Napa Valley Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2) were protected from abuse when Resident 1 and Resident 2 threw fluids at one another, exchanged verbal profanities, and Resident 2 hit Resident 1 on the shoulder. This failure resulted in an altercation between Resident 1 and Resident 2 and placed both residents at risk for physical and psychological harm. A review of Resident 1's admission record indicated she was admitted to the facility in April 2025 with medical diagnosis which included cirrhosis of the liver (permanent scarring of healthy liver [an organ that filters toxins, produces bile for digestion and regulates blood sugar] tissue) and cerebellar ataxia (damage to a part of the brain that regulates balance, posture and muscle coordination). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 1) when a staff member did not close the privacy curtain before providing incontinence care. This resulted in another resident observing Resident 1's exposed buttocks, after which the staff member laughed. This failure caused Resident 1 to experience embarrassment, humiliation, and diminished dignity, and created the potential for emotional distress, loss of trust in facility staff, and reluctance to request assistance with personal care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in safe and sanitary conditions in the food service department when:1. The walk-in fridge contained food items that were not labeled.2. The walk-in fridge and freezer number #3 contained food items that were expired. These failures had the potential to place residents at risk for developing food-borne illnesses (sickness by consuming contaminated food or drinks) by exposing residents to contaminated food and unsanitary practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and implement infection control practices and maintain a sanitary environment when:1. A contact precaution order was not in place when Resident 125 was identified to have a multidrug resistance organism (MDRO, a bacteria that have developed resistance to multiple antibiotics).2. Dirty items were found stored in the clean shower.3. An unlabeled urinal was found stored in a bathroom sink next to oral hygiene items in room [ROOM NUMBER]. Unlabeled oral hygiene items were found stored on top of a toilet lid in room [ROOM NUMBER].4. Enhanced Barrier Precautions (EBP- safety measures in place for residents with wounds or indwelling devices) was not implemented for one of 30 sampled residents (Resident 7) with a wound vac (medical device that heals slow-healing wounds by using gentle suction). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer notification to one of 30 sampled residents (Resident 6) or to his representative upon Resident 6's transfer to an acute care hospital on 4/2/2025. This failure had the potential for Resident 6 and/or his representative not to be informed of his rights to return to the facility following a hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to initiate and create a care plan (an individualized plan that provides direction on the type of care a patient needs) for one of 30 sampled residents (Resident 125), when Resident 125 was placed on contact precautions (infection control measures used to prevent the spread of infectious agents that can be transmitted through direct or indirect contact with a resident or their environment) on 5/12/2025. This failure had the potential to not provide the necessary care and treatment for Resident 125.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of 30 sampled residents (Resident 96) when there were no documented evidence Resident 96 was exhibiting wandering behavior prior to placing a wander guard bracelet (a wearable device designed to help prevent residents at risk of wandering from leaving a designated area in a care facility). This failure resulted in Resident 96's quality of life being negatively affected when Resident 96 stated he could not do the things he likes to do.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 30 sampled Residents (Residents 36 and 53) that:1. Resident 36's oxygen therapy was reviewed and updated to reflect her current clinical status. This failure had the potential to compromise the care provided to Resident 36.2. Residents 53's nasal cannula (a device used to deliver supplemental oxygen through the nose) was labeled and stored appropriately. This failure had the potential for residents to be exposed to infectious diseases.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient nursing staff were available to respond to call lights in a timely manner for one of 30 sampled residents (Resident 113). This failure resulted in Resident 113 experiencing long wait times and feelings of neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was not greater than five percent when four identified medication errors out of 27 opportunities were observed:1. Vancomycin (antibiotic used to treat serious bacterial infections) solution was not administered per medication label instructions for one of 30 sampled residents (Resident 50).2. Insulin Aspart (rapid acting medication used to decrease blood sugar) was administered at the wrong time for one of 30 sampled residents (Resident 39).3. Albuterol (medication used to prevent and treat breathing difficulties) was not administered per physician instructions for one of 30 sampled residents (Resident 16).4. Eliquis (medication to prevent and treat blood clots) was not administered per physician instructions for one of 30 sampled residents (Resident 16). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 39) remained free from significant medication error when rapid acting insulin (medication used to decrease blood sugar) was administered at the wrong time. This failure had the potential to result in Resident 39 experiencing adverse complications from hypoglycemia (condition in which blood sugar level drops below normal) including dizziness, sleepiness, passing out or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication cart (a cart that contains medications for residents) was locked while not in use and unattended. This failure had the potential to allow residents, staff and visitors to gain access to the medication cart.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the garbage was disposed of properly, when a garbage can lid and a garbage compactor (a machine that reduces the volume of trash by compacting it), were not closed and the surrounding area had piles of trash bags on the ground. This failure resulted in pest attraction and odor in the garbage disposal area.

Inspectors wroteBased on interview and record review, the facility failed to ensure a speech therapy evaluation for one of 30 sampled residents (Resident 60) was performed when ordered by the physician. This failure had the potential to result in Resident 60 receiving an inappropriate diet, choking or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary and comfortable environment when the Stop sign banners in Hallway 3A had hair and lint on the velcro areas of the banners. This failure had the potential to negatively affect the residents' homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin when one of two sampled residents (Resident 1) was found to have extensive bruising and pain to his left leg, that ultimately was found to be a fractured femur (broken thighbone, the longest and strongest bone in the human body) in the emergency department (ED), and facility staff were unable to explain how Resident 1 got the bruise. This failure prevented outside agencies from investigating the injury of a vulnerable resident who was nonverbal and unable to advocate for himself or explain how he was injured.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control policy when disposable razors were found either on top or partially inserted into sharps containers (containers specifically designed for items that are both contaminated and pose a puncture risk) in three communal (used or shared by multiple residents) shower/tub rooms. This failure had the potential risk of subjecting staff and residents to injury and blood-borne pathogen (infectious bacteria, virus, or fungus that can cause disease when transmitted through blood or other body fluids) transmission.

Inspectors wroteBased on interview and record review, the facility failed to maintain the safety one of two sampled residents when a staff member solely operated a mechanical lift to transfer Resident 1 from the bed to a recliner. This failure resulted in Resident 1 to fall and sustain a hematoma (a closed wound where blood collects and fills a space) on her head.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notification of the hospital transfer for one of two sampled residents (Resident 1) to her Responsible Party (RP). Failure to notify the Responsible Party (RP) of Resident 1's whereabouts had the potential for an inability for her to advocate for Resident 1's needs and preferences during the transfer process, and coordinate care with the receiving hospital.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen therapy (A medical treatment that provides supplemental or extra oxygen for breathing) was provided as ordered by the physician for two of two sampled residents on continuous supplemental oxygen (Resident 5 & Resident 6) when the nasal cannulas (A device consisting of a lightweight tube used to deliver supplemental oxygen) were not observed to be in their noses in the early morning hours of 10/08/24, and the oxygen settings were incorrect. In addition, the facility failed to ensure the administration of oxygen therapy was documented for one of three sampled residents (Resident 4). These findings had the potential to result in harm, suffering and death to the residents on oxygen therapy.

Inspectors wroteBased on interview and record review, the facility failed to provide enough nursing staff to deliver the nursing and related care and services required by the residents. Three of three unlicensed staff interviewed (Anonymous Staff D, Anonymous Staff E, and Anonymous Staff F) indicated the facility was extremely short-staffed for certified nursing assistants (CNAs), and this affected the quality of care the residents were receiving. This finding had the potential to result in inability for the residents to reach their full potential, neglect, and feelings of abandonment and frustration.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect when two certified nursing assistants (Unlicensed Staff A and Unlicensed Staff B) attempted to provide incontinence care (Cleaning the private areas and changing the undergarments of a patient with loss of bowel or bladder control) to Resident 1 against her wishes. This finding had the potential to result in injuries to Resident 1, frustration, sadness, and trauma.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse within two hours to the DEPARTMENT for one of three sampled residents (Resident 1). This finding had the potential to result in inability for the DEPARTMENT to investigate and advocate for Resident 1's rights, and possible continuous abuse to Resident 1 and other residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents at risk for elopement (Resident 3) eloped from the facility, when several steps to prevent it, such as completing the elopement risk assessment, creating a care plan to prevent elopement, and initiating interventions to keep her safe, were omitted. Resident 3 eloped form the facility on 8/20/24 while being COVID-19 positive and was found a block away from the facility on a high traffic street, by police. This failure had the potential to result in serious harm, including death, to Resident 3. This failure placed other residents of the facility and residents of the community at risk for becoming infected with COVID-19, a contagious and potentially deadly illness.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure there were adequate staff to care for three out of three sampled residents (Residents 2,3 and 4) needs when: 1. Residents 2, 3 and 4 complained of staffs late response to call lights and late provision of care due to short staffing. 2. Unlicensed staff statements the facility was short staffed, stating they have difficulty meeting their residents needs timely, or completing their task timely. These failures resulted in: 1a Resident 2 feeling frustrated, anxious, and afraid staff would not be available to assist her in case of a medical emergency. 1b Resident 3 feeling frustrated and upset waiting for a long time before staff responds to call light and 1c Resident 4 feeling unsafe and in fear something might happen to her and there would be no staff to assist her when she needed medical attention. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to: 1.ensure six out of nine licensed staff (Licensed Staff A,B, C, E, F and G) were aware of the facility ' s Antibiotic Stewardship Program (ASP, a coordinated program that promotes the appropriate use of antimicrobials, including antibiotics- a group of agents that share the common aim of reducing the possibility of infection and sepsis (body's extreme reaction to an infection). [...]

Inspectors wroteBased on interviews and record reviews, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice when Licensed Staff C allowed family members to administer medication to one out of two sampled residents (Resident 1). This failure was a safety risk and could potentially lead to incorrect dose administration and lack of patient education.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff wore face masks appropriately in patient care areas during a covid outbreak in the facility. This failure had the potential to spread infections among residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food at a palatable temperature when a test tray of beef stroganoff with noodles was not at a palatable temperature. This failure resulted in two anonymous residents complaining that hot foods were served cold.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ice machine in the kitchen was sanitized and maintained to prevent buildup of water deposits on outer surface. This had the potential for cross contamination and the spread of water borne pathogens to the residents that use ice in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a homelike environment for the residents when the walls of the residents ' communal areas and showers had crumbling dry wall, a loose tile, and a brownish black substance on the grout. This had the potential to result in residents feeling that the facility is not being maintained.

Inspectors wroteBased on interview and record review, the facility failed to provide care, consistent with professional standards of practice, to prevent pressure injuries (bedsores) to one of two residents (Resident 1), when the facility did not frequently and regularly turn and reposition Resident 1, who could not turn and reposition herself independently, and was at risk for developing pressure injuries. This failure resulted in Resident 1 developing two unstageable (unable to determine the exact extent of the wounds) pressure injuries, one on her sacrum (the tailbone area) and one on her buttocks area.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment to one of three residents (Resident 1) when the reading light above Resident 1's bed and the outlet in Resident 1's bathroom did not work. This failure resulted in Resident 1's not being able to read while in bed and not being able to charge her cell phone in the bathroom.

Inspectors wroteBased on interview and record review, the facility failed to issue the notice of discharge as soon as practicable to two of three residents (Residents 2 and 3); failed to timely provide a copy of the notice of discharge to the Ombudsman for three of three residents (Residents 1, 2 and 3); and failed to indicate a valid reason for discharge and to list the name of address of the Office of the State Long-Term Care Ombudsman and location to which the resident would be discharged on the notice of discharge to one of three residents (Resident 1). These failures could have resulted in Residents 2 and 3 not having enough time to prepare for discharge from the facility; the Office of the State Long-Term Care Ombudsman not assisting Residents 1, 2 and 3 during the discharge process; and Resident 3 not knowing where she would be discharge to.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident discharges in accordance with federal regulations for one of three residents (Resident 1) when the facility initiated the discharge of Resident 1 for the reasons of lack of insurance coverage and non-payment before Resident 1's insurance coverage lapsed and before non-payment by Resident 1's for charges related to her stay at the facility. This failure resulted in Resident 1 being subject to an invalid discharge process.

Inspectors wroteBased on interviews, and records review, the facility failed to ensure one of four sampled residents (Resident 1) was free from significant medication errors, when Resident 1 had a physician ' s order for 1) Dilaudid (an opioid [class of drugs that derive from, or mimic, natural substances found in the opium poppy plant] - used to relieve moderate to severe pain) 4 mg (milligram-a unit of mass) to give one tablet three times a day for pain management; and 2) Roxycodone (also an opioid) 5 mg to give 2 tablets every 4 hours as needed for pain management; however, the facility did not administer the medication according to the physician ' s order. This failure had the potential to result in ineffective pain management, over sedation, or possible dependence or addiction to the medication.

Inspectors wroteBased on interviews and records review, the facility failed to implement a physician ' s order for pain management for two of four sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 had a physician ' s order for Dilaudid (an opioid [class of drugs that derive from, or mimic, natural substances found in the opium poppy plant] used to relieve moderate to severe pain) 4 mg (milligram-a unit of mass) to be given three times a day for pain management; however, the facility did not administer the medication according to the physician ' s order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that three of three sampled residents (Resident 1, Resident 2 & Resident 3) were provided with activities of daily living (ADLs-Activities related to personal care such as dressing, bathing and toileting) as required in their comprehensive care plans. The three residents were not provided with incontinence care (Cleaning the skin and changing the soiled undergarments and clothing of people with bowel or bladder incontinence [inability to control urination and defecation (The discharge of feces from the body)]), and two residents (Resident 1 & Resident 2) were not provided with bed repositioning as needed. Resident 1 indicated having suffered serious psychological and emotional harm as a result of this lack of care including depression, feelings of neglect and discrimination, and anxiety attacks. [...]

Inspectors wroteBased on interview, and record review, the facility did not have sufficient staff to meet the care needs of three of three sampled residents (Resident 1, Resident 2 & Resident 3) when they were not provided with activities of daily living (ADLs-Activities related to personal care such as bathing and toileting) as required, and call lights were not answered promptly. The night of 8/11/23 one Certified Nursing Assistant (CNA) was assigned to provide services to 43 residents. In addition, staffing shortages occurred in all shifts. These findings had the potential to result in harm to the residents involved, inability for staff to respond to medical emergencies, and lack of health services provided to the residents of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' meals were palatable, appetizing and safe for ingestion. Three of four sampled residents (Resident 3, Resident 4 and Resident 5) complained about the food quality and taste. These findings could have resulted in decreased caloric intake, malnutrition, frustration, and decreased quality of life for the residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) was treated with dignity and respect when he was noted to be resting in bed in the early morning hours, with no blanket, no bed linens, and no clothing except for his disposable attends (A form of undergarment designed to be used / worn once and then thrown away), and a thin top sheet. Resident 2 voiced being terribly cold on multiple occasions, and when the call light was pressed to alert staff he needed a blanket, it took 10 minutes for a staff member to respond to it. These findings had the potential to result in suffering, frustration and feelings of distress for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to document in the facility assessment, the resources necessary to care for its residents competently during day-to-day operations. The staffing section on the facility assessment made it impossible to determine how many Certified Nursing Assistants (CNAs) were needed based on the census, condition of residents, or any other category that would provide specific information on the number of required CNAs per shift to meet the residents' needs. As a result, there were days and nights when the facility was extremely short staffed, including the night shift of 8/11/23, when one CNA (Unlicensed Staff E) was assigned 43 residents requiring assistance with ADLs (Activities related to personal care such as dressing, bathing and toileting). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to arrange a follow-up appointment for vision care for 1 of 20 sampled residents (Resident 60) when Resident 60 verbalized she could not see well and needed new eyeglass. This failure resulted to Resident 60's inability to pursue her interest to read, stopped Resident 60 from watching T.V., feeling sad and uncomfortable because of headaches.

Inspectors wroteBased on observation, interview and record review, the facility failed to store and prepare foods in a safe and sanitary environment when: 1. Cool down process for prepared food was not monitored 2. No air gap in the food production sink 3. Food storage were dirty 4. Food items were not labeled and dated 5. Dented cans of tomato sauce were in the dry storage area These failures could have resulted in foodborne illness and allergies to all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to monitor residents for potential COVID-19 infection when six of seven residents sampled for COVID-19 screening review (Residents 6, 46, 54, 60, 66, 91) were not monitored for symptoms of COVID-19, even after identifying a resident positive for COVID-19 in the facility. This failure could potentially lead to undetected COVID-19 infections in residents, spread of COVID-19 amongst staff and residents, hospitalizations, or death.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement person-centered care plans for 2 of 20 sampled residents (Resident 60 & Resident 53) when: 1 a. Resident 60 was found to have three broken/ decayed teeth after a dental exam and the facility did not develop a dental care plan to address prevention of potential complications from broken/ decayed teeth. This failure resulted in staff not assessing Resident 60 for dental problem. b. Resident 60 had verbalized she needed new eyeglass because could not see well and the facility did not implement their interventions as listed in Resident 60's vision care plan. This failure resulted in Resident 60 refusing to participate with activities of interest, feeling uncomfortable and sad.(Reference F 685). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement timely revision of comprehensive care plan for 2 of 20 sampled residents (Resident 60 and Resident 7) when: 1) Resident 60 had two incidents of accidental fall in a 43-day period which caused Resident 60 to experience physical discomfort; 2) Resident 7 had a care plan for assessment of medication side affects, for medications she was not prescribed for six years. This caused a pattern of yelling, screaming and anxiety for Resident 7 and other residents. This failure puts Resident 60 at risk for more incidents of falling that could potentially result to serious injuries or death, and Resident 7 at risk for not receiving medications that would reduce her non compliance and disruptive behavior.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure person centered care when pharmacological interventions for behaviors were not considered after non-pharmacological interventions were ineffective, for one sampled resident (Resident #7). This failure to review and consider medication therapy for behaviors related to a primary diagnosis of Schizoaffective disorder (Schizoaffective disorder is a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression.), and depression had the potential to result in increased anxiety, non-compliant behavior and contribute to increased agitation and behaviors.

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient number of dietary staff to provide food and nutrition services needed by the residents and to maintain cleanliness of the food storage units. This failure resulted in: 1. Freezers and refrigerators were not cleaned 2. Residents' food preferences were not updated 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow menus for: 1. five residents on renal diet and 17 residents on heart healthy diet 2. seven residents on pureed diet 3. 12 residents on fortified diet 4. 28 residents on mechanical soft/ground diet These failure resulted in residents not receiving their physician ordered diets and could result in residents not getting their nutritional needs to maintain normal body weight.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Provide food preferences to three sampled residents (Resident 36, 86 and 72). 2. Offer food substitute to five sampled residents (Resident 36, 86, 113, 157 and 158). These failures could result to residents losing appetite and potential weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide therapeutic diets to two residents on Renal diet (Resident 23 and 36). This failure could result to residents not receiving proper nutrition needed.

Inspectors wroteBased on interview and record review, the facility failed to follow Policy and Procedure (P&P) for the Quality Assurance and Performance Improvement (QAPI) Program, when they did not communicate QAPI initiatives, or seek input from staff, residents, and family members. This failure had the potential for the QAPI Committee to miss valuable feedback from the residents, family members and staff who provide direct resident care.

Inspectors wroteBased on interview and record review, the facility failed to notify responsible party and the physician for one resident (Resident 53) of a significant weight loss. This failure resulted in significant weight loss not monitored and addressed.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive assessment for 1 of 20 sampled residents (Resident 60) when a Minimum Data Set (MDS - an assessment tool completed by clinical staff to assess a resident's cognitive, psychological, physical, and functional capabilities) was not completed within 14 days of Resident 60's admission to hospice care. This failure resulted in an inaccurate representation of Resident 60's current clinical status and had the potential to cause inadequate care based on a delinquent comprehensive assessment and care planning.

Inspectors wroteBased on interview and record review, the facility failed to accurately document an MDS assessments for 1 of 20 sampled residents (Resident 60). This failure resulted to inaccurate reflection of resident status and incomplete comprehensive care plans to meet Resident 60's needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility's policy and procedure to ensure a PASARR (Medicaid Pre-admission Screening and Resident Review) was completed for one of 10 sampled residents (Resident 66). This failure had the potential to put residents at risk for not receiving the appropriate mental health care to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to communicate the recommendations of the restorative nursing assistants (RNA, provide rehabilitation care to help people regain or improve their physical, mental and emotional health) to the rehabilitation (rehab) department for one of six residents (Resident 91) sampled for ADL (activities of daily living) decline. This failure could potentially result in a decline in mobility, loss of independence, depression, and could cause Resident 91 to give up.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services to meet the nutritional needs of one resident (Resident 53) with feeding tube (medical device used to provide liquid nourishment, fluids and medications by bypassing oral intake). This failure resulted in Resident 53 having significant weight loss in 30 days.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services according to resident needs and professional standard of practice to one resident (Resident 53) with a feeding tube (medical device used to provide liquid nourishment, fluids and medications by bypassing oral intake). This failure resulted in: 1. Water flushing order not followed 2.

Inspectors wroteBased on record review and Administrator interview the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) Plan. Failure to assess areas of patient care priorities resulted in the facility's inability to self-identify areas for improvement.

Inspectors wroteBased interview and record review, the facility failed to re-check blood sugars and notify the physician/nurse practitioner, as ordered, of blood sugar levels greater than 450 for one of two sampled residents (Resident (R) 58), who were reviewed for insulin concerns. The facility identified 24 residents with physician orders for finger stick blood sugar level checks and 12 residents with physician orders for sliding scale insulin. Findings Include: The facility's policy titled, Change in a Resident's Condition or Status, dated 05/2017, indicated, . Our facility shall notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) . [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure the Consultant Pharmacist identified, and acted upon, irregularities for the use of an antipsychotic medication (Haldol decanoate) for one resident (Resident (R) 51), out of a survey sample of five residents and one expanded resident sample reviewed. Findings Include: Review of R51's, Resident Face Sheet, indicated the facility admitted Resident 51 on 03/19/13. Review of, Note to Attending Physician/Prescriber, dated 12/06/18, with a hand-written noted that a telephone order was obtained to have R51 seen by psych services to address her current use of Haldol. This note came from the Consultant Pharmacist. [...]

Inspectors wroteBased on observation, interviews, record review, and review of facility policy, the facility failed to ensure one of five sampled residents, (Resident (R) 51), had appropriate clinical indications for the continued use of an antipsychotic medication (Haldol decanoate), out of a survey sample of five and one expanded resident sample for unnecessary medications. (Cross Reference F756)