at 10:33 p.m., Resident 1, who was unable to communicate needs, was totally dependent on staff for care, and was unable to make decisions or consent to sexual activities, was recorded by a hidden, motion-activated video camera placed by Family Member 1 (FM 1) in front of the foot part of the bed, when RN 1 came to Resident 1's left side of the bed. RN 1 was observed lifting Resident 1's blanket covering the left foot, grasped his genital from his scrub pants (medical uniform with drawstring and/or elastic waists), and proceeded to rub his genital on the resident's left foot. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for four of six sampled resident (Resident 3, 7, 17 and 19) by: 1. Failing to ensure the emergency crash cart (a set of trays/drawers/shelves on wheels used for transportation and dispensing of emergency medication/equipment for life support protocols to potentially save someone's life) has an oxygen tank that is full. 2. Failing to ensure the Respiratory Therapist (RT-a certified medical professional who specializes in providing healthcare for your lungs) checks the emergency crash cart daily. 3. Failing to provide an oxygen tank at bedside for emergency use. These deficient practices can potentially delay the administration of oxygen during an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 20) and or the resident's representative (an individual with the authority to make decisions for others) were provided correct information on how a monitoring system (sensors that automatically detects respiratory rate and motion from up to eight feet away without anything on the bed or body, measures respiratory rate, bed exits, time in range and motion of any time the resident is within the range of the device) works before obtaining a consent (give permission for something to happen or agreement to do something) for its use. This deficient practice violated the residents' and responsible party's rights to make an informed decision.

Inspectors wroteBased on interview and record review, the facility failed to implement its facility's abuse policy by failing to conduct a thorough investigation of an allegation of sexual abuse by a staff to a resident for one of five sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse and placed the residents at risk for further abuse.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan for one of five sampled residents (Resident 20) by failing to create an individualized care plan for Resident 20 ' s ventilator (machines that helps you breathe) use. This deficient practice had the potential to negatively affect the delivery of necessary care and services.

Inspectors wroteBased on interview and review, the facility failed to maintain accurate and complete medical record for three of five sampled residents (Resident 6, 19 and 20) by: 1. Failing to ensure licensed nurses document administration of metoprolol tartrate (a medication used to treat high blood pressure) accurately and per physician's order for Resident 6 and Resident 19. 2. Failing to ensure staff document the time physician was notified for Resident 20 ' s change in condition on 8/12/2023. These deficient practices had the potential to result in inadequate management or Residents 6 ' s and 19 ' s high blood pressure and the medical records containing inaccurate documentation and can result in the delay of delivery of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the hospice services meet professional standards and principles and ensure necessary care was provided consistently for one of one sampled resident (Resident 21) who was receiving hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) by failing to ensure the facility designated a staff to coordinate with the hospice staff. This deficient practice had the potential to result in a delay or lack of coordination in delivery of hospice care and services to Resident 21.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control measures for three of five sampled residents (Resident 3 and Resident 2) by: 1. Failing to ensure Resident 3 ' s urinary drainage bag was not touching the floor. 2. Failing to ensure Licensed Vocational Nurse 6 (LVN 6) don (put on) protective gown before entering Resident 2 ' s room, who was placed on enhanced barrier precautions (an infection control intervention designed to reduce transmission [transfer] of multidrug-resistant organisms [MDRO- bacteria that have become resistant to certain antibiotics that can no longer be used to control or kill the bacteria]) before emptying the urinal (container with urine). [...]