Mountain View Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to conduct fall risk assessments (FRA-an evaluation used to determine an individual's likelihood of falling) after the episodes of falls on 11/17/25 and 12/19/25 for 1 of 2 residents (Resident 1). This failure had the potential not to determine the factors that may contribute to the risk of falling that may affect the development of appropriate nursing interventions to prevent possible repeated falls for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to identify and monitor the specific target behavior for the use of olanzapine (a psychotropic medication that affects the person's mind, emotions, and behavior) for bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) as manifested by agitation and labile mood for 1 of 2 residents (Resident 2). This failure had the potential for Resident 2's physician not to accurately evaluate the effectiveness of the use of olanzapine and may compromise Resident 2's psychological well-being.

Inspectors wroteBased on interview and record review, the facility failed to inform the Responsible Party (RP, the designated person who oversees a patient's medical, personal, or legal care decisions) for 1 of 2 residents (Resident 1) when:There was no written documentation in Resident 1's medical record that Resident 1's RP was notified prior to discontinuation of 1:1 observation (sitter) on 5/1/26 andThere was no written documentation in Resident 1's medical record that Resident 1's RP was informed of room changed on 12/4/25. These failures deprived Resident 1's RP of the opportunity to advocate alternative choices/options and participate in care planning for Resident 1's welfare and safety.

Inspectors wroteBased on interview and record review, the facility failed to follow standards of practice when medications were not given as prescribed for two of three residents (Residents 1 and 2):Resident 1's lamotrigine (a medication used to prevent seizures [uncontrolled jerking, blank stares, and loss of consciousness]) order and administration time was adjusted in the electronic health record (EHR) and lamotrigine was not given to Resident 1 on 10/7/25 and 10/8/25;Resident 2's lacosamide (a medication used to prevent seizures) order was incorrectly duplicated in the EHR and nurses did not administer the correct daily dose to Resident 2 on 10/21/25, 10/22/25, and 10/23/25. These failures resulted in missed medication doses, overmedication, and had the potential to result in health complications.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient preparation and orientation to ensure a safe and appropriate discharge for one of three residents (1) procedures to discharge on e of three residents (1) when: 1. The facility did not follow their policy on, Against Medical Advice (AMA, a patient's decision to leave a healthcare facility or discontinue treatment despite the recommendations of their doctor) when Resident 1 was discharged AMA after he did not return to the facility when he went out on pass (a temporary absence for an inpatient who has received official permission to leave a hospital or care facility but is not being officially discharged ) for several hours.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their procedure in completing the inventory list of personal effects form (a document used to record a resident's possessions, typically in a specific context like moving into a facility which serves as a record of belongings, often including details like descriptions, values, and dates of acquisition or loss) when the form was not signed by facility staff and resident upon discharge for one of three residents (Resident 1). This failure may lead to issues if the discharged resident claims of any missing items and no proof that this was all accounted for during discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure service provided to meet professional standards for two of three residents (1 and 2) when their fall risk assessments were not done quarterly. This failure resulted in the residents' fall risk and fall prevention not updated to the residents' conditions to prevent the residents from falling.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received the necessary care and services 1. For one of three residents (3) when Resident 3's order from the acute care was not followed; and 2. For three of three residents (3, 4, and 5) when the licensed nurses did not administer Resident 3, 4, and 5's blood pressure medications as ordered by the physician. These failures could negatively impact the residents' health and well-being.

Inspectors wroteDuring an observation inside Resident 25's room on 5/19/25 at 9:06 a.m., Resident 25 was observed lying in bed. Her Foley catheter drainage bag was left uncovered hanging on the right side of the bed towards the door. yellow colored urine was visible from the drainage bag. During a concurrent observation and interview on 5/19/25 at 9:12 a.m., with Certified Nursing Assistant Q (CNA Q), She confirmed that Resident 25's Foley Catheter drainage bag was left uncovered with the privacy bag. CNA Q further stated usually it should have cover with privacy bag . During a review of Resident 25's clinical record indicated Resident 25 was admitted to the facility with diagnosis including neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should). [...]

Inspectors wrote7. A review of Resident 67's physician's order, dated 11/13/24, indicated monitoring episodes of anxiety (a common reaction to stress that involves occasional worry about circumstantial events) manifested by restlessness and agitation. A review of Resident 67's physician's order, dated 12/12/24, indicated monitoring episodes of depression manifested by lack of interest. A review of Resident 67's Interdisciplinary Team (a group of individuals with different expertise and backgrounds who work together to achieve a common goal) on Psychotherapeutic Review, dated 5/13/2025, indicated Resident 67's behaviors exhibited two episodes of restlessness and agitation and one episode of lack of interest. [...]

Inspectors wrote3. Review of Resident 89's clinical record, indicated, Resident 89 was admitted to the facility on [DATE] with diagnoses including encephalopathy (condition affecting how the brain works), acute and chronic respiratory failure with hypoxia (a condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide), anemia (a condition where the body does not have enough red blood cells to carry enough oxygen to the body), thrombocytopenia (having a low number of platelets [tiny blood cells to stop the bleeding] in the blood). Review of the physician's order dated 5/2/24 and 9/5/24, indicated Resident 89 was on enteral feeding (liquid nutrients given through a tube inserted in the stomach) and enteral bolus feeding (liquid nutrients given over a short period multiple times a day), and was discontinued on 10/4/24. [...]

Inspectors wrote3. Review of Resident 10's clinical record titled, admission Record, indicated Resident 10 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, condition that limits airflow to the lungs), obstructive sleep apnea (disorder that affects breathing while sleeping), diabetes mellitus (a condition which affects the way the body processes blood sugar) and chronic kidney disease. During an observation on 5/19/25 at 8:54 a.m. in the room of Resident 10, Resident 10 was observed in bed receiving oxygen therapy at 2 L/min via nasal cannula. The O2 concentrator's filter located at the back of the equipment had grayish substance build up. During a concurrent observation and interview on 5/19/25 at 12:30 p.m. with the Director of Staff Development (DSD) in the room of Resident 10, the DSD confirmed the filter should not have grayish substance build up. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with a high abuse potential) when: 1. Registered Nurse (RN) D did not sign out the Controlled Drug Record (CDR, a count sheet nurses sign when administering controlled medications to record the usage and inventory of such medications) sheet after medication administration for six medications in one of three medication carts inspected. 2. Random controlled medication use audit for three out of five sampled residents (Residents 7, 102 and 426) did not reconcile. The residents' medications were signed out of the CDR, but not documented on the Medication Administration Record (MAR) to indicate they were administered to the residents. [...]

Inspectors wroteBased on interview and record review, the Consultant Pharmacist (CP) failed to identify and report to the facility medication-related irregularities during the monthly medication regimen review (MRR) for three of 26 sampled residents (Residents 81, 37, and 10), as follows: 1. Resident 81 received lidocaine 4% patch (topical medication applied to the skin for pain) longer than manufacturer's specification. 2. Resident 37 received Seroquel (an antipsychotic medication) for over 2 years without a gradual dose reduction (GDR, a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued); and had no risk-benefit assessment for the use of Seroquel and metoclopramide (medication used to treat various digestive conditions), medications that could cause or worsen movement disorders. 3. [...]

Inspectors wrote5. During a review of Resident 25's clinical records indicated Resident 25 was admitted to the facility with diagnosis including type diabetes mellitus (DM, a condition which affects the way the body processes blood sugar). During a review of Resident 25 physician's order indicated an order for Clopidogrel oral tablet 75 mg (milligram, unit of measure) Give 1 tablet by mouth one time a day for cva (cerebrovascular accident, which is another term for a stroke) ppx (prophylaxis, an attempt to prevent disease), dated 11/28/24. During a review of Resident 25's Medication Administration Record (MAR) indicated the nursing staff did not monitor the sign and symptoms of bleeding for Clopidogrel. [...]

Inspectors wroteBased on observation, interview, and record review, the facility document review, the facility failed to provide and served food that was palatable. These failures placed the 124 residents eating at the facility at risk of poor food intake further compromising their nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. There were a gallon 340 grams of whole bay leaves stored in the shelved more than one year from the opening date; 2. There were undated and unlabeled food items and staff-stored metal water bottle in the two-unit refrigerator for residents. 3. Metal tray and muffin pans used for food preparation and food service had black, gray, and yellow buildup; 4. A metal pipe in the kitchen faucet one was covered with gray and brown build up or stain; and 5. A sanitizing agent in red bucket were above the acceptable range. These failures had the potential to cause food contamination and food-borne illness to 124 of 124 residents who received their food from the kitchen.

Inspectors wrote4. Review of Resident 97's clinical record, indicated, Resident 97 was admitted on [DATE] with diagnoses including sepsis (body's extreme and potentially dangerous response to infection), urinary tract infection (infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra), primary osteoarthritis (joint pain and stiffness) left shoulder, anxiety disorder (mental health conditions characterized by excessive and persistent worry, fear, and nervousness). Review of Resident 97's Inventory of Personal Effects, dated 4/17/25, indicated the form was blank. During a concurrent interview and record review on 5/23/25 at 10:04 a.m., with the Director of Nursing (DON), the DON stated the Inventory of Personal Effects must be filled out upon admission. The DON stated there should be a note in the form indicating if the resident does not have any belongings. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were implemented in seven of 26 sampled residents (Residents 81, 96, 115, 375, 109, 45, and 51) when: 1. Registered Nurse (RN) H used one tissue to wipe eye drops from both of Resident 81's eyes, and RN H used a dry tissue to wipe Resident 81's eye drop cap that fell on the floor before capping it back on the bottle, 2. Licensed Vocational Nurse (LVN) E did not wear a gown and did not perform hand hygiene after touching potentially contaminated surfaces during medication administration through a feeding tube (a surgically placed tube used to administer food and medications in individuals who have trouble swallowing) for Resident 96. 3. LVN F did not perform hand hygiene after touching potentially contaminated surfaces during the blood sugar check for Resident 115. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the steam table was maintained in a safe operable condition according to manufacturer's guidelines and facility policy. This failure had the potential to impact the ability of dietary staff to prepare and serve food in a safe and sanitary manner. 124 residents are receiving food from the kitchen. During an observation of the lunch trayline meal service on 5/21/25, [NAME] V (CK V), CK V was observed checking the food temperature placed in steam table. She checked the food which included puree biscuit, puree beef, and BBQ sauce then she asked the Dietary Aide (DA) to reheat those food. The steam table was observed missing one out of six switch knobs from the right and missing red light indicator that is on. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their policy and procedure on self-administration of medication (resident takes medication without staff assistance) when there was no assessment performed for self-administration of medication, and medications were left at bedside for one of eight sampled residents (Resident 325). This failure had the potential for unsafe and improper administration of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure needs was accommodated for two of 26 sampled residents (Residents 279 and 278) when call light button (a red or white button used to call for assistance) was not within Resident 279 and 278's reach for use. This failure had the potential for a delayed response and not meeting Resident 279 and 278's needs.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure one of three residents (Resident 36) had been informed about having an advance directive (AD, legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf), when no documentation was found about advance directive and the Physician Orders for Life -Sustaining Treatment (POLST, a legal document stating the kinds of medical treatment patients want toward the end of their lives) was not completed and readily available in the event of a medical emergency. This failure had the potential to result in inability to make medical decisions and could lead to the delivery of unnecessary or inappropriate medical services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 37) reviewed for unnecessary medications received a gradual dose reduction (GDR, a stepwise tapering of a dose to determine if symptoms can be managed by a lower dose or if the medication can be discontinued) for Seroquel (a medication used to treat various psychiatric conditions) and a risk-benefit assessment for Seroquel and metoclopramide (generic for Reglan, a medication used for acid reflux) despite having a documented diagnosed abnormal movement disorder and drug-induced akathisia (a condition caused by medications resulting in an inability to stay still and an involuntary urge to move), conditions that could be caused or worsened by Seroquel and/or metoclopramide use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment for Resident 29 who was on oxygen (O2, a colorless, odorless gas) therapy and missed to complete the MDS significant change in status assessment (SCSA - a comprehensive assessment completed in nursing homes when a resident experiences a significant decline or improvement in their condition, according to federal regulations) for Resident 51 who had declined in the four areas of functional mobilities (the ability to move around and perform activities of daily living [ADL, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves] effectively and safely in one's environment). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for dining/eating with meals when the facility did not provide meal assistance to one of three residents (Resident 36). This failure had the potential to affect the psychosocial well-being of the resident and a decline in the activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

Inspectors wrote2. Review of Resident 47's clinical record titled, admission Record, indicated, Resident 47 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (a condition which affects the way the body processes blood sugar), spondylosis (wear and tear on the joints and disks of the spine), viral hepatitis (infectious disease that causes liver inflammation and damage), difficulty walking and muscle weakness. Review of Resident 47's minimum data set (MDS, federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 47's Brief Interview for Mental Status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 12 (0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 85 ) who received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with professional standards of practice when staff did not follow Resident 85's fluid restriction (limiting liquids). This deficient practice had the potential to result in Resident 85's fluid overload (a condition where there is an excessive amount of fluid in the body).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an assessment for the use of side rails was performed for one of 26 sampled residents (Resident 97). This failure had the potential to put Resident 97 at risk of entrapment and serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate social services (SS) support for one of three residents (Resident 54) when there was no documentation of SS support for Resident 54, and no person-centered care plan developed to meet Resident 54's mental and psychosocial well-being. This failure resulted in a lack of timely social services interventions for Resident 54.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 6.45% when two medication errors occurred out of 31 opportunities during the medication administration for one out of six residents (Resident 81). This failure resulted in Resident 81 not receiving medications as ordered and had the potential for Resident 81 to experience unnecessary pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were labeled in accordance with standards of practice and facility policy and procedures (P&P) when: 1. An opened bottle of dabigatran (generic for Pradaxa, a blood thinner) for Resident 278 was found without an open date in one of three medication carts. This had the potential for the medication to be used beyond its effective date; and 2. The direction for use on the pharmacy label was altered with handwritten markings for one of six residents (Resident 86) observed during medication administration. This had the potential for medication errors for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure a resident consistently received a pureed texture (a type of food that has been processed to a smooth, uniform texture, like pudding or apple sauce) diet as prescribed by a physician when one of five residents (Resident 36) on pureed texture diet did not receive the pureed food. This failure had the potential to result in Resident 36 not meeting the nutritional needs and aspiration (food, liquid, or other materials accidently enter the airway and lungs instead of going down to the esophagus to the stomach) with not properly pureed food.

Inspectors wroteBased on interview and record review, the facility failed to implement their antibiotic stewardship program (program intended to prevent overuse of antibiotics) for one of two sampled residents (Resident 21) when: 1. Resident 21 received several antibiotics (medications used to treat bacterial infections) for pneumonia and chronic bronchitis but no documentation that Resident 21 meet all the criteria that needed to be present for antibiotic use; 2. The prescriptions for antibiotics did not specify the duration and indication for use; 3. No documentation of monitoring antibiotic use; and 4. No documentation related to the program maintained by the Infection Preventionist (IP). These failures had the potential to increase the prevalence of multi-drug resistant organisms in the facility.

Inspectors wroteBased on interview and record review, the facility failed to secure the confidential medical records for two of three residents (1 and 2) when the facility released Resident 1's and Resident 2's medical records to persons who were not the legal representatives of these two identified residents. This failure violated the residents' rights to privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess and complete the Minimum Data Set (MDS, an assessment tool) for one of two sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions.

Inspectors wroteBased on interview and record review, the facility failed to provide a summary of the baseline care plan for one of two sampled residents (Resident 1) to the resident and resident's representative. This failure had the potential to result in the facility being unable to promote continuity of care, meet the resident's immediate needs, and ensure the resident and representative were informed of the initial plan on the delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement care plans for one of two sampled residents (Resident 1) when a care plan for a diagnosis of obesity was not developed. This failure had the potential to not meeting the resident's medical, nursing, and mental and psychosocial needs that were identified in Resident 1's comprehensive assessment.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to implement infection control practices when certified nursing assistant A (CNA A) placed soiled linen on Resident 1's room floor and janitor B (JAN B) walked in the hallway with gloves on. These failures had the potential to spread infection in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide care that allowed one of three residents (1) to remain safe when Resident 1 was a bariatric resident and only one certified nursing assistant (CNA) working with her. This failure resulted in Resident 1 fell off her bed and to the floor.

Inspectors wroteBased on interview and record review, the facility failed to provide respiratory care consistent with professional standards of practice for three of four residents (Resident 1, 2, and 3) on oxygen therapy when: 1. There was no documentation that Resident 1 was educated on the risks and benefits of refusal to use the BiPAP (bilevel positive airway pressure, a device that pushes air into the airway and provides airflow at two different pressures: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide radiological services were provided in a timely manner for one of three residents (Resident 1) when a stat (a common medical abbreviation for urgent or rush, from the Latin word statim, meaning immediately) chest X-ray (procedure that uses electromagnetic energy to create pictures of the inside of the body) was not done for Resident 1. This failure had the potential to delay treatment for the resident.

Inspectors wroteBased on interview and record review, the facility (Facility A) failed to permit five of 21 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) to remain at the facility and not transfer to another facility without appropriate reason/s for discharge when: 1. Resident 1 was transferred to Facility B by a facility-initiated discharge (a transfer or discharge which the resident objects to or did not originate through a resident's verbal or written request) without an appropriate reason for discharge in accordance with CFR 483.15(c)(regulation with specific criteria for discharge/transfer of residents). 2. Resident 2 was transferred to Facility B by a facility- initiated discharge without an appropriate reason for discharge in accordance with CFR 483.15(c). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident/resident's representative(s) and The Office of the State Long-Term Care (LTC) Ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand 30 days prior to date resident is discharged for four of four sample residents (Resident 1, Resident 2, Resident, 3, & Resident 4). This failure resulted in Resident 1, Resident 2, Resident 3, Resident 4, and State LTC Ombudsman not being informed of the resident's transfer timely, removed the opportunity for the State LTC Ombudsman to advocate on the resident's behalf, deprived the residents to be informed of resident rights regarding transfer/discharge, and had the potential for all four resident's to be inappropriately discharged .

Inspectors wroteBased on observation, interview, and record review, the facility failed to comply with this state regulation by having more residents and/or beds set up for use than the number of which it was licensed (123 beds) without prior temporary permission and /or approval from CDPH (California Department of Public Health) when the approved program flex or waiver (emergency program flex approved by Centralized Program Flex Unit [CPFU] during COVID [Coronavirus disease] that allowed the facility to have more residents than its licensed bed capacity) expired on [DATE]. This failure had the potential to affect the quality of care that the facility provides to their residents.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards for one of three residents (Resident 1) when: 1. Resident 1's physician order for fingerstick blood sugar monitoring (procedure to test blood sugar levels by pricking a fingertip to get a small amount of blood) was not followed; 2. Resident 1's bladder was not scanned timely after admission. These failures had the potential to result in health complications.

Inspectors wroteBased on observations, interviews, and review of facility recipes policy, the facility failed to serve food that was palatable and well-seasoned. Specifically, the facility failed to season foods served to residents as required by planned menus. This affected all residents who received food from the kitchen.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was accurate and updated to include major mental illness upon admission for 1 (Resident #76) of 7 sampled residents reviewed for PASARRs.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to develop a comprehensive care plan for cognitive impairment for 1 (Resident #86) of 3 sampled residents reviewed for dementia care.

Inspectors wroteBased on interview and record review the facility failed to notify one of three sampled residents' (Resident 1) responsible party (RP, refers to an individual who is legally authorized to make decisions on behalf of a resident) when Resident 1 was moved to another room on 8/23/2023. This failure violated Resident 1's RP right to be informed prior to the room change on 8/23/2023.

Inspectors wroteBased on interview and record review, the facility failed to ensure the interdisciplinary team (IDT, staff from different disciplines who work together to plan and provide care) care conference meeting was scheduled upon residents' return from the hospital for one of three sampled residents (Resident 1). As a result, Resident 1 and the RP were not able to participate in planning Resident 1's care upon returned from the hospital on 8/18/23.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents' (Resident 1) physician;s order for basic metabolic panel (BMP, a blood test that checks the body's fluid balance and levels of electrolytes and sees how well the kidneys are working) blood tests were performed as ordered by the physician. This failure had the potential to affect the well-being anc clinicla condition of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to safely monitor the administration of 5% dextrose in water (D5W) intravenous (IV, tube inserted into a vein) fluid for one of 12 sampled residents (Resident 49) when a physician order was not followed regarding daily basic metabolic panel (BMP, a blood test that measures your glucose (sugar) level, kidney function, electrolyte and fluid imbalance), failed to monitor the amount of D5W IV fluids administered to Resident 49, and failed to implement the fluid imbalance care plan intervention to monitor for signs of fluid imbalance such as mentation changes (loss of alertness), and edema (swelling caused by excess fluid trapped in the body's tissues). These failures resulted in Resident 49's fluid overload (too much fluid in the body) which may have caused, or contribute to, Resident 49's deterioration in health, and ultimate death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed when: 1. One staff did not sanitize her hands before donning PPE and entering a resident's room; 2. One staff did not wear the proper personal protection equipment (PPE) when entering multiple residents' rooms in the yellow zone; 3. Visitor screening logs had missing entries for recording temperatures; 4. One staff did not know the correct contact time for a disinfecting product; 5. Two staff did not correctly wear masks in the green zone; 6. A restorative nursing assistant (RNA) did not perform hand hygiene in between tasks; 7. Certified nursing assistant (CNA) G was wearing a facemask with an exhalation valve; 8. One staff used toilet water to rinse out the resident's urinal; 9. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a bowel and bladder training program for four of 12 sampled residents (Residents 21, 14, 41, 7) and two non-sampled residents (44, and 298), when there was no evidence of documentation the program was implemented. This failure had the potential to cause residents' decline in bowel and bladder control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when: 1. Scoop was left inside the flour container; 2. Sanitizer bucket was stored below the preparation sink together with chopping boards and uncovered fruits and vegetables; 3. Two chopping boards had deep cuts; 4. Rack to store sandwich bags had yellowish color; 5. Cake sprinkles did not have an open date; 6. Grayish particles were observed near the refrigerator's fan and vent; 7. There was a buildup of icicles in the freezer; 8. Chopping boards, tray of bananas and tray of onions were below the sink preparation table; 9. Three spatulas were chipped and; 10. Dietary aide did not demonstrate the proper procedure for testing the strength of sanitizer used for sanitizing food contact surfaces. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards for four of 12 sampled residents (Residents 9, 41, 298, and 10) when: 1. Registered nurse F (RN F) administered Augmentin (antibiotic to treat infection) to Resident 9 when he was allergic to Augmentin. 2. A licensed nurse left the medication at the bedside table and documented as not administered for Resident 41; 3. A physician order for fluid restriction was not followed for Resident 298; 4. A licensed nurse did not clarify a physician order regarding water flush of gastrostomy tube (g tube; a tube inserted in the abdomen to bring nutrition directly to the stomach) before and after giving the medication to Resident 10. These failures could potentially affect the quality of care provided to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care was provided in accordance with the physician order and the standards of care for one of one resident on humidified oxygen (Resident 36). This failure had the potential to place the resident at risk for discomfort and further complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure for two of 12 sampled residents (Residents 10 and 298) were free from unneccesary medications when the residents were not monitored for possible side effects of anticoagulant medications. This failure had a potential for risk of bleeding and bruising.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy when the following were found in a Medication Cart for Station 1: 1) Several medications unlabeled, and prepoured in cups and 2) an open insulin bottle with no open date and discard date. These failures can put residents at risk for adverse drug reactions.