Murrieta Health and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure discharge plan was arranged and followed up, for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 not to receive the necessary support and services to meet the resident's care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and treatment was provided, for one of four residents reviewed (Resident 1), when the resident's left great toe skin condition was not evaluated and referred to the physician for further treatment. This failure resulted in a delay in the care and treatment of Resident 1's skin condition and had a potential risk for further complications such as infection.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to ensure the sanitary requirements were met in the kitchen when: -An opened bag of frozen ground meat had an opened date of 7/11/24.-An opened container of Italian seasoning had a use-by date of 2/25/26.-The wire racks in the walk-in refrigerator were observed with dust.-A table-mounted can opener was observed with a brown sticky substance.-A pizza cutter was observed with crusty debris.-Five clear plastic bowls, five metal baking trays, and three plastic storage containers were stored and stacked on top of each other while still wet. [...]

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to ensure the residents' food brought by visitors were properly labeled and stored in the refrigerator. This failure had the potential to expose highly susceptible residents who stored their foods in the unit refrigerator to foodborne illnesses (any illness resulting from eating contaminated/spoiled foods) due to cross-contamination (the transfer of harmful substances or disease- causing microorganisms to food).

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to dispose and store trash in a sanitary manner. This failure had the potential to increase the risk of pest infestation in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with physician orders and professional standards of practice when a medication error rate of 8.62% was identified, with five medication errors out of 58 medication administration opportunities, during medication administration observations for four of eight residents observed (Residents 38, 148, 168, and 169). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:The Maintenance Assistant (MA) did not perform hand hygiene before entering and after leaving a room on Enhanced Barrier Precautions ([EBP] - an infection control prevention designed to reduce the transmission of multi-drug-resistant organisms (MDROs) in healthcare settings, particularly nursing homes). An Activity Assistant (AA) did not perform hand hygiene before entering and after leaving a room on EBP.A Physical Therapy Assistant (PTA) did not perform hand hygiene and did not wear proper personal protective equipment ([PPE] - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before and after providing care to Resident 46, who was on EBP.Resident 46's respiratory supplies had no label. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written information concerning the right to formulate an Advance Directive (a written document specifying an individual's medical care wishes) for three of 26 sampled residents (Residents 3, 7, and 88). This failure could pose significant risks that may negatively affect the residents' quality of life and medical care, leading to medical interventions that do not align with the residents' preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure accuracy of the Preadmission Screening and Resident Review ([PASRR] - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level 1 Screening assessment for one of 26 sampled residents (Resident 3). This failure resulted in the missed identification of a serious mental illness that could potentially lead to improper placement or failure to provide appropriate specialized treatment for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 26 sampled residents (Resident 73) who received necessary assistive devices to support eating and maintain independence, had a required physician's order for their use. This failure had the potential to affect the resident's safety, dignity, and ability to receive individualized care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure IV (Intravenous- fluids given directly into the blood stream) therapy was provided consistently in accordance with the professional standards of practice, physician orders, and comprehensive person-centered care plans for two of four sampled residents (Residents 2 and 59) when:-There was no documented evidence indicating that Resident 2's IV antibiotic was administered on 2/4/26 and 2/5/26 as ordered.-There was no documented evidence that Resident 2's PICC line (Peripherally Inserted Central Catheter - a thin flexible tube inserted to a large vein in the upper arm used to deliver medications for long term treatments) was flushed with normal saline on 2/4/26 and 2/5/26 as ordered. -Resident 2's PICC line dressing had no label.-Resident 59's PICC line dressing was not changed as ordered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an oxygen administration order was obtained for one of five sampled residents investigated for oxygen treatment (Resident 166). This failure could result in Resident 166 experiencing oxygen toxicity (lung damage caused by breathing excessive oxygen at high pressure) due to the administration of excessive or inappropriate supplemental oxygen, potentially leading to respiratory failure (when lungs cannot properly transfer oxygen into blood causing severe breathing difficulty).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled substances (controlled substance [CS] - medications with high potential for abuse and addiction) when:The Controlled Drug Records ([CDR] - a medication count sheet, an inventory record used to document the receipt, use, and count of controlled substances) for one out of nine randomly selected residents (Resident 56) did not reconcile with the Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). [...]

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operations of the Food and Nutrition Services Department. Dietary Aide (DA) 2 was unable to correctly explain the procedures to test the chemical concentration measured in parts per million (ppm - a unit of measurement) of the quaternary sanitizing solution (a chemical solution used to kill germs on surfaces) to sanitize food contact surfaces. This failure had the potential to expose 131 of 132 highly susceptible residents who received food from the kitchen to foodborne illnesses (any illness resulting from eating contaminated/spoiled foods) due to cross- contamination (the transfer of harmful substances or disease- causing microorganisms to food). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure complete, accurate, and consistent documentation for two of 26 sampled residents' (Residents 59 and 60) medical records when:Resident 59's medical record did not accurately reflect the resident's PICC line (Peripherally Inserted Central Catheter - a thin flexible tube inserted to a large vein in the upper arm used to deliver medications for long term treatments) dressing change. 2. Resident 60's activity records were not accurately and consistently completed. These failures had the potential for these two residents to receive inconsistent care coordination and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the resident call light system (a device that residents can press to ask staff for help) in good working order for two of 26 sampled residents (Residents 13 and 171). This failure had the potential to delay staff response to resident needs and compromise resident safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and treatment was provided, for one of four residents reviewed (Resident A), when Resident A had high blood pressure. This failure had potential for a delay in the care and treatment to address Resident A's high blood pressure and could affect the resident's overall health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1) was discharged to a facility that would be able to provide the care required by the resident. Resident 1 was discharged to an assisted living facility (ALF- a residential community providing housing, meals, and personalized support for older adults or people with disabilities who need help with daily activities [ADLs- activity of daily living] but not round the clock skilled nursing [high level medical care requiring the expertise of licensed professionals like registered nurses, licensed vocational nurses, and therapist]), which was unaware of the presence of the unstageable pressure injury ( a full thickness skin and tissue loss where the actual depth of the wound is completely obscured by slough [soft, yellowish, stringy, dead tissue] or eschar) on the right heel. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess the bruise on the right arm for one of six sampled residents (Resident 1), when it was initially observed by a Certified Nursing Assistant (CNA) on November 17, 2025. This failure resulted in delayed provision of interventions which placed the resident at risk for complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for two of four residents (Residents A and B), were free from abuse when: 1. For Resident A, Certified Nursing Assistant (CNA) 1 refuses to take care of the resident and stated I am not your slave, and 2. For Resident B, CNA 1 provided care to the resident in a rough manner. These failures had the potential for Residents A and B to experience physical and emotional distress from the abuse from CNA 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse by a Certified Nursing Assistant (CNA) was reported to the California Department of Public Health (CDPH - a State Agency [SA]) immediately or within two hours according to the facility policy and procedure, for one of four residents (Resident B). This failure had the potential to result in the delay in the investigation of the allegation of abuse and could further expose the vulnerable residents from further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were answered timely, for three of five sampled residents, (Residents 1, 3, and 5). This failure had the potential to negatively affect Residents 1, 3, and 5's psychosocial well-being, and could affect the residents' overall health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment for safe self-administration of medication was conducted, for three of 28 residents (Resident 382, 388, and 389) when: 1. One opened box of Allergy Calm (brand of tablet used to treat allergies) tablet medication was found on the over bed table of Resident 382; 2. One opened plastic bottle of 15 ml (milliliters - unit of measurement) Afrin (brand of nasal spray used to treat congestion) nasal spray was found on the over bed table of Resident 388; and 3. One opened 77 g (grams- unit of measurement) tube of Alevex (brand of lotion use for pain) lotion was found on the over bed table of Resident 389. These failures had the potential for Residents 382, 388, and 389 to receive multiple doses of medication without proper monitoring, which could lead to harmful effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory tubings were changed according to the facility's policy and procedure, when: 1. For Resident 17, the nebulizer tubing (tubing that turns liquid medication into a mist that can be inhaled) was dated June 23, 2024; 2. For Resident 19, the nebulizer tubing, oxygen tubing (nasal cannula [N/C] - a tube used to deliver oxygen through the nose), and the tubing from the humidifier bottle to the oxygen concentrator (plastic bottle that infuses the normal flow of oxygen with water droplets) were all dated November 21, 2024; and 3. For Resident 80 the oxygen tubing and humidifier bottle (moistens the air) were dated November 24, 2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when: 1. Residents 88 and 101's discontinued and expired medication were identified stored inside a medication cart along with active/unexpired medications. This had the potential for residents to receive the wrong medication; and 2. Residents 90, 76, and 55's medical record had missing documentation for the administration of controlled substance (CS - those with high potential for abuse and addiction) medications. The CS medications were signed out on the Antibiotic or Controlled Drug Record Medication (count sheet, an inventory sheet that keeps record of the usage of controlled medications), but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure, for two of five sampled residents (Residents 34 and 5) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications, including quetiapine (brand name Seroquel, an antipsychotic medication for bipolar disorder, depression, and schizophrenia) when: 1. Resident 34 was administered quetiapine without an appropriate indication and/or clinical justification, without an annual GDR (gradual dose reduction) attempt in 2024, and no resident-centered non-pharmacological (any treatment or method used to improve health that doesn't involve taking medication) behavioral interventions were implemented prior to initiation and during use of quetiapine; and 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication were properly stored and labeled when: 1. One (1) expired medication was stored in the medication cart together with unexpired medications; 2. Opened medications were stored without an open date; 3. IV (intravenous - into the vein) Cart 3 contained several expired IV supplies; and 3. The treatment cart contained multiple expired wound care supplies. These failures had a potential for residents to receive medications or medical supplies with unsafe and reduced effectiveness from being used past their discard date; medication errors due to medications not being labeled or removed from active stock; and inadequately monitored medications, which could lead to unsafe and ineffective medications for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in the kitchen when: 1. Brown-black substance was observed in several areas where the walls and ceiling seams meet in the walk-in refrigerator; 2. Ice formed on the inside doors and seals of the six-door reach-in freezer; 3. Several open packages of food items were observed in the reach-in freezer; and 4. Air vents on the ceiling had brown dust coating. These failures had the potential to cause food-borne illnesses in a highly susceptible resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1a. The nursing staff failed to properly clean and disinfect shared blood pressure (BP- pressure of blood in blood vessels) cuff according to the disposable bleach wipe manufacturer's specified contact time (the time the resident equipment was to be in contact with the bleach disposable wipes to kill micro-organisms). In addition, the facility failed to properly clean and disinfect the shared stethoscope after use according to facility's policy, for Residents 282, 283 and 100; 1b. The nursing staff failed to properly clean and disinfect the resident's prefilled insulin (medication for diabetes) pen before use according to manufacturer's specifications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat resident with dignity and respect, for one 130 residents (Resident 385), when the resident's urinary bag was not covered with a dignity bag (used to cover a urine collection bag). This failure had the potential to affect Resident 385's psychosocial well being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD - a written instruction, such as a living will, relating to the provision of treatment and services when the individual becomes unable to decide) was available in the medical record, for one of one residents reviewed for Advance Directives (Resident 68). This failure had the potential to result in Resident 68's wishes related to the provision of medical treatment and services to not be followed if Resident 68 became unable to make decisions for himself.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable homelike environment, for one of 28 residents reviewed (Resident 384), when multiple damaged window blinds were observed. This failure had the potential to disrupt the residents' daily living needs and environment.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy and procedure on antibiotic stewardship (a set of coordinated efforts aimed at promoting the appropriate use of antibiotics to optimize patient outcomes while minimizing the risk of antibiotic resistance and adverse effects), for one of five sampled residents reviewed (Resident 390) when there was a delay in obtaining the urinalysis specimen and was not evaluated for antibiotic time out (a healthcare practice where a review of antibiotic therapy occurs within a predetermined time frame after the initial prescription) within 72 hours. These deficient practices had the potential to result in the development of antibiotic-resistant organisms (organisms not affected by antibiotics).

Inspectors wroteBased on interview and record review, the facility failed to ensure the pneumococcal vaccine (vaccines against the bacterium Streptococcus pneumoniae [bacteria that can cause pneumonia]) was offered, for one of five residents reviewed for immunizations (Resident 31) . This failure had the potential for Resident 31 not fully be protected against pneumonia (infection of lungs).

Inspectors wroteBased on interview and record review, the facility failed to accurately document in the Electronic Medication Administration Record (EMAR) scheduled time of medication administration, for one of three residents (Resident 1). This deficient practice can have the potential for inappropriate communication between the staff and an inaccurate picture of resident's care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough assessment of the wounds and notification to the physician after a change of condition was identified for one of three sampled residents (Resident 1). This failure has the potential to result in worsening of the pressure injuries (skin or soft tissue injuries that form due to prolonged pressure exerted over specific areas of the body), acquired by Resident 1, resulting in infection and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented to prevent the spread of COVID-19 (coronavirus-an illness caused by a virus that can spread from person to person), when: 1. A Certified Nursing Assistant (CNA) did not wear face shield during care of resident who tested positive for COVID-19 and was under isolation/droplet precaution room (a room where patient is placed after being confirmed or suspected with infection with germs that can be spread to others by speaking, sneezing, or coughing). In addition, this CNA did not discard N95 (NIOSH approved respirator mask) mask after caring and/or exiting resident's room in isolation/droplet precaution room, and used the same N95 mask when caring to a non-COVID positive residents; 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified when one of the three sampled residents (Resident 1), refused a medication ordered by the physician. Resident 1 refused lactulose ( medications used to treat constipation and used to treat or prevent certain conditions of the brain that are caused by liver failure) three times when it was ordered by the physician on February 27, 2024. This failure has the potential to result in the physician not being aware of the resident's condition which could affect the treatment plan for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory (lab) tests were completed as ordered by the physician, for one of three residents reviewed (Resident 1). The physician ordered for a stat (without delay) laboratory work up on March 1, 2024, were not completed. This failure had the potential to result in a delay of diagnosis and necessary treatment for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records reflected the reasons why medications were ordered by the physician for one of the three sampled residents (Resident 1). The medical record reflected two medications (lactulose and dicyclomine) were ordered by the physician on February 27, 2024. This failure has the potential for the medical records not to fully reflect an accurate status of Resident 1's treatment while at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician orders were followed for two (Resident A and Resident B) out of six residents. This failure delayed care for for Resident A and Resident B and had the potential to cause further complications with their existing comorbidities (two or more diseases or medical conditions in a patient).

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge plan was discussed with the resident and resident representative prior to discharge from the facility, for one of three residents reviewed (Resident A). This failure had the potential for Resident A to be discharged /transferred unsafely and could lead to worsening of the resident's overall condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct respirator fit testing for four of four sampled staff members (Certified Nursing Assistants [CNA] 1 and 2; Treatment Nurse [TN]; and Licensed Vocational Nurse [LVN] 1) in accordance with the facility policy and procedure. This failure had the potential for employees and a vulnerable population to be exposed to COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate infection control practices in preventing the transmission of the coronavirus infection (Covid-19-illness caused by a virus that can be transmitted from person to person) were implemented in accordance with the facility's policy and procedure and Center for Disease Control (CDC) guidelines. The facility also failed to maintain an infection control program designed to screen and prevent the development and transmission of disease and infection of staff and residents, when: (1) One of three sample residents' ( Resident 1) room did not have a signage for transmission-based precaution (TBP-infection-control precautions in health care) and personal protective equipment (PPE-equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) for staff and visitors. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility employees had a current active CPR (a lifesaving procedure used to restart a person's heartbeat and breathing after one or both have stopped) when one of the four sampled facility employees had expired CPR certifications. This deficient practice had the potential for facility residents to receive emergency care that was not up to date leading to resident harm and/or death.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of mistreatment, and abuse, involving Resident 1, to the California Department of Public Health (CDPH), immediately but not later than 2 hours after the allegation was made. The facility was made aware of the allegation on November 3, 2023. This failure has the potential for the allegation not to be investigated which placed the other residents at risk for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service safety when: 1. The ice machine was not cleaned and sanitized properly per manufacturer's guidelines; 2. There were various sizes of metal sheet pans stacked wet and stored in the dry area; 3. Two Dietary Aides (DA) did not perform handwashing in-between tasks; 4. The dietetic services did not have a system for thawing frozen meats; 5. The microwave for resident's food in the nourishment room located in Nursing Station 3 was dirty; 6. Resident's food was not stored at safe temperatures in the nursing station refrigerators; 7. There were several expired food and beverage items found in the resident's food refrigerator in Nursing Station 3; 8. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash container lids were kept securely covered to prevent the potential attraction of pests and vermin (nuisance animals that could spread diseases). This failure had the potential for attracting insects and vermin, which could result in food-borne illnesses in a highly susceptible population of 140 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was available in the resident's record, for three of 20 residents reviewed for AD (Residents 1, 91, & 235). This failure had the potential for Residents 1, 91, and 235's AD to not be readily retrievable by the staff and the physician, making them unaware of, and unable to honor, the residents' wishes regarding their medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided meet professional standards of practice, for four of 140 residents reviewed (Residents 59, 74, 234 and 484), when: 1. For Resident 59, one opened and unlabeled tube of anti-fungal cream was observed on top of the resident's nightstand; 2. For Resident 74, one bottle of unlabeled Tums (medication used for heartburn) was observed on top of the resident's nightstand; 3. For Resident 484, one zip lock bag of unknown capsules and tablets was observed on top of the resident's nightstand; and 4. For Resident 234, staff left one medicine cup containing several medications at the resident's bedside table. These failures had the potential for Residents 59, 74, 484, and 234 to receive medications unsafely.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory care was provided, for three of three residents reviewed for respiratory (Resident 7, 51, and 26) when: 1. For Resident 7, one humidifier bottle (a medical device used to increase moisture and decrease dryness of oxygen use) was undated and one nasal cannula tubing (tubing placed through the nose and connected to an oxygen machine) was undated; 2. For Resident 51, one humidifier bottle was undated; and 3. For Resident 26, the nebulizer (machine used to administer medication through inhalation) tubing was undated. These failures could place residents who use oxygen and hand held nebulizers at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staffing was provided for vulnerable residents in the facility, when the Direct Care Service Hours Per Patient Day (DHPPD - the actual hours of work performed per patient day by a direct caregiver) on multiple dates from February 23 to March 21, 2023, was below the state-mandated minimum requirement of 2.4. This failure had the potential for residents' needs to not be met and could affect the quality of care provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when: 1. There were missing documentation of administration of controlled substances (CS) in the resident's medical record, for two of the three residents reviewed (Resident 74 and 62). This had the potential for CS misuse or abuse; 2. Discontinued medications in the medication cart that were no longer used were stored along with active medications for resident use. This had the potential for residents to receive wrong medications; 3. The thermometer in the medication refrigerator displayed 25°F (degree Fahrenheit - unit of measurement). This had the potential for residents to receive ineffective medication therapy; 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two Dietary Aides (DA) had the appropriate skill set to safely perform the daily operations of the Food and Nutrition Services Department when proper procedures for hand washing were not followed. This failure had the potential to place 137 out of 140 highly susceptible residents, who received food from the kitchen, at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diets during the lunch meal on March 20, 2023, and March 21, 2023, when: 1. One resident (Resident 53) with Minced/Moist, RCS (restricted concentrated sweet), Low fat/Low Cholesterol, NAS (no added salt - no salt packet on meal tray) diet did not receive yellow cake. 2. One resident (Resident 74) with Regular RCS, NAS, double protein diet got one slice of barbeque pork instead of two slices. 3. Two residents (Residents 10 and 52) who had orders for one bottle of Boost Plus (a nutritional drink to help gain or maintain weight) with their meals, had substitutions of one carton of healthshake. 4. One resident (Resident 61) with puree, fortified, high protein diet, did not receive 8 (eight) oz (ounce - unit of measurement) of milk as indicated in diet manual. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the food preferences, for three out of 137 residents, when: 1. Resident 9 who was on puree (smooth, creamy pudding like texture)/fortified (containing added nutrients)/high protein/RCS (diabetic) diet with tray instructions of applesauce, pudding, mashed potato with meal, did not receive pudding; 2. Resident 86 who was on Regular Liberal Renal (low sodium, phosphorus, and protein) diet and preferred a Chef's salad with onion and no tomato, received a Chef's salad with tomato and no onion; and 3. Resident 20 who was on Regular RCS diet and preferred sugar-free pudding with meal, did not receive sugar-free pudding. These failures had a potential to result in decreased food intake and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident was treated with dignity and respect, for one of one resident reviewed for dignity (Resident 1), when the resident waited to be fed and the Certified Nurse Assistant (CNA) 1 was observed standing while feeding the resident. This failure had the potential for Resident 1 to not attain his highest practicable physical and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure midodrine (medication used to treat low blood pressure) was administered appropriately according to the physician's order, for one of 28 residents reviewed (Resident 234), . This failure had the potential for Resident 234 to receive unnecessary medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation of every effort made to try non-pharmacological intervention and had failed was provided prior to initiating an antipsychotic medication, for one of five residents reviewed for unnecessary medication (Resident 40). This had the potential for Resident 40 to receive unnecessary psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate for medication pass observation did not exceed five percent (%). The medication error rate was 6.9% .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. There was a written date on the vial of Novolin R (fast acting regular insulin for control of blood sugar) to indicate when it was removed from the medication refrigerator and stored in the medication cart at room temperature; and 2. The medication bottle was properly labeled in accordance with the facility's policy and procedure. These had the potential for less effective, expired medication to be administered to the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was assessed for the need to offer influenza and pneumococcal vaccines upon admission, for one of five residents reviewed for influenza and pneumococcal immunizations (Resident 42). This failure had the potential for the resident to acquire influenza infection and pneumonia infection.

Inspectors wroteBased on interview and record review, the facility failed, for one of five residents reviewed for immunizations (Resident 3), to notify Resident 3's representative (RR) when a new case of COVID-19 (Corona virus disease 2019- a respiratory disease caused by a virus that can be transmitted from person to person) was identified in the facility. This failure had the potential to negatively affect the physical, mental, emotional, and well-being of residents, their representatives and their families and could potentially impact resident's quality of life related to a possible exposure to COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to ensure the COVID-19 (Corona virus disease 2019- a respiratory disease caused by a virus that can be transmitted from person to person) vaccine was offered on admission, for one of five residents reviewed for COVID-19 immunization (Resident 42). This failure had the potential to result in Resident 42 not getting the full protection against the COVID-19 virus.