North Long Beach Post Acute

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide adequate supervision for three out of nine residents sampled (Resident 6, 7, and 12) in the secured Behavioral Unit of the facility. a. The facility failed to prevent a physical altercation between Resident 6 and 7 during a smoke break in the patio on 7/16/2026. This failure resulted in Resident 6 sustaining a superficial linear scratch, measured at 0.1 centimeter (cm) by 1 cm, to the left side of the bridge of the nose with scant amount of blood. Resident 6 also sustained a superficial scratch to the left upper lip with scab (dry, protective crust that forms over a cut) forming, measured at 1 cm by 0.1 cm. Resident 6 had a 5th metacarpal neck/head fracture of the right hand (broken bone in the hand) which was still healing and the current altercation caused localized swelling in the same hand. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to accommodate one of one resident's (Resident 11) family member's (FM 1) request to not have Certified Nurse Assistant (CNA) 6 as a care giver. The failure violated residents' rights and had the potential to result in negative psychological outcomes.

Inspectors wroteBased on interviews and record reviews, the facility failed to complete an annual performance evaluation (a regular check-in where a company looks at how well an employee does their job) for Certified Nurse Assistant (CNA) 6 who was facing allegations of abuse from one out of five sampled residents (Resident 8) and complaints from Resident 11's family member (FM 1). The failure to conduct a performance evaluation on an employee facing complaints places the residents at risk for compromised safety, poor service and poor quality of care which can be detrimental to the residents' health.

Inspectors wroteBased on interview and record review, the facility failed to:a. Protect the residents' rights to be free from physical abuse from each other. Resident 36, Resident 54 and Resident 55 were involved in a physical altercation for two of three sampled residents (Resident 54 and Resident 55) reviewed for physical abuse sustained injuries, when facility staff were unable to de-escalate Resident 54's behavior.b. Protect the residents' rights to be free from sexual abuse (unwanted touching) by staff to resident for one of one resident (Resident 35) reviewed for sexual abuse, when Primary [NAME] (PC) 2, touched Resident 35's leg inappropriately. c. Protect the residents' rights to be free from physical abuse by Resident 36 for one of one resident Resident 44, when Resident 36 hit Resident 44 in the face. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a follow up resolution for one of seven residents who attended the resident council meeting (Resident 36) for the grievances filed from previous resident council meetings for:Increased smoke breaks and increased use of phone time throughout each day, on 5/13/2026 andIncreased number of snacks on throughout each day 6/26/2026. This deficient practice resulted in violating the resident council and Resident 36's right to voice grievances and receive a response leaving the resident council and Resident 36 feeling unheard and frustrated.

Inspectors wroteBased on observation, interview, and record review the facility failed to report all alleged violations to the State Survey Agency (CDPH) and local law enforcement including: a. An allegation of staff to resident sexual abuse (unwanted touch) for one out of six (Resident 35) sampled residents b. An unusual occurrence (an unexpected or atypical event that deviates from the norm or expected pattern) of illicit drugs (substances that are illegal to manufacture, possess, sell, or use) being brought into the facility and possibly consumed by two out of six sampled residents (Resident 54 and Resident 79) c. Documentation in Resident 44's chart indicated Resident 44 had a laceration (laceration (deep, ripped cut or gash caused by a hard blow or blunt impact) and bleeding from the mouth with no indication of how it happened. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to investigate all alleged of abuse. The facility failed to investigate: a. An allegation of staff to resident sexual abuse (unwanted touch) for one out of six sampled residents (Resident 35) b. Resident 44's laceration and bleeding from the mouth, an injury of unknown origin and report the incident and results of the investigation to the California Department of Public Health (CDPH) These deficient practices had the potential for trends of abuse and unusual occurrences going unnoticed, exposure to continued abuse, and psychological trauma to residents for not having their abuse allegations investigated.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were competent with reporting and investigating injuries of unknown origin, when staff failed to report and investigate an injury of unknown origin for one of one sampled residents (Resident 44). This failure placed Resident 44 and other residents of the facility at risk for continued abuse due to injuries of unknown origins going unreported and not investigated.

Inspectors wroteBased on interview and record review, the facility failed to:Ensure facility staff were aware of a resident's history of elopement (unauthorized leave of absence) Ensure facility staff Supervised the Residents' whereabouts to prevent the Resident from leaving the facility without facility staffs knowledge for one of one residents (Resident 1) on 6/20/2026. This deficient practice resulted in Resident 1 eloping from the facility on 6/20/2026, putting Resident 1 at risk for serious injury, harm, or death from hazards in the community, including traffic accidents, falls, exposure to environmental conditions or inability to obtain needed medical assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of two sampled residents (Resident 1) had ongoing monitoring for Resident 1's condition after experiencing a change of condition (COC). This deficient practice had the potential for Resident 1 to experience emotional distress due to not receiving the necessary care needed following the incident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 2). The facility failed to:1. Document Resident 2's location, condition, or communications after the resident was taken by police on 4/22/2026 and facility received an email from General Acute Care Hospital (GACH) 2. This failure had the potential for lack of continuity of care, and inability to ensure the residents' safety and wellbeing.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a rolling stool (a mobile seating device featuring a padded seat, a lift for adjustable height, and 360 degree swivel casters) was not left in the facility's dining/activity room where it posed a safety hazard to residents due to the rolling mechanism of the chair, for one out of three residents (Resident 1). This deficient practice resulted in Resident 1 losing her balance and falling while attempting to sit on a rolling stool. Resident 1 complained of pain to her right hip and left rib area and was transferred to a General Acute Care Hospital (GACH) where she was assessed with multiple right rib fractures (broken bones). This deficient practice had the potential to cause harm to other residents who were in the area where a rolling stool was left unattended.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1's responsible party's (RP) request was honored when he requested Resident 1 to be removed from the podiatrist patient list. This deficient practice resulted in Resident 1 being seen by the podiatrist on 5/6/2025.

Inspectors wroteBased on interview and record review, the facility failed to notify Resident 1's Responsible Party (RP) of a significant change in condition, when Resident 1 had a fall that occurred on 8/29/2025 at 4:39 a.m. Resident 1's RP not notified until 7 a.m. This deficient practice had the potential to delay the RP's involvement in care decisions and compromised the residents' right to informed participation in their care. This deficient practice resulted in an approximately two-and-a-half-hour delay in notifying Resident 1's RP.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light (alerts care givers that the resident required assistance) were within reach for two out of four sampled residents (Resident 4 and Resident 5). As a result of this deficient practice Resident 4 and Resident 5 were at risk of not having their needs met in a timely manner

Inspectors wroteBased on interview and record review, the facility failed to protect two out of four sampled residents (Resident 1 and Resident 2) from verbal abuse (mental abuse that involves the use of oral or written language directed to a victim. Verbal abuse can include the act of harassing [unwanted offensive or humiliating comments or behavior], insulting [a rude expression intended to offend or hurt), scolding (point out and criticize some fault or error, often angrily], criticize sharply, or excessive yelling towards an individual) and neglect (in the context of caregiving, neglect is a form of abuse where the perpetrator, who is responsible for caring for someone who is unable to care for themselves, fails to do so) by certified nursing assistant (CNA) 1. As a result of this deficient practice Resident 1 felt upset and Resident 2 felt bad, like a burden, and upset. [...]

Inspectors wroteBased on interview and record review the facility failed to monitor the fluid intake (the amount of liquids consumed by an individual) for one out of two sampled residents (Resident 6), who was at risk of dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake). As a result of this deficient practice Resident 6 was placed at risk for developing dehydration. Resident 6 was readmitted to a general acute care hospital (GACH) with a diagnosis of severe dehydration on 6/29/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to store food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins for residents who eat food from the kitchen by not: 1. Checking the chemical sanitation of the dish washer and documenting the results. 2. Ensuring to store food with label and open date. 3. Ensure facility staff was not wearing jewelry while preparing pudding. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and observe infection control measures by failing to: a. Ensure Restorative Nursing Aide 1 changed isolation gowns (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) in between provision of direct, high contact care for Resident 13 and Resident 30 who were both on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug-resistant organisms). b. [...]

Inspectors wroteA. Based on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 38) had the mental capacity (the ability to make an informed decision based on understanding a situation, the options available, and the consequences of the decision) to sign an informed consent (permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits) for his psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications. This deficient practice had the potential for Resident 38 to sign consent for a psychotropic medication without being aware of the risks and benefits. B. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately document the Minimum Data Set (MDS - a resident assessment tool) for three of 12 sampled residents by failing to: a. Ensure Resident 87's hemodialysis status was reflected on the MDS. b. Ensure Resident 111's accurate discharge destination was documented. c. Ensure the accuracy of information in the MDS assessment for one of three sampled residents (Resident 32) who was on oxygen therapy. This failure had the potential to negatively affect resident's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement care plans for two of six sampled residents (Resident 60, Resident 67) when: a. The facility failed to ensure a care plan for Divalproex (medication to treat outbursts of aggression related to dementia and other behavioral disturbances) was developed and implemented for one of four sampled residents (Resident 60). This deficient practice placed Resident 60 at risk for physical harm and injury and had the potential to delay necessary monitoring and safety interventions. b. Resident 67 did not have a care plan in place for his use of Quetiapine Fumarate (Seroquel, medication used to treat psychosis [a mental state characterized by a loss of contact with reality]). These deficient practices had the potential for Resident 60, Resident 67 to not receive personalized care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure hydrocodone-acetaminophen (a controlled medication [medications that the use and possession of are controlled by the federal government] in combination with acetaminophen [a medication used to treat pain] used to relieve pain) was administered to Resident 12 only for the prescribed severe pain level and as per physician orders, affecting one of three sampled residents during medication administration (Resident 12). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent from a resident's responsible party for one of five sampled residents (Resident 79). This failure had the potential to result in violating the resident's right to be informed and refuse treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light device was within reach for one of six sampled residents (Resident 41). This deficient practice had the potential to prevent Resident 41 from receiving necessary care and services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the medical doctor (MD) was notified when one out of two residents (Resident 71) had multiple blood sugar levels that were over 400 milligram ([mg]unit of measure weight])/deciLiter (dl unit of measure of volume) (reference range 70 and 100 mg/dL). This deficient practice had the potential to cause a delay in treating the elevated blood sugar levels for Resident 7, and risk transfer to the general acute care hospital (GACH) for treatment of high blood sugar.

Inspectors wroteBased on interview and record review, the facility failed to provide a written 7-day bed hold notice for one of two sampled residents (Resident 87). This failure had the potential to result in violating Resident 87's right to be informed upon transfer of the bed-hold period permitting the resident to return to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Licensed Vocational Nurse (LVN) 1 did not crush delayed release ([DR] medication released over an extended time) divalproex (a medication used to treat seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) and did not administer crushed divalproex delayed release and crushed lorazepam (a controlled medication [medications that the use and possession of are controlled by the federal government] used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) together for one of three sampled residents (Resident 2) during medication administration observation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: A. One of six sampled residents (Resident 41) was sitting upright when eating lunch. This deficient practice placed Resident 41 at risk for aspiration (inhaling small particles of food or drops of liquid into the lungs) and choking. B. Two of three residents (Resident 45) were transferred by two persons in a mechanical lift ( a mechanical device used to safely transfer individuals who have limited mobility from one place to another ). This deficient practice had the potential to result in Resident 45 falling from the mechanical lift and causing injury.

Inspectors wroteBased on interview and record review, the facility failed to perform a trauma informed care assessment for one of two sampled residents (Resident 64) who was diagnosed with post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). This deficient practice had the potential for Resident 64 to experience triggers (memories tied to the traumatic event) in the facility and had the potential for re-traumatization (the experience where past traumatic memories are triggered, leading to further physical and psychological harm, often due to inadequate care or inappropriate situations).

Inspectors wroteBased on interview and record review, the facility and consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) failed to identify that Resident 69's clonazepam (a controlled medication [medications that the use and possession of are controlled by the federal government] used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) did not indicate a specific duration of treatment and did not indicate a stop date, affecting one of four sampled residents for unnecessary medications (Resident 69). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication administration and adequate monitoring of side effects for one of two sample residents (Resident 53) who was receiving an anticoagulant (a medication used to prevent and treat blood clots that can cause severe health issues in the blood vessels and the heart) medication and were at high risk for bleeding. This deficient practice had the potential to cause a delay in necessary care and services resulting in injury or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for two of three sampled residents (Residents 2 and 12) by failing to: 1. Ensure Resident 2's divalproex (a medication used to treat seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) delayed release ([DR] medication released over an extended time) was not crushed. 2. Ensure Resident 2's crushed divalproex delayed release tablet and crushed lorazepam (a controlled medication [medications that the use and possession of are controlled by the federal government] used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) tablet were administered separately. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 12) was free from significant medication error during medication administration, by failing to ensure hydrocodone-acetaminophen (a controlled medication [medications that the use and possession of are controlled by the federal government] in combination with acetaminophen [a medication used to treat pain] used to relieve pain) was administered to Resident 12 only for the prescribed severe pain, on the pain level scale (a tool used to measure the intensity of pain 1-4 mild pain, 5-7 moderate pain, 6-10 severe pain) and as per physician orders. This deficient practice failed to provide hydrocodone-acetaminophen in accordance with physician orders or professional standards of practice and had the potential to result in drug overdose, drug misuse and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure discontinued lorazepam (a controlled substance [a medication with a high potential for abuse] used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) 2 milligrams (mg - a unit of measurement for mass) per milliliters (mL - a unit of measurement for volume) oral solutions for Residents 44 and 63 were removed from Station 1 Medication Room Refrigerator and disposed of in accordance with the facility's policy and procedures (P&P) titled, Disposal of Medications and Medication-Related Supplies - Controlled Medication Disposal, dated 1/2025, Medication Destruction, dated 1/2025 and Discontinued Medications, dated 1/2025, affecting one of one inspected medication room (Station 1 Medication Room). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide specialized rehabilitative (rehab) services (services that require specialized training and experience of a licensed therapist or therapy assistant) to two of six sampled residents (Residents 16 and 41) by failing to: 1. Ensure Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function), Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities), and Speech Therapy (ST, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) evaluations were provided in accordance with physician's orders for Resident 16. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure; a. The medical record for one of six sampled residents (Resident 71) was accurate by failing to ensure the physician's orders for Resident 71's right leg weight bearing restrictions were accurately documented. This deficient practice had the potential to negatively impact the provision of necessary care and services, cause miscommunication among staff, and cause a decline in range of motion (ROM, full movement potential of a joint), mobility, and overall function. b. Restorative Nursing Aide ([RNA], nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) services provided were accurately documented for one of three sampled residents (Resident 48). [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to identify and implement corrective action on repeated systemic problems that were identified from the last survey process, affecting 102 of 102 residents: a. Ensure staff were notifying the medical doctor of any change in condition in residents. b. Ensure the accuracy of Minimum Data Set (MDS, a resident assessment tool) for residents. The deficient practices placed the residents at risk of not receiving the quality treatment necessary to adequately meet their highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to offer and educate coronavirus ([Covid-19] n infectious disease caused by the SARS-CoV-2 virus) vaccinations to staff per facility's policy for six of seven sampled employees. This failure had the potential to place all residents at risk for infection of Covid-19.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician for two of three sampled residents on: a) 5/22/2025 when Resident 3 was transferred to a general acute care hospital (GACH) for difficulty breathing, b) 5/23/2025 when Resident 4 had a new skin redness to the nose area, and c) 5/26/2025 when Resident 4 was refusing care, had agitation, and increased confusion. This failure had the potential to result in a delay of care for Resident 3 and Resident 4.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from physical restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body) by failing to: 1. Assess Resident 1 for possible causes of behaviors and implement interventions before the application of physical restraints. 2. Notify the physician of Resident 1 ' s continued agitation and obtain a Physician Order for the use of Physical restraints before applying the restraints. 3. Develop a care plan to address the need for the implementation of physical restraints. 4. Attempt to use less restrictive interventions before application of physical restraints on Resident 1. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to: a. Obtain informed consent for Ativan for one of three sampled residents (Resident 3) prior to administration b. Monitor and document manifested behaviors for the administration of Ativan and Seroquel for one of three sampled residents (Resident 1). These deficiencies have the potential to result in the use of unnecessary medication, or non-therapeutic use of psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to initiate a fall risk care plan for one of two sampled residents (Resident 1) when Resident 1 was identified as a fall risk. This failure resulted in Resident 1 experiencing a fall on 5/23/2025 and sustaining a skin tear to the right elbow.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was transferred to a General Acute Care Hospital (GACH) due to blood in her urine, was readmitted to the facility, when it was determined by the GACH that Resident 1 was appropriate for transfer back to the facility (2/24/2025). This deficient practice resulted in Resident 1 remaining in the GACH for 20 days after attempts to transfer her back to the facility were made by the GACH. This deficient practice had the potential to cause Resident 1 anxiety and non-continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 4) was not hit by Resident 5. This deficient practice resulted in Resident 4 being punched in the stomach by Resident 5 and had the potential for Resident 4 to suffer physical or psychosocial harm as a result. This deficient practice had the potential for other residents in the facility to be subjected to suffer physical abuse.

Inspectors wroteBased on interview, and record review, the facility failed to treat resident with dignity, when Certified Nurse Assistant (CNA) 1 spoke disrespectfully to one of three residents (Resident 2). This deficient practice had the potential to compromise the resident ' s emotional well-being and violate their right to respectful and dignified care.

Inspectors wroteBased on interview and record review, the facility failed to document a resident had refused a physician ' s visit for one of three residents (Resident 1) when Resident 1 refused psychiatric care and treatment. This failure has the potential to result in Resident 1 ' wishes and rights not being respected or miscommunicated among staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident ' s (Resident 4), who did not have capacity to understand and make decisions, Responsible Parties (RPs 1 and 2), were invited and attended an Interdisciplinary Team (IDT- the resident and or RP along with various healthcare professionals who meet to coordinate the resident's care plan) care conference on /11/22/2024. This deficient practice violated Resident 1 and RPs 1 and 2 right to be informed and active participants to discuss Resident 1 ' s plan of care and services with the IDT and had the potential for a delayed discussion of needed care and services.

Inspectors wroteBased on interview and record review, the facility failed to notify one of three sampled resident ' s (Resident 4) primary care doctor (MD 1) and Responsible Parties (RPs 1 and 2) when Resident 4 ' s coronavirus disease 2019 (COVID-19 an infectious disease caused by the SARS-CoV-2 virus which affects the respiratory [breathing] system) test was not completed as ordered. This failure resulted in Resident 4 ' s COVID-19 status being unknown and could have resulted in Resident 4 being positive for COVID-19. This deficient practice had the potential to cause a delay in treatment to Resident 4, and result in the spread of COVID-19 to all staff, residents, and visitors in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 1) personal belonging list (inventory list) was updated when Resident 1 received and kept a debit card in his possession and assist Resident 1 in safeguarding the key to Resident 1 ' s bedside drawer. These failures had the potential for Resident 1 ' s belongings to be unaccounted for and his personal items to be unsafe.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement comprehensive plan of care for the use of Plavix (blood thinner medication) on one of four sampled residents (Resident 1). This failure had the potential to result in inadequate monitoring and assessment of Resident 1 ' s bruises on both arms after an allegation of abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Housekeeper (HK 1) did not run over the resident ' s foot with the laundry cart (a large, blue, storage device with wheels used to deliver residents ' clothing and clean linens in bulk) for one of two sampled residents (Resident 1). Resident 1 sustained left foot fracture. The facility failed to: 1. Ensure Housekeeper (HK 1) did not overfill a laundry cart (a large, blue, storage device with wheels used to deliver residents ' clothing and clean linens in bulk) with clean linen and clothing preventing HK1 to have a clear view when transporting the laundry cart around the facility. On 7/20/2024 HK 1 run over Resident 1 left foot with a laundry cart while transporting it to Station 2. 2. Ensure HK 1 followed the facility policy and procedure titled, Laundry Initiative Module 2: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for two of eight sampled residents (Resident 61 and Resident 102) with limited range of motion ([ROM] full movement potential of a joint {where two bones meet}) and mobility by failing to: 1. Monitor and assess Resident 61's ROM in each joint of both arms and legs during the quarterly Rehab Screening (brief assessment of a resident's abilities) from 11/5/2021 to 6/12/2022 in accordance with the facility's policy titled, Resident Mobility and Range of Motion, which indicated the facility will identify the resident's ROM of the joints as part of the resident's comprehensive assessment. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call light was within reach for two of seven sampled residents (Resident 20 and 57). This deficient practice had the potential for Resident 20 and 57 not able to find the call light to call for assistance when needed, and experienced loss of self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify nursing and the primary physician of the change in condition (COC- major decline or improvement in a resident's status that will not resolve itself without intervention) for two of eight sampled residents (Resident 102 and 61) with limited range of motion ([ROM], full movement potential of a joint {where two bones meet}) and mobility (ability to move) concerns by failing to: a. Report Resident 61's increased pain and ROM impairments in the left leg indicated on the Rehab Screening (brief assessment of a resident's abilities), dated 11/5/2021. b. Report Resident 102's significant decline in mobility and activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) indicated on the Rehab Screening, dated 4/5/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure thoroughly investigate the background of Registered Nurse Supervisor (RNS 1) who had history of disciplinary actions on her nursing license during hiring process. This failure had the potential to place residents at risk for abuse and gross negligence (repeated failure to provide required nursing care or exercise precaution in a situation which the nurse knew or should have known could result in patient harm).

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a Preadmission Screening and Resident Review (PASARR: required screening for individuals with serious mental illness to ensure needs are met and are placed in an appropriate environment) assessment was resubmitted for a resident who was newly diagnosed with a mental illness for one of one sample residents (Resident 89). 2. Follow up and PASARR recommendation to obtain Level II evaluation for three of three sampled residents (Resident 11, 15 and 57). These deficient practices had the potential for Resident 89,11,15, and 57 not receiving the necessary and appropriate psychiatric (diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) level of treatment and evaluation in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure availability and administration of Restasis ([Generic name cyclosporine] a medication used to treat dry eye disease) in accordance with physician orders or professional standards of practice for one of three sampled residents (Resident 60.) This deficient practice increased the risk for Residents 60 to suffer from eye complications including dry eyes. 2. [...]

Inspectors wroteBased on observation, interview and record review facility failed to follow their policy on food handling and storage in the refrigerator by not dating prepared food stored in the refrigerator. This deficient practice had the potential to cause food borne (illness caused by food contaminated with germs or toxins) diseases among the facility residents who depend on facility prepared food for daily feeding

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures on two of six sampled residents (Resident 48 and Resident 80) by failing to: a. Ensure doffing of (removal) personal protective equipment ([PPE] specialized clothing or equipment worn by an employee for protection against infectious materials) properly after rendering care to Resident 48. b. Practice infection prevention measures by placing medications in unclean and unsanitary conditions for one of three observed residents during medication administration (Resident 80). These failures had the potential to spread infection among residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to implement antibiotic stewardship program (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) for three of seven sampled residents (Resident 12,47, and 111), by prescribing an antibiotic without meeting the criteria of their protocol (checklist or guide to initiate antibiotic). This deficient practice had the potential to put Resident 12,47, and 111 at risk for antibiotic resistance (not effective to treat infection) and inappropriate use of antibiotic.

Inspectors wroteBased on interview and record review , the facility failed to track and update Covid 19 ( contagious and highly transmissible respiratory disease caused by a virus) immunizations among the staff and residents. This deficient practice had the potential to cause an outbreak of Covid among the staff members and residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Eensure one of three sampled residents (Resident 3) provided privacy while sitting on a wheelchair wearing an incontinent brief (diaper). This deficient practice had the potential to affect Resident 3's self-worth and dignity. 2. Ensure one of eight sampled residents (Resident 61) who had limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move) was dressed in their own clothes and not in a hospital- type gowns. This failure had the potential to negatively impact Resident 61's psychosocial (social conditions related to mental health) well-being and prevented Resident 61 from receiving movement to the left arm during activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of ten residents (Resident 105) during Resident Council Meeting (organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care and life) know how to file a grievance. This deficient practice had the potential to violate resident's rights to have his grievance heard and addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 16 and 56) were free from unnecessary restraint (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) as evidenced by: 1. Resident 16 having a bolster mattress (mattress has a defined perimeter that helps to create a secure and stable edge around the bed) with no order, no assessment, and no consent (permission for something to happen). 2. Identify, and appropriately monitor the use of built-in bolster pads in Resident 56's bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an orthopedic (branch of medicine dealing with the correction or prevention of deformities, disorders, or injuries of the bones and associated soft tissue) specialist appointment for one of eight residents (Resident 102) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move) in accordance with the physician's order, dated 6/25/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform a quarterly pain evaluation for one of eight sampled residents (Resident 102) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move). This deficient practice had the potential to prevent Resident 102 from receiving adequate pain management and additional intervention for Resident 102's left knee contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 74) did not receive unnecessary psychotropic medications (medications which affect perception, mood, consciousness, and behavior). This deficient practice had the potential to place Resident 74 at risk for adverse consequences due to unnecessary prolonged use of psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than less than five percent (%) affecting three of three residents observed for medication administration (Residents 60, 80 and 106) by failing to: a. Ensure availability and administration of Restasis ([Generic name - cyclosporine] a medication used to treat dry eye disease) for Resident 60 in accordance with physician orders. b. Ensure proper administration of Advair Diskus ([Generic name - fluticasone-salmeterol] a combination medication delivered through a device in the form of inhalation powder to treat breathing problems) for Resident 80 by ensuring rinsing of mouth after use per prescriber instructions. c. Hold amlodipine (a medication used to treat high blood pressure) dose administration for Resident 106 per prescribed blood pressure parameters. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure removal of expired calcium plus vitamin D3 ([D3 - cholecalciferol a form of vitamin D] a dietary supplement to treat calcium and vitamin D deficiency, and promote bone health), bisacodyl (a medication used to treat constipation and bowel irregularity), vitamin B12 (a vitamin used to treat anemia and prevent vitamin B12 deficiency), simethicone (a medication used to relieve bloating and discomfort of gastrointestinal [the organs through which food passes after swallowing and digestion] gas) and cranberry (a dietary supplement used to prevent urinary tract [a medical term used to describe drainage system for removing urine] infection) tablets, per manufacturer requirements, from one of one inspected medication room (Medication Room Station 1). 2. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA) failed to provide documented evidence of the implementation of their Quality Assurance and Performance Improvement (QAPI-data driven approach to quality improvement) plan in reference to facility falls, weight management and wound management issues identified. This deficient practice had the potential to have reoccurring deficient practices that can impact the quality of care for the residents.

Inspectors wroteBased on interview and record review, the facility failed to offer pneumococcal (Pneumococcal vaccines are vaccines against the bacterium Streptococcus pneumoniae) vaccines on one of five sampled resident ( Resident 112). This deficient practice placed Resident 112 at a higher risk of acquiring and transmitting pneumonia to other residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one adjustable height therapy mats located in the therapy gym had a flat surface instead of a slanted position. This deficient practice had the potential to cause a safety and fall hazard for resident requiring the mat for therapy intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess functional limitation (limited ability to move a joint that interferes with daily functioning) in range of motion ([ROM] full movement potential of a joint [where two bones meet]) for two of eight sampled residents (Resident 15 and 57) with limited ROM and mobility (ability to move). This deficient practice provided inaccurate information sent to the federal database and had the potential to result in delayed or missed identification of joint range of motion changes, inaccurate care planning, and inadequate provision of services and treatments for Resident 15 and 57.

Inspectors wroteBased on interview and record review, the facility failed to ensure, residents, assessed at risk for falls, did not have a fall, for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure a Certified Nurse Assistant (CNA 3) did not leave Resident 1 unsupervised when Resident 1 was sitting at the edge of the bed. 2. Ensure CNA 3 followed the facility's policy and procedure (P&P) titled Answering the Call Light which indicated to call another staff for help by using the call light for assistance. CNA 3 left Resident 1 sitting at the edge of her bed unattended and went to the resident's restroom to get some gloves. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep three out of five sampled residents' (Resident 3, Resident 4, and Resident 5) call lights within reach. This deficient practice had the potential to prevent residents from receiving timely assistance, and compromise the residents safety and health. a. During a review of Resident 4 ' s Face Sheet (admission record), the Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Type II Diabetes Mellitus (DM: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to document the resident ' s wound care treatments for one of two sampled residents (Resident 1) to indicate the treatment was performed for a resident who has multiple skin complications. This deficient practice has the potential to negatively affect tracking the effectivness of the wound treatments and has potential for Resident 1's wounds to get worse. a. During a review of Resident 1 ' s Face Sheet (admission record), the Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE] with diagnoses including acute osteomyelitis (infection of the bone) on left ankle and foot, Type II Diabetes Mellitus (DM: [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a history of striking another resident and a staff person was monitored for agitation to prevent further aggressive behavior toward staff and residents. This deficient practice resulted in Resident 1 becoming agitated and then left alone to enter the facility's dining room where he hit a resident (Resident 2) in the face.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure the dietary manager had a current unexpired certificate that reflected the dietary manager (DM 1) possessed the education and experience to competently perform the responsibilities of a dietary manager. This failure had the potential to result in the an improperly managed food and nutrition services that can pose detriment to the residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Dietary Aide 3 (DA3) demonstrated the correct calibration technique (process of validating the thermometer was working properly) in accordance with its policy and procedure on How to Calibrate a Thermometer. This deficiency had the potential to result in food being held at unsafe temperature levels, thus potentially compromising food safety and contaminating foods that facility residents consume.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to follow the facility's policy regarding storing food brought in by visitors to ensure three (3) of 3 residents' refrigerators (refrigerators in station 1, 2, and the yellow zone), used for storing residents' personal food from visitors, were safe and sanitary by ensuring: 1. Residents' Refrigerators were clean. 2. All items in the resident's refrigerator were labeled with date and residents name. 3. Temperature of the refrigerators were monitored on a daily basis and maintained at the recommended temperature range. 4. Any food items that have been stored for 7 days are discarded. 5. Foods were in a sealed container to prevent cross contamination. This deficient practice had the potential to result in contamination of residents' food items and food-borne illnesses (food poisoning). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care that maintained or enhanced a resident's dignity and respect in full recognition of resident's individuality for three (3) out of the 12 sampled residents (Resident 148, 196 and 93), by failing to: A. Ensure Resident 148's was attended to and not left in a wet and soiled diaper for a prolonged period. B. Ensure the Speech Therapist (ST) fed resident 196 at eye level. C. Ensure the Director of Staff Development (DSD) fed Resident 93 at eye level. These deficient practices had the potential to affect the residents' self-esteem and self-worth resulting in a decline in psychosocial well-being and a diminished quality of life. A. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of 29 sampled residents (Resident 82 and 69) had accurate assessments, by failing to: A. Ensure Resident 82's weight was not documented on the MDS when it was not obtained. B. Ensure Resident 69's upper extremities functional limitations were assessed and documented accurately on the MDS to reflect Resident 69's lack of functional limitations. This deficient practice had the potential to negatively affect Resident's 82 and 69 plans of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized plans of care with measurable objectives, timeframes, and interventions to meet the residents' needs for three (3) of 29 residents (Resident 94, 82, 7). The facility failed to ensure: A. Resident 94, who was assessed to have bilateral (both ears) hearing loss, had a careplan developed and implemented for hearling loss. B. Residents 82, who was at risk for significant weight loss, a care plan was implemented. C. Resident 7's careplan for mobility was properly implemented. These deficiencient practices had the potential to result in: A. Diminished quality of life due to ineffective communication interventions, for Resident 94. B. A risk for dehydration and further weight loss, for Resident 82. C. A higher risk for impaired mobility for Resident 7.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide services that met professional standards of care for two residents (Residents 63 and 27) when: A. Licensed Vocational Nurse (LVN) 2 did not clarify with the physician that Resident 63's bubble pack (medications dispensed organized and filled in a 28 to 31-day cycle allowing users to take each dose according to the calendar by punching out each bubble) count was not the same as the medication administration record (MAR) and physician orders. B. LVN 5 did not to alert Resident 27's physician when Resident 27's bubble pack and over-the counter (OTC) label were not the same as the MAR and physicians order. These deficient practices resulted in Resident 63 not receiving the correct form (e.g. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) out of 29 sampled residents (Resident 85) received treatment and care in accordance with the physician`s order by failing to: 1. Ensure per the physicians order for Resident 85 to wear a wander Guard (monitoring device such as a Wander guard bracelet may be used to help ensure safety) bracelet was monitored every shift. This deficient practice had the potential for Resident 85 to elope from the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 2 of 2 sampled residents (Resident 22 and 7) received the Restorative nursing assistant (RNA) services ordered by the physician. This deficient practice placed Resident 22 and 7 at risk for a decrease of physical function and at risk for contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow it's diet menu instructions for the mechanical soft texture (a diet that involved only foods that were physically soft, with the goal of reducing or eliminating the need to chew the food) for one of one resident reviewed for meal service (Resident 65) by not ensuring the parsley sprig was in a proper mechanical soft form. This deficiency inadvertently put Resident 65 at high risk for aspiration (condition in which food, liquids, saliva, or vomit is breathed into the airways)and could have further compromised Resident 65's medical status.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store and prepare food under sanitary conditions in one (1) of 1 kitchen, by failing to: A. Ensure six (6) of 6 residents (Residents 32, 94, 196, 12, 75, and 31) who were served and ate over-easy eggs (egg gets fried on both sides, but it's not cooked for very long on the second side, so the yolk remains runny and uncooked) were cooked from pasteurized eggs (eggs that have gone through pasteurization, a process that kills germs in foods and drinks) and that all eggs served were cooked to a minimum of 145 degrees Fahrenheit (temperature scale) for at least 15 seconds. B. Ensure 1 of 1 ice machine was clean. C. Ensure 1 of 1 dietary staff did not enter the kitchen with personal belongings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were maintained as evidence by: a. Licensed Vocational Nurse (LVN) 1 failed to don (put on) complete personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) and perform hand-hygiene prior to entering a transmission-based precaution room ([TBP] additional measures focused on the particular mode of transmission used in addition to standard precautions) room. b. Certified Nursing Assistant (CNA) 2 failed to perform hand-hygiene in between assisting multiple residents in the dining room. c. [...]

Inspectors wroteBased on interview and record review, the facility failed to update the inventory list for one of one sampled resident (Resident 33). This deficient practice resulted in the loss of Resident 33's important papers and prescription glasses with the potential for misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of 29 sampled resident (Resident 82) had an accurate weight loss assessment for 3 months. This deficient practice had the potential to result in the Resident not receiving proper nutrition and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 3 sampled residents (Resident 148) was provided dependent care and services to maintain personal hygiene. This deficient practice resulted in Resident 148 being left unattended in bed with wet and soiled adult briefs for a prolonged period of time.

Inspectors wroteBased on observation, interview, and record review, the facility's staff failed to ensure a resident received the proper assistive devices to maintain hearing abilities by not assisting in arranging for an audiologist referral consultation for one of 6 sampled residents (Resident 94). This deficient practice resulted in a delay of services and Resident 94 not being able to hear adequately during a conversation.

Inspectors wroteBased on observation, interview and record review, the facility failed to label one bottle of multi-dose ophthalmic medication (eye drops) for Resident 17. This deficient practice increased the risk that Resident 17 could have received medication that had become ineffective due to failure to label open date, possibly leading to health complications.