Newport Subacute Healthcare Center

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medication was administered as ordered by the physician for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1's aztreonam (antibiotic) and ceftazidime- avibactam (antibiotics) IV medications were administered as ordered. This failure had the potential to not clear the infection and negatively affect the resident's health.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete for two of five sampled residents (Residents 2 and 4). * The facility failed to ensure Resident 2 and 4's MAR were complete. These failures had the potential for the residents' health care needs to not be met as the medical records were incomplete.

Inspectors wroteBased on interview, closed medical record review, and the facility P&P review, the facility failed to provide the necessary treatment and services to maintain the highest practicable well-being for one of 12 sampled residents (Resident 2). * The facility failed to ensure Resident 2's change of condition was monitored every shift for at least 72 hours accordingly. This failure had the potential to negatively affect the resident's health and well-being and increase the risk of not providing the resident with an appropriate and individualized care.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 12 sampled residents (Resident 3) was complete and accurate. * The facility failed to ensure Resident 3's date of death was recorded accurately by different IDT members. This failure had the potential to show inconsistency of care as the clinical information was not accurate.

Inspectors wroteBased on observation, interview, closed medical record review, and facility P&P (Policy and Procedure) review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for one of nine sampled residents (Resident 4).* The facility failed to ensure Resident 4 was adequately monitored and provided with the necessary care and interventions to prevent multiple incidents of ingesting foreign objects. In addition, the facility failed to initiate a change in condition and notify the physician when Resident 4 had vomited a foreign object on 4/22/26. These failures resulted in Resident 4's multiple hospitalizations and two surgical procedures for the removal of a foreign object and potentially contributed to diagnosis of sepsis (the body's extreme, life-threatening response to an infection).

Inspectors wroteBased on interview, closed medical record review, and the facility P&P, the facility failed to ensure an injury of unknown source was reported for one of nine sampled residents (Resident 1). * The facility failed to report an incident of unknown source when the facility was informed by the acute care hospital of Resident 1's admission to the ICU related to subdural hematoma. This failure had the potential for the injury of unknown origin to go unreported and posed a delay in the injury prevention to other residents.

Inspectors wroteBased on interview, closed medical record review, and the facility P&P, the facility failed to ensure an injury of unknown source was investigated for one of nine sampled residents (Resident 1). * The facility failed to investigate an incident of unknown source when the facility was informed by the acute care hospital of Resident 1's admission to ICU related to subdural hematoma. This failure had the potential for the injury of unknown source to go uninvestigated and posed a risk for the delay of injury prevention to other residents of the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the care plan for one of nine sampled residents (Resident 3). * The facility failed to timely develop a care plan and implement the neuro check intervention when Resident 3 had a fall on 4/1/26. In addition, the facility failed to update the care plan interventions when Resident 3 had another fall on 4/24/26. These failures had the potential to place the resident at risk for falls and injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for one of nine sampled residents (Resident 2). * The facility failed to obtain a physician's order for the administration of cough medication for Resident 2. In addition, the facility failed to follow its Medication Administration P&P when Resident 2's cough medicine was left at bedside table, despite the resident not being assessed or approved to self-administer medications. These failures had the potential to result in negative outcomes for the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1's physician's progress notes were accurate. In addition, Resident 1's Task Documentation had multiple missing entries. These failures had the potential for the resident's care needs to not be met as their medical information was inaccurate and incomplete.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete for two of seven sampled residents (Residents 2 and 5). * The facility failed to ensure Resident 2's MAR and TAR were complete. * The facility failed to ensure Resident 5's progress notes were complete. These failures had the potential for the residents' health care needs to not be met as the medical records were incomplete.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 1) reviewed for restraints was free from physical restraints. * The facility failed to ensure the use of physical restraints was based upon identified medical symptoms. Additionally, the facility failed to conduct an assessment to determine the existence of medical symptoms, attempt less restrictive measures, and develop a care plan for Resident 1's bilateral hand mittens. * The facility failed to inform Resident 1's responsible party of the potential risks and benefits and obtain consent for the use of Resident 1's bilateral hand mittens. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of seven sampled residents (Resident 1) was provided the necessary GT services. * The facility failed to ensure Resident 1 was administered the TwoCal HN (a nutritional supplement that is calorie and protein dense) enteral feeding as per the physician's order and failed to ensure it was documented in the MAR. These failures had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of seven sampled residents (Resident 1) had accurate and complete medical records. * The facility failed to ensure Resident 1's MAR documentation regarding multiple medication orders were completed. This failure had the potential for the resident's health care needs not be met as the medical record was incomplete and inaccurate.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary treatment and services to maintain the highest practicable well-being for one of twelve sampled residents (Resident 10). * The facility failed to monitor Resident 10 who was on antibiotic treatment for UTI. In addition, the facility failed to ensure Resident 10's plan of care was updated to address Resident 10's treatment interventions and management of the UTI. This failure had the potential for the delay of the identification of the adverse effects related to the resident's use of antibiotic treatment and for the resident to not receive the appropriate and individualized care that could potentially affect the resident's health and well-being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with a cleanable surface. * The facility failed to ensure the heavy-duty blender used for puree preparation was air dried and free of food residue prior to storing and stacking. * The facility failed to ensure the ice machine drainpipes had an air gap and not touching the drains. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * The facility failed to ensure an infection control surveillance report/log and mapping were completed for the months of May and June 2025. * The facility failed to ensure Resident 24 was placed on EBP (Enhanced Barrier Precautions) per the physician's order. * The facility failed to ensure an EBP sign was placed outside of Room C for Resident 37 who had a Quinton catheter and indwelling urinary catheter, and for Resident 67 who had an AV fistula. * The facility failed to ensure the facility staff did not refill the residents' water from the bathroom sink. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to properly obtain the informed consent (permission granted in the knowledge of the possible consequences) for the use of psychotropic medications (medications affecting brain activity) and bedrails from the residents or from the responsible party (person designated to make decisions on behalf of the residents). The facility failed to obtain the informed consent for the psychotropic medications for three of five sampled residents (Residents 3, 20, and 70) reviewed for unnecessary medications and one nonsampled resident (Resident 24) reviewed for the use of the bedrails. * The facility failed to obtain renew the informed consents for the Abilify (antipsychotic medication) and Prolixin (antipsychotic medication) medications after six months for Resident 3. [...]

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the copy of the resident's medical record was provided upon request within two working days for one of three residents reviewed for closed records (Resident 101). * The facility failed to provide Resident 101's requested medical record and facility documents to the legal representative until 13 days after the initial request was received. In addition, the facility's resident care policies and daily posting of the staffing record were not provided as requested to Resident 101's legal representative. This failure had the potential for violating Resident 101's and their legal representative rights to access their medical health information.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the written information regarding how to formulate an advanced directive for five of 16 final sampled residents (Residents 5, 6, 8, 83, and 90) reviewed for advanced directives. * The facility failed to provide the written information and assistance regarding how to formulate the advanced directive for Residents 5 and 90. * The facility failed to inform, provide, and document the written information regarding the residents' right to formulate the advanced directives for Residents 6 and 83. * The facility failed to provide the written information regarding the right to formulate the advanced directive for Resident 8. These failures had the potential for the residents to receive inaccurate and delayed treatment compatible with the residents' wishes during an emergency.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to immediately notify the physician and family of a change in condition for one of four final sampled residents (Resident 9) reviewed for pressure ulcers. * The facility failed to notify Resident 9's physician and resident representative regarding Resident 9's change of condition when Resident 9 developed MASD (Moisture-Associated Skin Damage, general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage) to the coccyx (tailbone). This had the potential to negatively impact Resident 9's physical wellbeing and prevent the resident 's representative from being fully aware and understand the resident's treatments and course of actions.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of five unnecessary medication sampled residents (Residents 2, 20, and 24) were free from unnecessary psychotropic drugs. * The facility failed to ensure Resident 24 was monitored for the behavior manifestation per the physician's order for Risperdal (antipsychotic medication) and failed to monitor the orthostatic hypotension related to the use of antipsychotic medication. In addition, the facility failed to monitor the number of hours of sleep for Resident 24 related to the use of trazodone (antidepressant medication). [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered plan of care to reflect the individual care needs for four of 21 final sampled residents (Residents 8, 68, 70, and 99), one of five residents (Resident 20) reviewed for unnecessary medications, and one of three closed record residents (Resident 10) reviewed. * The facility failed to develop a care plan to address Resident 8's use of an enteral feeding. * The facility failed to implement the care plan intervention of checking Resident 10's blood pressure every 12 hours to address Resident 10's hypotension diagnosis. * The facility failed to develop the comprehensive person-centered care plan to address Resident 20's use of divalproex sodium, Remeron, and Nuedexta medications. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of the pressure injuries (localized area of skin damage and underlying tissues caused by prolonged pressure or shear forces) for three of four final sampled residents (Residents 9, 62 ,and 83) reviewed for pressure injuries. * The facility failed to ensure the licensed nurses accurately documented the assessment of Resident 9's MASD to the coccyx. * The facility failed to ensure the low air loss mattress setting was consistent with Resident 62's weight and set on the alternate mode setting. * The facility failed to ensure Resident 83's low air loss mattress setting was accurate per the physician's order. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to assess the appropriateness and continued use of the indwelling urinary Foley catheter (flexible tube that passes through the urethra and into the bladder to drain urine) for one of two final sampled residents (Resident 37) reviewed for urinary catheter. * The facility failed to ensure Resident 37 was assessed for the appropriateness and continued use of the indwelling urinary Foley catheter. This failure had the potential to predispose Resident 37 to catheter associated urinary tract infection.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one of one final sampled residents (Resident 99) and one nonsampled resident (Resident 100) reviewed for the IV care. * The facility failed to ensure Resident 99's PICC line catheter was measured on 8/23/25, per the physician's order. * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented in Resident 100's medical record. These failures had the potential to delay the identification of the IV catheter related complications for the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for four of four final sampled (Residents 3, 9, 68, and 70), and two nonsampled resident (Residents 24 and 100) reviewed for respiratory care. * The facility failed to administer the oxygen to Resident 3 per the physician's order and failed to ensure the oxygen concentrator was functioning properly. In addition, the facility failed to ensure Resident 3's nasal cannula was dated and labeled and changed weekly. * The facility failed to ensure Resident 9's oxygen tubing was changed and dated. * The facility failed to ensure Resident 24's set-up bag for the Yankauer (a rigid tonsillar suction device used for suctioning the mouth and oropharynx) suction was changed weekly. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate dialysis care was provided for four of five final sampled residents (Residents 9, 37, 68, and 99) and two nonsampled residents (Residents 67 and 100) reviewed for dialysis services. * The facility failed to ensure Resident 9's physician's order to obtain the pre and post weights on the dialysis days were followed. Resident 9's post dialysis weights were not obtained on the dialysis days. * The facility failed to ensure the emergency dialysis kit kept at bedside was complete and included clamp scissors for Residents 37 and 100. * The facility failed to ensure a dialysis e-kit was available at bedside for Residents 67 and 99. * The facility failed to ensure the emergency dialysis kit was kept at Resident 68's bedside. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of three final sampled residents (Residents 6, 37 and 99) and one nonsampled residents (Resident 67) remained free from accident hazards due to the use of the side rails. * The facility failed to ensure the physician's order was obtained for the use of bilateral half side rails for Resident 6. In addition, the facility failed to ensure a care plan was developed to address the use of the bilateral half side rails for Resident 6. * The facility failed to ensure the less restrictive interventions were completed prior to the use of the half side rails for Residents 37 and 67. * The facility failed to ensure a physician's order and consent were obtained prior to the use of bilateral side rails for Resident 99. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 21 final sampled residents (Residents 70 and 99) were free from the unnecessary medications. * The facility failed to ensure Resident 70 who was on apixaban (medication used to prevent blood clots) was monitored for signs and symptoms of bleeding. * The facility failed to monitor Resident 99 for the signs and symptoms of bleeding related to the use of apixaban medication (medication used to prevent blood clots). These failures had the potential for the residents to receive unnecessary medications and develop significant adverse effects.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12.5%. Two of two licensed nurses (LVNs 3 and 12) were found to have made errors during the medication administration to two nonsampled residents (Residents 54 and 89). * LVN 3 failed to properly administer the potassium chloride tablet (supplement) as per the physician's order to Resident 89 when LVN 3 crushed the potassium chloride tablet and using an improper amount of water to reconstitute the medication. The physician's order specified to dissolve the potassium chloride medication with 60 ml of water, however, LVN 3 only used 10 ml. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications. * The facility failed to remove expired medical supplies from Medication Room A. * The facility failed to ensure two prescription topical medications were labeled with the physician's order in Medication Cart A. In addition, the facility failed to ensure the facility staff's over-the-counter medications were not stored in Medication Cart A with the facility's house wound supplies. * The facility failed to ensure two prescription inhalational medications were labeled and dated in Medication Cart B. * The facility failed to ensure an opened insulin vial, and two opened insulin pens were labeled with the date opened in Medication Cart C. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in two of two garbage dumpsters. * The facility failed to ensure the lids for the two garbage dumpsters were fully closed. This failure had the potential to attract pest/rodents that carried diseases.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary hospice services for one of one final sampled resident (Residents 11) reviewed for hospice services . * The facility failed to ensure Hospice A's plan of care including the physician's orders were integrated into Residents 11's care. * The facility failed to ensure the complete documentation of the hospice staff visits were available for Resident 11. * The facility failed to ensure Resident 11's IDT meeting included the hospice staff. These failures posed the risk for the delay in communication and provision of the hospice care between the hospice provider and facility.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to monitor and address the use of the antibiotics for two final sampled residents (Residents 68 and 90) and one nonsampled resident (Resident 26) reviewed for antibiotic stewardship. * The facility failed to ensure the McGeer's criteria assessment was completed in a timely manner for Resident 26 when the resident was started with antibiotics on 7/18/25. * The facility failed to ensure the McGeer's criteria were assessed for Residents 68 and 90 when the residents were prescribed with antibiotics. These failures had the potential for the antibiotics to be used when they were not indicated and the development of antibiotic-resistant bacteria.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to administer the pneumococcal vaccine (a vaccine given to protect the resident from pneumococcal disease) to one of five final sampled residents (Resident 35) reviewed for immunizations. * Resident 35's medical record failed to show documented evidence Resident 35 was administered with the pneumococcal vaccine or had refused the pneumococcal vaccine. This failure increased the resident's risk of being infected by the pneumococcal disease and its associated complications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to administer the COVID-19 (infectious disease caused by the SARS-CoV-2 virus- Severe Acute Respiratory Syndrome Corona virus 2 that causes COVID 19) vaccine to one of five sampled residents (Resident 35) reviewed for COVID-19 vaccination. * The facility failed to ensure COVID-19 vaccine was administered to Resident 35. This failure increased the resident's risk of being infected by the COVID-19 disease and its associated complications.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the resident's zone entrapment assessment was completed and the measurements were recorded upon installation during the admission when identifying areas of possible entrapment with the use of side rails for two final sampled residents (Residents 6 and 37) and one nonsampled resident (Resident 67) reviewed for the use of the side rails. * The facility failed to ensure Residents 6, 37, and 67's entrapment assessments were completed upon the installation of the residents' bilateral half side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to promote the dignity and respect for two of 21 final sampled resident (Residents 3 and 51). * The facility failed to ensure CNA 8 was seated at an eye-level while assisting Resident 3 with his meal. * The facility failed to ensure CNA 9 was seated at eye-level while assisting Resident 51 with his meal. These failures posed the risk of not treating the residents with the dignity and respect.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to provide the written Notice of Medicare Non-coverage (NOMNC) form CMS-10123, and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form CMS-10055 for one of four residents (Resident 37) reviewed for beneficiary notification. The NOMNC and SNFABN forms are used to inform the residents of their potential financial liability, appeal rights, and protection should they wish to receive care and services that may not be covered by Medicare. This failure had the potential of not allowing Resident 37 and/or their representative to make an informed decision regarding their Medicare servicesFindings: Medical record review for Resident 37 was initiated on 8/28/25. Resident 37 was admitted to the facility on [DATE], and readmitted on [DATE]. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, sanitary and homelike environment for one final sampled resident (Resident 35) and four nonsampled residents (Residents 25, 32, 66, and 93) * Residents 25 and 93 were observed in Room A, and Residents 32, 35, and 93 were observed in Room B. The bathroom shared between Rooms A and B was observed with a hole on the wall, under the bathroom sink. This failure posed the risk of unsanitary conditions and an entry for pests into the facility, which could negatively affect the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify the resident and/or their representative of the transfer and reasons for the transfer, and the facility's bed hold policy in writing when the resident was transferred to the acute care hospital for one of three final sampled residents (Resident 37) reviewed for acute care hospitalization. This failure had the potential for the resident and/or their representative of not knowing about the appeal process and the circumstances of the resident's transfer/discharge should the resident and/or their representative believe the transfer or discharge was inappropriate or involuntary, and to be unaware of their rights to request a bed hold and return to the first available bed should the resident's acute care hospital stay exceed the seven-day bed-hold period.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to provide the appropriate care and services for the use of the GT for one of five final sampled residents (Resident 72) and one nonsampled resident (Resident 45) reviewed for the GT feeding. * The facility failed to ensure the GT feeding formula was not stored at bedside and the GT formula label was accurate and matched the physician's orders for Residents 45. * The facility failed to ensure the GT feeding Jevity 1.5 Cal (a calorically dense, high-protein, fiber-fortified liquid formula which provides complete, balanced nutrition) was not left unattended at the bedside for Resident 72. These failures posed the risk of complications related to the use of the GT for Residents 45 and 72.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the posted staffing information included the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. In addition, the staffing information did not include actual DHPPD (Direct Care Services Hours Per Patient Day) and CNA DHPPD. This failure had the potential to result in an incomplete staffing information provided to the public.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 1) was free from physical restraints. * The Facility failed to ensure Resident 1 had a physician's order, consent, and completed assessment prior to the use of the right hand mittens. Additionally, the facility failed to initiate a care plan when the right hand mitten was provided to Resident 1. These failures posed the risk for Resident 1 and her responsible party not to be informed of her treatment and potentially compromising the resident's independence and psychosocial well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individualized respiratory care needs for one of five sampled residents. * The facility failed to ensure a plan of care was developed to address Resident 1's episodes of pulling out the tracheostomy tube, putting the nasal cannula in the mouth, biting the cannula, and chewing the oxygen tubing. This failure had the potential for not providing Resident 1 the appropriate, consistent, and individualized care and negatively impact the resident's health and well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the necessary care and services was provided to one of five sampled residents (Resident 1) who was at risk for fall. * The facility failed to notify the physician and responsible party, and initiate a care plan when Resident 1 had an incident where her head was found hanging on the bed. This failure had the potential for the delay in providing the necessary care and services and posed a risk for Resident 1 to sustain serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care/services were performed prior to the use of the bedrails for one of five sampled resident (Resident 1). * The facility failed to ensure Resident 1 had a physician's order, consent, and assessment prior to the use of the bilateral upper bedrails. Additionally, the facility failed to initiate a care plan when the bilateral upper bedrails were provided to Resident 1. These failures had the potential to put Resident 1 at risk for serious injury.

Inspectors wroteBased on interview, and medical record review, the facility to ensure the safe practices were followed for Resident 1 when the facility failed to provide the required two-person assistance as required during a resident transfer for Resident 1. As a result, Resident 1 sustained an assisted fall and an abrasion to the left upper back. This failure placed Resident 1 at risk for serious injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the safe practices were followed for two of four sampled residents (Residents 1 and 2) when: * The facility failed to provide two staff's assistance as required during a mechanical lift for Resident 1. As a result, Resident 1 fell from the mechanical lift and sustained the acute spinal processes fractures in the cervical and thoracic spines. * The facility failed to ensure the facility's P&P for safe transfers was followed when Resident 2's shower bed was not locked during the resident's transfer from bed to the shower bed. These failures resulted in the actual harm for Resident 1 and placed Resident 2 at risk of serious injuries.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 1). * Resident 1 made an allegation of abuse on 7/5/25; however, the facility failed to initiate the change of condition assessment and monitoring of Resident 1 every shift for 72 hours. This failure had the potential for the resident to not receive the appropriate care and monitoring to prevent the development of complications and/or delayed medical treatments related to the allegation of abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 2) was free from the unnecessary medications. * The facility failed to follow the physician's order to hold the midodrine (blood pressure support) medication when Residents 2's SBP was greater than 120 mmHg. This failure had the potential for Resident 2 to develop significant side effects.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary G-tube care and services for three of six sampled residents (Residents 4, 5, and 6 ) reviewed for enteral feeding. * The facility failed to ensure Residents 4 and 5's G-tube medication ports were kept clean and patent. * The facility failed to ensure the physician's orders to flush enteral feeding with 30 ml before and after medication were followed for Resident 6. These failures posed the risk of developing complications related to enteral feeding.

Inspectors wroteBased on observation, interview, medial record review, and facility P&P review, the facility failed to ensure one of nine sampled residents (Resident 5) was provided an environment free from the physical restraints. * Resident 5 was observed multiple times with a soft mitten restraint to his right hand. There was no active physician's order, updated informed consent, and updated care plan for the soft mitten on Resident 5's right hand. * There was no appropriate assessment completed prior to placing a soft mitten restraint on Resident 5. * Resident 5 was not monitored for the use of the restraints. These failures had the potential to negatively affect Resident 5's physical mobility and psychosocial well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the reporting of a reasonable suspicion of a crime was completed in a timely manner for one of nine sampled residents (Resident 2). * The facility failed to ensure Resident 2's allegation of neglect against RT 1 was reported timely to the CDPH L&C Program and local law enforcement agency. This failure had the potential for abuse and injury to go unreported and uninvestigated timely.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to fulfill a medical record request in a timely manner for one of nine sampled residents (Resident 3). This failure had the potential to violate the resident's rights.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory services were provided as ordered for one of nine sampled residents (Resident 2). This failure had the potential to result in negative health outcomes for the resident.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the written information on the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which received such requests to the residents and/or their representatives; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request upon the resident transferring to an acute care hospital for three of three sampled residents (Residents 1, 2, and 3) reviewed for discharge. This failure had the potential for the residents to not receive accurate information to determine if they wanted to appeal the transfer or discharge and return to the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to follow their post fall protocol for two of 10 sampled residents (Residents 8 and 9). * Resident 8 experienced the falls on 4/20 and 4/22/25. The facility did not implement additional interventions for fall prevention after Resident 8's second fall on 4/22/25. Additionally, Resident 8's post fall neurological assessments were not completed as ordered for the fall on 4/20/25. * Resident 9's post fall neurological assessments were not completed as ordered for falls on 5/16 and 5/29/25. These failures had the potential for the residents to experience additional preventable falls and a potential delay in identification and interventions for post fall head injuries.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs for one of three sampled residents (Resident 3). * The facility failed to ensure Resident 3's medication was administered as ordered. This failure had the potential for Resident 3 to experience adverse effects.

Inspectors wroteBased on interview, medical record review and facility document review, the facility failed to ensure to conduct an investigation for an abuse allegation was completed in a timely manner, report the results of the abuse investigation to the CDPH, L&C Program within five working days and inform Resident 2's family member of the results of the investigation for one of the two sampled residents (Resident 2). * Family Member 1 reported to the facility CNA 3 pinched Resident 2 on 2/13/25. The facility submitted the results of the investigation on 2/21/25, eight days after the incident had occurred. This failure posed the risk for Resident 2 to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was properly discharged from the facility. This failure had the potential to place Resident 1 at risk for not receiving continuity of care in the hospital. Review of facility's P&P titled Transfer or Discharge, Facility-Initiated revised 10/2022 showed in the Orientation for Transfer or Discharge (Emergent or Therapeutic Leave) section showed in part for an emergency transfer or discharge to a hospital or other acute care institution, implement the following procedures: Orient/ prepare the resident for transfer; and prepare for medical record transfer. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse by staff for one of four sampled residents (Resident 1). * Resident 1's hands were held down and tapped by CNA 5 while being fed by CNA 5. This failure had the potential to cause the injury and physical and/or psychosocial harm to the resident.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure privacy was provided to one of three sampled residents (Resident 3) as evidenced by: * Resident 3's privacy curtain was not pulled while providing the ADL care and assessment. This failure posed the risk to negatively affect the dignity of Resident 3 and violate Resident 3' rights to privacy.

Inspectors wroteBased on observation and interview, the facility failed to consistently provide a safe environment for the residents, staff, and visitors as evidenced by: * Two of the six facility doors were observed unlocked. This failure resulted in an unauthorized person entering a resident's room, which posed the risk of an unsafe environment for the residents, staff, and visitors.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the assessment for the risk for entrapement, physician's order and informed consent were obtained prior to the use of side rails for five of 11 final sampled residents (Residents 20, 40, 8, 7, and 15) and two nonsampled (Residents 10 and 539) reviewed for side rails. This failure had the potential to place the residents at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure 46 of 78 residents who received food from the kitchen received the proper diets and portion sizes when the facility's menus and recipes were not followed. * The facility failed to ensure the residents with mechanical soft diets received ground meat as shown on the Spring Cycle Menu Week 1 dated for 5/1/24. * The facility failed to ensure the finely chopped diet was on the diet manual or approved on the spread sheet and failed to ensure mechanical soft finely chopped diets were followed. * The facility failed to ensure the puree recipes for meats, vegetables, and potatoes were followed. * The facility failed to ensure 10 out of 10 residents with a CCHO diet (diet low in carbohydrates) received plain ice cream as shown on the Spring Cycle Menu Week 1 dated for 5/1/24. [...]

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen when there were 46 of 78 residents receiving food from the kitchen. * The facility failed to ensure the cooling log was done for the egg salad and failed to ensure the cooling log for the roast beef was fully completed. * The facility failed to ensure the ice machine was properly cleaned. * The facility failed to ensure the temperature log for the resident refrigerator were completed. * The facility failed to ensure food preparation utensils and equipment were in good, sanitary, and cleanable working conditions: a. One blue and two green cutting boards were heavily marred b. Two rubber spatulas were chipped c. One small frying pan and one pot with black residue d. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P. * The facility failed to maintain an accurate infection control surveillance program for January through March 2024. The facility used Surveillance Data Collection Form and Infection Control Surveillance form that showed inaccurate or missing information. This failure posed the risk for not identifying residents' infections and thereby, preventing the implementation of interventions to control the potential transmission of communicable diseases to other residents in the facility. * The facility failed to follow practices on handling, storing, and processing laundry so as to prevent the spread of infection. This failure posed the risk for transmission of disease-causing microorganisms. [...]

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the essential kitchen equipment was in the safe and operating condition as evidence by: * The facility failed to ensure one of one handwashing sink in the kitchen provided adequate water pressure and hot water. * The facility failed to ensure the walk-in Refrigerator 1 was absent of pooling water on the floor. * The facility failed to ensure the ice machine was properly cleaned as per the ice machine cleaning instruction. * The facility failed to ensure Freezer 1 door was absent of ice buildup. * The facility failed to ensure Freezer 1 door was free of caulking from peeling off with black residue and base board was not loose and free from black residue. These failures had the potential to spread infection and provide inadequate working equipments.

Inspectors wroteBased on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to conduct a regular bed inspection as part of a regular maintenance program to identify areas of possible entrapment for 12 of 12 residents reviewed for side rail use; 11 final sampled residents (Residents 7, 8, 12, 15, 16, 20, 22, 40, 387, 837, and 838), and one nonsample resident (Resident 10). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents reviewed for unnecessary medications (Resident 4) and one of two residents reviewed for restraint use (Resident 4) were informed of the use of the psychotropic medication (medication affecting brain activities associated with mental processes and behavior) and restraint. * The facility failed to ensure the informed consents were obtained prior to administering the Seroquel (antipsychotic medication) and bilateral hand mittens for Resident 4. This failure had the potential for Resident 4 to not be informed of the potential risks and benefits of the medication and restraints.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to offer and/or follow up on the advanced directive availability for two of 18 final sampled residents reviewed for advanced directives (Residents 6 and 12). * Resident 12 was not offered information to formulate an advanced directive. * The facility failed to ensure Resident 6 had an advance directive or a follow up was made to inquire whether or not Resident 6 had an advance directive. These failures had the potential for the residents' final wishes for medical treatment not being communicated with health care staff.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to follow their P&P for two of two final residents reviewed for the hand mitten use (Residents 4 and 22). * Resident 22's order for documentation of releasing their hand mitten did not follow facility P&P. * The facility failed to ensure Resident 4's bilateral hand mittens were monitored every two hours, and release for 15 minutes as per the physician's order. These failures resulted in inaccurate documentation of hand mitten removal, which had the potential for a delay in identifying and documenting adverse outcomes from the hand mittens use.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the splints (a medical device that stabilizes a part of your body and holds it in place) and orthosis (the correction of disorders of the limbs or spine by use of braces and other devices to correct alignment or provide support) were applied and the ROM exercises were provided to two of four final sampled residents reviewed for ROM functions(Residents 20 and 41). * The facility failed to ensure Resident 20 was provided with the restorative nursing services as ordered by the physician when the ROM exercises were not provided and the splint and orthosis were not applied. * The facility failed to ensure Resident 41's splint and orthosis were applied as ordered by the physician. These failures had the potential for decline in the residents' ROM and mobility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the environment free from accident hazards. * The facility failed to ensure the fall mat was placed on the floor as ordered by the physician for one of one nonsampled resident (Resident 10). * The facility failed to ensure the doorway to Room A was free of obstruction. * The facility failed to ensure the smoking supplies were stored for safety and the quarterly smoking safety assessments for one of one final sampled resident reviewed for smoking (Resident 387) was completed timely. * The facility failed to ensure the cleaning solutions were safely stored. A bottle of Awesome Floor Cleaner was left on the floor beside Resident 837's bedside cabinet. These failures posed the risk for the unsafe environment and risk of accidents for the residents in the facility.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary GT care and services for two of eight final sampled residents reviewed for GT care (Residents 4 and 6). * The facility failed to ensure Residents 4 and 6 were positioned safely at 30 to 45 degrees during the enteral feeding via GT. This failure posed the risk for developing complications related to the residents' GT.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary and safe respiratory care services to meet the needs of one of three final sampled residents reviewed for respiratory care (Resident 838). This failure had the potential to affect the resident's respiratory health and well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to meet the needs of the residents. * The emergency kits for the facility's oral medications and intravenous medications were not replaced in a timely manner for two of seven emergency kits (Emergency Kit 1 and Emergency Kit 2) inspected in the facility. This failure had the potential to contribute to a decreased availability of medications in an emergency. Findings. Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy revised January 2018 showed the emergency needs for medication are met by using the facilities approved emergency medication supply or by special order from the provider pharmacy. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure three of five final sampled residents (Residents 6, 15, and 937) reviewed for unnecessary medications were properly monitored for their medications. * Resident 15 was administered Humulin N insulin (an intermediate acting insulin, a medication used to lower blood glucose or sugar) without monitoring Resident 15's blood sugar as per the physician's order. * Resident 937 was administered hydralazine (medication to treat high blood pressure) when Resident 937's blood pressure was below the parameter prescribed by the physician. * Resident 6 was administered metoprolol (medication to treat high blood pressure) when Resident 6's blood pressure was below the parameter prescribed by the physician. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were safely and securely stored. * The facility failed to ensure the medication cart did not have an expired bottle of Dakins solution (wound cleanser) for one of seven medication carts (Treatment Cart 1). * The facility failed to ensure Medication Cart A was not left unlocked and unattended. * The facility failed to ensure the safe storage of a medication cup containing a white cream found at Resident 937's bedside. * The facility failed to ensure the safe storage of two opened packets of Vitamin A and D ointment found at Resident 19's bedside. * The facility failed to ensure safe storage of one bottle of Guayabron Suplemento Alimentico (nutritional supplement) found at Resident 837's bedside cabinet. [...]

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the facility's P&P on Resident Food From Outside Sources was updated and followed as evidence by: * The facility failed to ensure food items in the residents' refrigerator was labeled and dated. * The facility failed to ensure the policy was updated to meet state regulations. * The facility failed to ensure the visitors and staff were educated on safe food handling of outside food. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the facility's garbage and refuse was properly disposed as evidence by: * The facility failed to ensure two of two waste dumpsters were properly closed. * The facility failed to ensure the organic waste and recycling barrels were used as per state mandate SB1383. * The facility failed to ensure the area behind the waste dumpsters were free from debris. These failures had the potential to cause unsafe sanitary conditions and potential to harbor pests and rodents.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure Resident 387's hospice visit notes and cares provided were part of the resident's medical record. This failure resulted in Resident 387's hospice schedule and provided cares not being communicated to the facility staff, which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to inform the physician of the residents with prescribed antibiotics with signs and symptoms not meeting McGeer's Criteria (criteria used by long-term care facilities to determine a true infection). This failure had the potential for antibiotics to be used when not indicated and development of antibiotic resistant bacteria.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the pneumococcal vaccines were offered and administered to five of 11 final sampled residents reviewed for the pneumococcal vaccines (Residents 2, 6, 15, 16 and 937). This failure posed the risk for the residents to contract pneumonia.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents reviewed for Covid-19 vaccines (Residents 6, 15, and 16) were offered the Covid-19 vaccine. This failure resulted in the residents not receiving the vaccine in a timely manner once they were eligible to receive it, which had the potential to negavetively impact the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents reviewed for resident rights (Resident 8) was provided care in a manner that prompted dignity and respect. * Resident 8's urinary drainage bag was not covered. This failure had the potential to diminish the resident's self-esteem and self-worth.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to accurately inform the residents of the language communication and their rights to speak the language of their choice. This failure posed the risk for minimizing the residents' quality of life and not informing them of the facility's rules and expectations on language communication while residing in the facility.

Inspectors wroteBased on observation, interview and medical record review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of 18 final sampled residents (Residents 41 and 838). * The facility failed to develop a care plan problem to address Resident 41's activity participation. * The facility failed to ensure a care plan was developed to address Resident 838's bilateral 1/2 (half) side rails. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of 18 final sampled residents reviewed for care plans (Resident 8) was revised to reflect the resident's current care needs and interventions. * The facility failed to revise the plan of care for Resident 8 to address the change in Resident 8's suprapubic catheter (a hollow flexible tube used to drain urine from the bladder through a cut in the abdomen) size. This failure posed the risk of not providing the resident with individualized and person-centered care.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain accurate medical records and ensure the residents' personal health information was kept private for their residents. * The facility failed to ensure the documents were free from the use of erasing materials such as white correction tape. * Two of two survey binders contained confidential resident information. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate and could have potentially allowed unauthorized staff or visitors access to residents' confidential medical or personal information.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record for one of five sampled residents (Resident 4) was accurate. This failure had the potential for the residents' care needs to not be met.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicious of a crime in accordance with section 1150B of the Act when the facility did not report the allegation of abuse to the CDPH, L&C Program, Long-Term Care Ombudsman, and local law enforcement officials in timely manner for one of six sampled residents (Resident 1). The facility did not report Resident 1's allegations of abuse against the Activities Assistant to the CDPH L&C Program, Long-Term Care Ombudsman, and local law enforcement officials within two hours as per the facility's P&P within two hours. This failure had the potential to delay the investigation of the alleged physical abuse and for the staff to not take prompt and appropriate corrective actions to prevent further abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to report the result of the investigation to the CDPH, L&C Program, Orange District Office within five working days for one of six sampled residents (Resident 1). This failure had the potential to not protect the residents from possible abuse and/or delay in providing the necessary care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the change in condition evaluation and monitoring was completed and the physician was notified of the allegation of physical abuse for one of six sampled residents (Resident 1). This failure had the potential for Resident 1 to not receive necessary services to meet highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Residents 2) received the medication as ordered by the physician. This failure had the potential to place Resident 2 at risk for medical complications.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the grievance form was completed to show the actions taken and follow up for one of two sampled residents (Resident 2). This failure had the potential for the resident to not be fully informed about the resolution to his grievance.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the call light system was functioning for 33 of 54 beds (Beds A, B, C, D, E, F, F, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, andGG.) This failure had the potential of an unsafe environment by endangering the health, safety, and welfare of the affected residents who were assigned to those beds.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of six sampled residents (Residents 1 and 3) and one nonsampled resident (Resident A) had the functioning call light buttons available or a way to call the staff. This failure had the potential for the residents to not be able to call for assistance and receive help in a timely manner. * Resident 1 was wheelchair bound and dependent on the staff for assistance in bed mobility, toileting, and transfers. Resident 1 did not have a functional call light and was unable to get a hold of staff when needed help. * Resident 3 was wheelchair bound and needed assistance with transfers, dressing, and eating. Resident 3 did not have a working call light button and had to wheel herself out of the room to call for help. [...]

Inspectors wroteBased on interview, record review, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 5) who received nutrition via a gastrostomy tube was not given food by mouth. This failure had the potential for Resident 5 to choke and have poor health outcomes.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) received the appropriate care and services as ordered by the physician and as documented in the plan of care related to an indwelling urinary catheter. Resident 1 was observed to not have any urine output by CNA 1 during the night shift (2300 to 0700 hours); however,CNA 1 failed to report this finding to the licensed nurse. This failure had the potential to cause a delay in necessary care and services for Resident 1.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the safety of one of four sampled residents (Resident 1) when the facility did not place the alleged staff on leave with no resident contact during an abuse allegation as per their P&P. This failure put Resident 1 and other residents at risk for further abuse. * Resident 1 alleged CNA 1 hit him on the back of the head while unplugging his fan. Resident 1 stated he had throbbing pain to the back of his head on the pain level of five to six (on a pain scale of 0-10 with 0 = no pain and 10 =worst pain); however, the alleged CNA (CNA 1) continued to stay at the facility and was reassigned to care for other residents. This failure had the potential to result in serious injury and/or psychosocial harm and put the vulnerable residents for further abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the care plan of one of four sampled residents (Resident 1) was reviewed and revised after Resident 1 reported an abuse allegation toward CNA 1. This failure put Resident 1 at risk of not receiving resident-centered care. Review of the facility's P&P titled Care Planning - Interdisciplinary Team revised March 2022 showed assessments of residents are ongoing and care plans are revised as information about the resident and the residents' condition change. Medical record review for Resident 1 was initiated on 8/25/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Medical record review for Resident 1 was conducted on 9/1/23. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the presence of competent staffing to meet one of four sampled residents' (Resident 1) needs safely and in a manner to promote the resident's rights, physical, mental, and psychosocial well-being. * RN 1 failed to send CNA 1 home after the abuse allegation was made against CNA 1 as per the facility's P&P. * RN 1 failed to create or revise Resident 1's care plan after the abuse allegation. * RN 1 failed to document a Change of Condition of the abuse allegation. * The IDT meeting was not set up with Resident 1 after the abuse allegation These failures had the potential to result in serious injury and/or psychosocial harm to Resident 1 and other residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure a full-time supervisor to oversee the day-to-day operations of the food service department was employed. This failure posed a risk of lack of adequate supervision of the daily kitchen functions which could lead to food borne illness for the 28 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by the following: * The facility failed to ensure the food seasoning were stored in sanitary condition. * The facility failed to ensure the expired foods were discarded. * The facility failed to ensure the kitchen equipment and ice machine were maintained in sanitary condition. * The facility failed to ensure the kitchen staff performed hand hygiene. * The facility failed to ensure the kitchen equipment was air dried. * The facility failed to ensure the cutting boards were in sanitary condition and with cleanable surface. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and manufacturer's guidelines review, the facility failed to ensure the facility equipment was maintained in safe operating condition when: * For Medication Cart 1, the glucometer's (a device that measures the amount of sugar in the blood) serial number did not match the serial number for the glucometer tested on the quality control log. The lot number for the glucometer test strips in Medication Cart 1 did not match the lot number on the quality control log for the cart. This failure had the potential risk of inaccuracy for the blood glucose test results. * The dish machine required minimum wash temperature and sanitizer concentration levels were not reached. This failure placed the 28 residents who received food from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 17 final sampled residents (Resident 50) was treated with dignity. * CNAs 1 and 3 were talking to each other in a foreign language while providing ADL care to Resident 50 whose primary language was English. This failure resulted in not ensuring resident's rights to be treated with respect and dignity.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide personal privacy for one nonsampled resident (Resident 52). * LVN 2 failed to close Resident 52's privacy curtain when she administered the medications via GT. Resident 52's abdomen was exposed during the procedure. In addition, RT 1 provided tracheal suctioning without provided privacy to Resident 52. These failures had the potential to expose the residents' uncovered body parts to the public view and affect self esteem and self-worth.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to develop the plans of care to reflect the individual care needs for two of 17 sampled residents (Residents 3 and 36 ). * The facility failed to develop a comprehensive care plan to address Resident 3's use of Ativan (antianxiety medication) and the side effects of Ativan. * The facility failed to develop a care plan to address Resident 36's preference to use his bare hands to feed himself during meals. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure two of 17 final sampled residents (Residents 24 and 30) attained and maintained their highest practicable physical well-being. * The facility failed to ensure Resident 24 was up in a high back tilt wheelchair as tolerated on non-dialysis days as per the physician's order. This failure posed the risk for the resident to develop physical, psychosocial, emotional complication that may arise from being bed bound. *The facility failed to ensure Resident 30 had a physician's order for the use of splint on the left hand. This failure resulted in Resident 30 wearing a splint on his left hand without any indication, time frame for how long to wear the device, or monitoring.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure ulcers for two of 17 final sampled residents (Residents 6 and 58). * The facility failed to offload Resident 6's heels from pressure as ordered by the physician. * The facility failed to ensure Resident 58's low air loss mattress (pressure redistributing support surface) was set appropriately according to the resident's weight and physician's order. These failures had the potential of Residents 6 and 58 not receiving the appropriate care and services to promote healing or prevent the development of the pressure ulcers.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the 72-hour neurological assessments were conducted completely for one of 17 final sampled residents (Resident 51) at the frequency as per the physician's orders after the resident had sustained three unwitnessed falls. This posed the risk for delayed recognition of a neurological change or injury.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide safe respiratory care to meet the needs of one of 17 final sampled residents (Resident 6). * The facility failed to ensure Resident 6 was placed on the ventilator settings ordered by the physician. Changing the ventilator settings without the appropriate orders had the potential to result in poor health outcomes for the resident.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 17 final sampled residents (Resident 6) remained free from accident hazards related to the use of elevated side rails. Resident 6's assessments showed side rails were not appropriate or indicated; however, Resident 6 was observed with elevated side rails in place. This had the potential to place Resident 6 at risk for entrapment and serious injury.

Inspectors wroteBased on interview, observation, medical record review, and facility P&P review, the facility failed to ensure the physician's order for ferrous sulfate was complete for one nonsampled resident (Resident 52). This had the potential for the wrong dose being administered to the resident.

Inspectors wroteBased on observation and interview, the facility failed to ensure the medication error rate was below 5%. * The medication error rate was 22.58%. LVN 2 failed to administer the medications according to the physician's order and facility's P&P for Resident 52. This failure had the potential for drug interactions.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed as evidenced by: * [NAME] 1 failed to follow the recipe for the pureed veal patty during the puree preparation process. * Resident 29 had a physician's order for a fortified mechanical soft, finely chopped diet; however, the resident was served a mechanical soft, finely chopped diet. These failures posed the risk of the residents' nutritional needs not being met.

Inspectors wroteBased on observation, interview, and facility P & P review, the facility failed to ensure the food items brought to the facility for the residents by the family or visitors were stored for future consumption. This failure posed the risk for 28 residents who were on an oral diet to not have a homelike environment.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of 17 final sampled residents (Resident 51) who received hospice services. * The facility failed to ensure Resident 51's hospice record included in the medical record. Resident 51's comprehensive plan of care, physician certification, hospice visitation calendars were not found in the medical record. This failure posed the risk for delay in the communication between the hospice provider and facility which may affect resident care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 17 final sampled residents (Resident 58), was offered the influenza vaccine. This failure had the potential to negatively impact Resident 58's health.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide a safe environment for one of 17 final sampled residents (Resident 33) and one nonsampled resident (Resident 1). * An exposed fluorescent light fixture was observed over Resident 33's bed. * The facility failed to ensure the electrical and antenna wall outlets with exposed wires were covered in Resident 1's room. These failures the potential for an unsafe environment for the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage and refuse were properly stored for two of two garbage dumpsters. The lids of the two garbage dumpsters were observed with gaps in between the lids covering the garbage dumpsters. This failure had the potential to harbor pests or rodents which carry diseases.