North Valley Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to remain free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1), when on 5/22/2026, Resident 2 punched Resident 1 in the face and body several times with a closed fists (a person's hands with the fingers bent inward toward the palms and held tightly closed). This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care and supervision of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate measurement and documentation of a skin tear (a wound that happens when the layers of skin separate or peel back) in accordance with professional standards of practice and the facility's policy and procedure (P&P) for one of four sampled residents (Resident 1). This deficient practice had the potential to adversely affect wound assessment, monitoring, treatment planning, and the delivery of care and services necessary for wound healing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the ice machine bin was kept clean. 2. Ensure drinks were maintained below 41 degrees Fahrenheit ( F- unit for temperature). These failures had the potential to result in foodborne illness (illness caused by eating or drinking contaminated foods or beverages) for 84 of 87 residents who receive water and drinks from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a resident to signal his or her need for assistance from staff) was within reach for one of one sampled resident (Resident 97). This deficient practice had the potential to result in Resident 97 not being able to call for facility staff assistance and delay in the provision of necessary care and services which could negatively affect the residents' comfort and well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide two of two sampled residents (Resident 22 and Resident 54) quarterly financial statements. This failure had the potential to result in mismanagement of the residents' funds and to prevent the residents from making informed financial decisions regarding their finances.

Inspectors wroteBased on interview and record review, the facility failed to provide two of two sampled residents (Resident 22 and Resident 54) receiving Medicaid (a joint federal and state program that provides free or low-cost health coverage to people with limited income and resources) benefits notification when the amount in the resident's account reached $200 less than the resource limit for one person, specified in section 1611(a)(3)(B) of the Act. This failure had the potential to result in the residents losing Medicaid eligibility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) addressing the use of an arm splint (medical device that stabilizes a part of your body and holds it in place) for one of 18 sampled residents (Resident 7). This deficient practice had the potential to negatively affect the delivery of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident unable to carry out activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) received the necessary services to maintain neatly trimmed fingernails and toenails for one of two sampled residents (Resident 25). This deficient practice had the potential to negatively affect Resident 25's dignity.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to follow up on a reoccurring right big toe ingrown nail after a 30-day treatment from 4/2/26/ to 5/2/26 when on 5/18/26 the resident had an ingrown again on the same toenail without orders to treat for one of two sampled resident (Resident 25) investigated under non-pressure skin conditions. This deficient practice placed Resident 25, who has a diagnosis of type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), at risk for infection and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries/ulcers (PI/PU, injuries to the skin and underlying tissue resulting from prolonged pressure) by failing to ensure the low air loss mattress (LALM, a mattress designed to prevent and treat PIs) was on for one of four sampled residents (Resident 1). This deficient practice had the potential for the worsening of, or development of new PI/PUs to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) that includes and supports dementia care needs for one of three sampled residents (Resident 7) with dementia. This deficient practice had the potential to negatively affect the delivery of services to residents living with dementia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control measures by failing to ensure Certified Nursing Assistant 1 (CNA 1) did not place her personal bag on a chair inside the resident's room for one of three sampled residents (Resident 48). This deficient practice placed Resident 48 at risk for exposure and possibly contracting infectious microorganisms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect, promote, and honor one of three sampled residents (Resident 23) right of not receiving cardiopulmonary resuscitation (CPR - emergency measures including manual chest compressions and rescue breaths to revive a person when breathing or heartbeat has stopped) measures as indicated in the Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for end-of life decisions communicated by a resident able to make informed decisions and if unable, by the resident's representative), dated [DATE]. Resident 23's POLST indicated Do Not Resuscitate (DNR- a medical order written by a doctor to instruct health care providers not to do CPR) instructing staff not to do CPR. The facility failed to ensure: 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure to provide the name of the medication and its indication (reason for the use of the medication) prior to administration of the medication, affecting one (1) of five (5) residents observed for medication administration (Resident 3). This deficient practice violated Resident 3's rights to make decisions regarding their medication regimen, withhold treatment or seek alternatives, potentially resulting in psychosocial harm.

Inspectors wroteBased on interview and record review the facility failed to: 1. Include the witness signatures on the Medication Disposition Record/Pass Log for seven (7) non-CMs disposed on 2/14/2025, 13 on 2/28/2025, and eight (8) on 3/23/2025. 2. Account for one (1) dose of Controlled Substances (also known as Controlled Drug and Controlled Medications [CS, CD, CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 21, in one (1) of two (2) inspected medication carts (Medication Cart Station 1 Cart 1.) 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 28 total opportunities contributed to an overall medication error rate of 10.72% affecting two (2) of five (5) residents observed for medication administration (Resident 45 and 48.) The medication errors were as follows: 1. Resident 45 did not receive a form of vitamin B complex (a supplement containing several B vitamins used in production of red blood cells) as ordered by Resident 45's physician. 2. Resident 48 received docusate (docusate (a medication used for bowel [intestine] management,) and cyanocobalamin (a medication used to treat low levels of vitamin B12), at a different time than ordered by Resident 48's physician. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label one open insulin (medication used to regulate blood sugar levels) Humulin N (intermediate-acting insulin) Kwikpen (a type of device containing insulin) stored at room temperature for Resident 70, in accordance with manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart Station 1 Cart 1.) This deficient practice increased the risk that Resident 70 could receive medication that had become ineffective or toxic due to inadequate storage, and labeling, experience medication adverse consequences (unwanted, uncomfortable, or dangerous effects that a medication may have) resulting in the negative impact to residents' health and well-being possibly leading to health complications, hospitalization, or death.

Inspectors wroteBased on interview and record review, the facility failed to keep a copy of a resident's Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) in the medical record for one (Resident 21) out of 6 sampled residents reviewed under Advance Directive. This deficient practice had the potential to create confusion, which could lead to conflict with the resident's wishes regarding his/her health care.

Inspectors wroteBased on interview and record review, the facility failed to update a resident's care plan (a comprehensive document that outlines a patient's healthcare needs, goals, and interventions) to reflect his current nutrition status for one (Resident 2) out of two sampled residents investigated for tube feeding (a method of providing nutrition to individuals who are unable or unwilling to eat or drink adequately). This deficient practice had the potential to result in the resident receiving incorrect care from providers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) was set according to the resident's weight for one of three sampled residents (Resident 21) reviewed under the pressure ulcer/injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care area. This deficient practice had the potential to place Resident 21 at risk for discomfort and increase the resident's risk for the development of pressure injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses attempted nonpharmacological interventions (treatments or strategies that do not involve the use of medications) prior to administering as needed (PRN) hydrocodone-acetaminophen (medication used to treat severe pain) for one (Resident 18) out of four sampled residents reviewed for pain management. This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects such as drowsiness, constipation, and decrease in respiration.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of two sampled residents (Resident 27) investigated under dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) received services consistent with professional standards of practice by failing to ensure the pre-dialysis assessment was communicated to Resident 27's dialysis center on 3/7/2025. This deficient practice placed the resident at risk for developing complications such as bleeding at the dialysis access site, high or low blood pressure, and delays in care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of 22 sampled residents (Resident 64) had accurately documented medical records when the resident's code status (a patient's documented wishes regarding the level of medical intervention to be provided in a medical emergency, specifically if their heart or breathing stops) indicated in Resident 64's Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), dated [DATE] and signed by the physician on [DATE] was not accurately reflected in the admission Record and Interdisciplinary Care Conference meeting notes, dated [DATE]. This deficient practice placed the resident at risk for not having her wish to allow for a natural death honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 36 of 38 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, and 40) met the square footage requirement of 80 square feet (sq. ft. - unit of measurement) per resident in multiple resident rooms. The room size for these rooms had the potential to have inadequate space for resident care and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with a safe, clean, comfortable, and homelike environment for five of six sampled residents (Resident 2, 3, 4, 5, and 6) by failing to provide a clean bathroom. The deficient practice violated the residents' right to a comfortable, homelike environment and had the potential to negatively impact the quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices by failing to ensure a shared bathroom for five of six sampled residents (Resident 2, 3, 4, 5, and 6) was not soiled with dried up feces (stool) on the bathroom floor and toilet bowl. This deficient practice had the potential to result in the spread of infection placing residents, staff, and visitors at risk to be infected with germs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the facility use no more than two layers of linen when use a low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure injuries [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) for one of two sampled residents (Resident 1). This deficient practice had the potential to impede wound healing process and cause further skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1), who's toenails were long, thick, and curved, received foot care and treatment. This deficient practice had the potential to result in complications such as an infection or injury to the resident and had the potential to result in a negative impact on the resident's self- esteem.

Inspectors wroteBased on interview and record review, the facility failed to arrange timely a nephrology (branch of medicine concerned with the kidneys) consult for one of six sampled residents (Resident 1) when on 8/10/2023, the facility admitted Resident 1 with a follow up order for a nephrology appointment in one week, however, the facility did not arrange the follow up appointment until 9/21/2023. This deficient practice had the potential to result in a delay of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Physician Progress Notes (record that documents the physician's role in the assessment, evaluation, and care of residents) were completed as required, for one of six sampled residents (Resident 1). This deficient practice had the potential for inconsistent care coordination due to incomplete records and placed Resident 1 at risk for poor continuity of care and care needs.

Inspectors wroteBased on interview and record review, the facility failed to provide timely radiology ( a branch of medicine that uses imaging technology to diagnose and treat disease) service for one of six sampled residents (Resident 1) when on 9/27/2023, Resident 1's physician ordered for a magnetic resonance imaging (MRI - a noninvasive medical imaging test that produces detailed images of the internal structure of the body) for lumbar (lower part of the back) and thoracic (middle portion of the spine) compression fracture (break in a bone caused by pressure and in which the bone collapses) however, the facility did not arrange the MRI until 10/10/2023. This deficient practice had the potential to result in an undiagnosed problem which could have placed Resident 1 at higher risk for a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to permit one of six sampled residents (Resident 1) to return to the facility after hospitalization. Resident 1 was permitted to the facility on 5/24/2024. This deficient practice subjected Resident 1 to an unnecessary prolonged hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure resident's personal belongings were returned to the resident's representative for one of three sampled residents (Resident 1). This deficient practice resulted in the violation of Resident 1's representative's right by not receiving Resident 1's belongings upon Resident 1's discharge.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 1), who was identified to have an indwelling catheter (a flexible plastic or rubber tube that is inserted into the bladder to drain the urine). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.

Inspectors wroteBased on interview and record review the facility to ensure one of three sampled residents (Resident 1) received care and services in accordance with professional standards of practice by failing to: 1. Administer Resident 1's Acetaminophen (a medication used to relieve mild to moderate pain) as prescribed by the Attending Physician when resident reported a ten out of ten pain on 12/28/2022. 2. Ensure a pain risk assessment was completed when a new onset of pain was identified on 12/28/2022 and quarterly as per facility policy. These deficient practices resulted in Resident 1 experiencing severe untreated pain (pain rated at ten out of ten, on a pain scale from zero to ten, where ten is the worst possible pain) on 12/28/2022 and placed Resident 1 at risk for further pain and suffering.

Inspectors wroteBased on interview and record review, the facility failed to implement their facility's medication administration policy by failing to ensure a licensed nurse signed the Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) after administering Albuterol Sulfate (a medication used to treat wheezing [a high pitched or coarse whistling sound heard when one breathes] and shortness of breath (SOB) caused by breathing problems) to one of three sampled residents (Resident 1) on 3/7/2023. This deficient practice had the potential to result in medication errors and had the potential to result in confusion on the delivery of care and services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that orientation was provide to hospice (a type of medical care for residents who are in the last stages of life) staff as per facility for two of two sampled residents (Resident 1 and Resident 2) as per facility policy. This deficient practice had the potential to delay coordination and delivery of hospice services.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure licensed nurses signed one of six sampled resident's (Resident 49) Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) for 3/2024 after administering Hydrocodone-Acetaminophen (Norco- medication that treats pain) and Alprazolam (medication to treat anxiety [feeling of uneasiness]) to the resident. 2. Ensure licensed nurses signed one of six sampled resident's (Resident 65) MAR for 3/2024 after administering Lorazepam (medication for anxiety) 0.5 mg to the resident. 3. Ensure licensed nurses signed one of six sampled resident's (Resident 139) MAR for 3/2024 after administering zolpidem tartrate (a medication given to treat insomnia) 10 mg to the resident. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) was acted upon for two of five sampled residents (Resident 51 and 12 by failing to: 1. Ensure the pharmacist recommendation on 9/26/2023 to verify duration of therapy of Lovenox (anticoagulant medication [blood thinner]) and consider oral replacement was discussed with the provider and provide a rationale why Lovenox was only discontinued on 12/19/2024 for Resident 51. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor a resident's behaviors for all nursing shifts, who was prescribed an antipsychotic medication (medications used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) for one of five sampled residents (Resident 46) investigated for unnecessary medications. This deficient practice had the potential to result in adverse reaction (undesired harmful effect resulting from a medication or other intervention) or impairment in the resident's mental or physical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices by failing to: 1. Ensure three packs of frozen sliced ham and four packs of frozen ribs observed in the facility freezer were labeled with a received date (the date a food is first delivered to the facility). 2. Ensure newly delivered was not stored directly on the facility floor. These deficient practices had the potential to place 80 of 84 residents that receive food from the facility's kitchen, at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks). 3. Ensure leftover food brought from outside was stored in the refrigerator or discarded for one of one sampled resident (Resident 12). [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents' (Resident 70) personal belongings upon the resident's discharge to the General Acute Care Hospital (GACH) This deficient practice resulted in the loss of Resident 70's pants, shirts, socks, and phone charger without reimbursement from the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 71) and/or responsible party (RP) the right to be informed of in advance of the risks and benefits of a psychoactive medication (medications capable of affecting the mind, emotions, and behavior), Depakote (mood stabilizer medication), when the medication order was documented incorrectly on informed consent forms. This failure resulted in a violation of Resident 71's and their responsible party's right to make an informed decision regarding the use of a psychoactive medication.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan (a written document that summarizes a patient's needs, goals, and care) within 48 hours of admission for one of one sampled resident (Resident 82) investigated under anticoagulant (medication that stops your blood from clotting too easily) use. This deficient practice had the potential to result in a negative impact on residents' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a form where licensed nurses can summarize a person's health conditions, specific care needs, and current treatments) for one of four sampled residents (Resident 46) for a diagnosis of diabetes mellitus (DM, a chronic condition that affects the way the body processes blood glucose [sugar]). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 46.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that Medical Doctor 1 (MD 1) signed the physician orders for one of three sampled residents (Resident 71) during MD 1's visit to the facility. This deficient practice had the potential for confusion, poor continuity of care and follow-up on the resident's status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the control solution (a solution containing sugar that is used to checking that the glucometer [a blood glucose {blood sugar} monitoring machine] is working as intended) was labeled with an open date (when a nurse first opens the container and writes the date it is open to ensure it is removed from circulation in a timely manner) in one of three medication carts (Station 1 Medication Cart). This deficient practice had the potential to compromise the therapeutic effectiveness of the control solution and can lead to inaccurate glucometer readings.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete clinical records in accordance with accepted professional standards and practices for two of two sampled resident's (Resident 48 and Resident 71) Physician Documentation of Informed Consents (PDIC - informed consent) by failing to: 1. Ensure Resident 48's PDIC for Wellbutrin (medication used to treat depression) 100 milligrams (mg, a unit of measurement) was signed and dated. 2. Ensure Resident 71's PDIC for Depakote (mood stabilizer medication) 125 mg was dated by the physician who obtained the informed consent. This failure had the potential to result in confusion in the care and services for Resident 48 and Resident 71 and placed the residents at risk of receiving unwanted treatment and/or not receiving appropriate care based on their wishes due to incomplete resident medical care information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a resident's nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) oxygen tubing was not touching the floor for one of two sampled residents (Resident 82) investigated for infection control. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. 2. Based on observation, interview, and record review, the facility failed to maintain infection control practices by failing to ensure one of one sampled resident's (Resident 138) nasal cannula was labeled and dated. This deficient practice had the potential to cause contamination of the oxygen tubing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to fix one of one sampled resident's (Resident 28) call light (device used by residents that when pressed informs facility staff that assistance is being requested) after being told by Resident 28 that his light was not functioning. This deficient practice had the potential to cause a delay in resident care and for the residents' needs to remain unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure space requirements of 80 square feet for each resident were met in multiple resident bedrooms which had the potential to result in inadequate space to provide safe nursing care and privacy in 36 of 39 rooms (1, 2, 3, 4, 5, 6, 7, 8, 10, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40). The room size for these rooms had the potential to have inadequate space for resident care and mobility.

Inspectors wroteBased on interview and record review, the facility staff failed to assess and document the dialysis access sites accurately and completely for two of two sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in confusion regarding Resident 1 and Resident 2 ' s access site condition and in identifying the patency of the dialysis access site that could lead to a delay in receiving hemodialysis (HD or dialysis - a process of purifying the blood of a person whose kidneys are not working normally through a machine that removes blood from your body, filters it through a dialyzer [artificial kidney] and returns cleansed blood back to the body) treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who required hemodialysis (HD or dialysis - a process of purifying the blood of a person whose kidneys are not working normally through a machine that removes blood from your body, filters it through a dialyzer [artificial kidney] and returns cleansed blood back to the body) treatment, received care in accordance with standards of practice by failing to ensure Resident 1 ' s order for Vancomycin (a medication used to treat serious bacterial infections) intravenous (IV - a method of putting fluids, including drugs, into the bloodstream) therapy was transcribed (documented) in the resident ' s physician orders. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of three sampled residents (Resident 1), when the facility discharged Resident 1, who required continuous supplemental oxygen (therapy that helps people with lung disease or breathing problems get the oxygen [a colorless, odorless gas, an essential component of air] their bodies needs to function), to Family Member 1 ' s (FM 1) home on 9/6/2023 without durable medical equipment (DME- equipment and supplies ordered by healthcare provider for everyday use which include supplemental oxygen equipment [medical device that gives resident ' s extra oxygen]) in place. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and orderly discharge was provided to one of three sampled residents (Resident 1) who required the need for continuous supplemental oxygen (therapy that helps people with lung disease or breathing problems get the oxygen [a colorless, odorless gas, an essential component of air] their bodies need to function) by: 1. Failing to ensure that Resident 1 and Family Member 1 (FM 1) were provided durable medical equipment (DME- equipment and supplies ordered by healthcare provider for everyday use which includes supplemental oxygen equipment [medical device that gives resident ' s extra oxygen] and front wheel walker [FWW - a device that helps with walking and lowers the risk for falls]) prior to discharging resident home. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective discharge plan to meet the health and safety need was provided to one of three sampled residents (Resident 1) by: 1. Failing to ensure that Resident 1 and Family Member 1 (FM 1) were provided durable medical equipment (DME- equipment and supplies ordered by healthcare provider for everyday use which includes supplemental oxygen equipment [medical device that gives resident ' s extra oxygen] and front wheel walker [FWW - a device that helps with walking and lowers the risk for falls]) prior to discharging resident home. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for three of three sampled residents (Resident 1, Resident 2, and Resident 9). This deficient practice had the potential to result in a delay in or lack of delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop baseline care plans for one of three sampled residents (Resident 8) within 48 hours of admission. This deficient practice had the potential for the facility not to meet Resident 8 ' s immediate care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one of three sampled residents (Resident 2), with a peripherally inserted central catheter (PICC line-a long, flexible catheter [thin tube] that's put into a vein) was provided with a PICC line dressing change (a PICC line requires that the dressing be changed every seven (7) days or as needed due to the high risk of infection) on 9/1/2023 as ordered by the physician. This deficient practice placed Resident 2 at increased the risk for sepsis (the body's extreme response to an infection. Sepsis is a life-threatening medical emergency ) from a central line-associated bloodstream infection (CLABSI- a serious infection that occurs when germs [usually bacteria or viruses] enter the bloodstream through the central line).

Inspectors wroteBased on interview and record review, the facility failed to ensure that a residents' History and Physical (H&P) was documented and placed in one of three sampled resident ' s (Resident 8) medical record by the physician within the same day of his visit in which the assessment was completed as per facility policy. This deficient practice had the potential to result in a risk of poor continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 2), when Registered Nurse 1 (RN 1) falsely documented that he provided a peripherally inserted central catheter (PICC line-a long, flexible catheter [thin tube] that's put into a vein) dressing change (a PICC line requires that the dressing be changed every seven [7] days or as needed due to the high risk of infection) as ordered by the physician for one of three sampled residents (Resident 2) on 9/1/2023. This deficient practice had the potential to result in confusion regarding Resident 2 ' s condition and what care and services provided to Resident 2.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection prevention and control practices for one of three sampled residents (Resident 2) with a peripherally inserted central catheter (PICC line-long, flexible catheter (thin tube) that's put into a vein), when Registered Nurse 1 (RN 1) failed to provide Resident 2 with a PICC line dressing change (a PICC line requires that the dressing be changed every seven [7] days or as needed due to the high risk of infection) on 9/1/2023 as ordered by the physician. This deficient practice placed Resident 2 at increased the risk for sepsis (the body's extreme response to an infection. Sepsis is a life-threatening medical emergency ) from a central line-associated bloodstream infection (CLABSI- a serious infection that occurs when germs [usually bacteria or viruses] enter the bloodstream through the central line).