Northridge Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of five sampled residents (Resident 3). This deficient practice had the potential to delay the provision of services and Resident 3's needs not being met. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and maintain its infection control program for one out of five sampled residents (Resident 3) when Licensed Vocational Nurse 2 (LVN 2) did not wear the required personal protective equipment (PPE- special clothing or equipment that protects healthcare workers and patients from germs and infections) while Resident 3 was on novel respiratory transmission-based precautions (are enhanced infection control measures used when a patient is suspected or confirmed to have a new or emerging respiratory pathogen that spreads via airborne or droplet routes, in addition to Standard Precautions [are the minimum infection prevention practices applied to all patients to prevent the spread of infections in healthcare and other care settings]). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) was free from medications errors by failing to: 1. Ensure the scheduled 9 p.m. dose of atorvastatin calcium (a medication used to lower cholesterol) was administered as ordered or, if not administered, that the omission and reason were documented in the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). 2. Ensure that the licensed nurse who administered the resident's medications accurately documented the medication administration in the MAR. [...]

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/her need for assistance from staff) was within reach of a resident while the resident was in bed for one of three sampled residents (Resident 1). This deficient practice had the potential to delay the resident's ability to request assistance, which could result in delayed staff response, delayed provision of necessary care and services, and unmet resident needs. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to follow up with the physician after notification of a change of condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) when a resident had an abnormal laboratory result and failed to monitor the resident after a change of condition for one of five sampled residents (Resident 5). This deficient practice had the potential result to negatively affect the provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical record was accurately documented for one of five sampled residents (Resident 4), consistent with accepted standards of professional practice and the care and services provided. This deficient practice had the potential to adversely affect the resident's plan of care, and the delivery of necessary care and services. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a pest-free environment by not ensuring effective pest control in one of four sampled residents' rooms (Resident 3's room). This deficient practice placed the residents at risk for vector-borne diseases (illnesses caused by viruses or bacteria transmitted through the bites of infected living organisms, primarily blood-feeding insects). During a review of Resident 3's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated that the facility admitted Resident 3 on 5/13/2026 with diagnoses that included left total hip replacement, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). [...]

Inspectors wroteBased on interview and record review, the facility's licensed nurses failed to accurately complete Fall Risk Evaluation assessment for one of four sampled residents (Resident 1). This deficient practice had the potential to place the resident at increased risk for falls and fall-related injuries due to the failure to appropriately identify and evaluate fall risk factors. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide radiology (a branch of medicine that uses imaging technology to look inside the body) services in accordance with the physician's order for one of four sampled residents (Resident 2), following a fall incident. The facility failed to ensure timely completion of a radiology service to evaluate Resident 2's left foot, which was noted to have swelling and pain rated four (4) out of 10 (on a scale where zero indicates no pain and 10 indicates the worst pain imaginable). This deficient practice had the potential to result in a delay in diagnosis and treatment of the resident's condition. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective infection prevention and control program when Certified Nursing Assistant 1 (CNA 1) failed to report the presence of roaches observed in a resident's room for one of four sampled residents' rooms (Resident 3's room). This deficient practice had the potential to create unsanitary conditions and contribute to cross-contamination (the transfer of harmful germs from one surface, object, or food to another), placing residents, staff, and visitors at increased risk for infection. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure facility staff notified the resident representative after one of three sampled residents (Resident 1) had a change of condition after being found on the floor next to the bed with an injury. This deficient practice resulted in Resident 1's representative not being notified of Resident 1's change of condition and had the potential for of the resident representative to be unable to make informed decisions regarding Resident 1's treatment and plan of care.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) laboratory results were communicated with the physician in a timely manner. This deficient practice had the potential for Resident 1 to have a delay in care and services, increased risk for worsening infection and decrease in overall health status.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) had complete information documented on the change of condition form (COC-a form used by the facility document changes in resident's condition including actions taken and notification of the physician and responsible party) by failing to document Resident 1's physician's response to Resident 1's change of condition. This deficient practice had the potential to delay necessary treatment, care and services, placing Resident 1 at risk for a decline in overall health status.

Inspectors wroteBased on interview and record review the facility failed to accurately and safely provide pharmaceutical services to one of three sampled residents (Resident 1) by failing to: 1. Ensure licensed nurses sign/initial the form titled Controlled (medications which have a potential for abuse and may also lead to physical or psychological dependence) Drugs Count Record at the end of each shift to verify the count and accountability of controlled medications. 2. Ensure Licensed nurses documented the correct remaining amount of morphine sulfate in the form titled Controlled Drug Record for Liquid Only. 3. Ensure the date and time of administration of morphine sulfate was accurately documented in Resident 1's Antibiotic or Controlled Drug Record for Liquid Only and electronic medication administration record (eMAR). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the baseline care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of three sampled residents (Resident 1). These deficient practices had the potential to negatively affect the provision of care and services provided to Resident 1. Based on interview and record review, the facility failed to implement the baseline care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of three sampled residents (Resident 1). These deficient practices had the potential to negatively affect the provision of care and services provided to Resident 1.

Inspectors wroteBased on interviews and record reviews the facility failed to: 1. Complete a pain assessment upon admission when Resident 1 verbalize pain on 5/8/2026 at approximately 5:24 p.m. 2. Provide timely pain management interventions for Resident 1, including non-pharmacological and pharmacological interventions (administer pain medications, including available house stock acetaminophen and controlled medications [CM-medications which have a potential for abuse and ay also lead to physical or psychological dependence] accessible through the emergency kit [e-Kit] such as hydrocodone-acetaminophen [Norco]). 3. Document medication administration of Norco and morphine sulfate in the electronic medication administration record (eMAR). 4. Conduct and document pre-administration and post-administration pain assessments for Resident 1. [...]

Inspectors wroteBased on interview and record review the facility failed to implement its policy and procedure titled, Physician's Untimely Visit, for one of three sampled residents (Resident 1) when Resident 1's physician did not conduct the initial comprehensive visit within 72 hours of admission. This failure had the potential for the physician to miss identifying and addressing Resident 1's early care needs, including pain management.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1) by failing to complete Resident 1's Clinical admission Record and admission Notes. This failure had the potential to delay identification of Resident 1's needs and impact timely care planning.

Inspectors wroteBased on interview and record review the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) received treatment and care in accordance with professional standards of practice by:1. Failing to ensure Resident 1 received Methadone (a medication used to treat severe pain), as ordered by the physician on 4/27/2026. 2. Failing to ensure Resident 2 received Apixaban (a medication used to assist with preventing a stroke [blood flow to part of the brain is blocked]), Losartan Potassium (a medication used to treat high blood pressure), Famotidine (a medication used to decrease the amount of stomach acid produced in the body) and Modafinil (a medication used to treat excessive sleepiness), as ordered by the physician on 4/22/2026 and 4/27/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff monitored and documented intake (food and fluid consumption) and output (urine and stool amounts) in accordance with professional standards of practice and per the facility's policy and procedure (P&P) for one of six sampled resident (Resident 1), who had fluid restrictions. This deficient practice had the potential to result in unrecognized hydration needs and hypervolemia (fluid overload).

Inspectors wroteBased on interview and record review, the facility failed to accurately assess and document a resident's fall risk assessment for two out of six sampled residents (Resident 1 and 2) by failing to: 1. Ensure Resident 1's Fall Risk Evaluation was completed thoroughly and accurately. 2. Ensure Resident 2's systolic blood pressure (SBP - the first number in a blood pressure reading, which measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) was completed lying and standing when performing Resident 2's Fall Risk Evaluation. These deficient practices had the potential to place the residents at risk of injury from falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician telephone order indicated a signature and title of the licensed nurse who transcribed the information and failed to ensure a physician countersigned the telephone order per the facility's policy and procedure (P&P) for one of six sampled residents (Resident 1). This deficient practice had the potential to result in failure to deliver the necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Notify residents of the location of results of the most recent survey (means the Statement of Deficiencies [Form CMS-2567] generated by the most recent standard survey for four (Resident 7, Resident 71, Resident 75, and Resident 81) of six sampled residents who attended the resident council meeting. 2. Post the results of the most recent standard survey of the facility. These deficient practices had the potential for residents and family members to not know how the facility is performing regarding resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (meal tickets) containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were not shredded prior to disposing in the waste container. This failure had the potential to violate 84 of 90 residents' rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure that dependent residents received necessary services for activities of daily living (ADL) when the facility failed to provide five of nine showers scheduled from 12/31/2025 to 1/28/2026 for one of three sampled residents (Resident 32). This deficient practice had the potential to negatively affect Resident 32's personal hygiene and compromise resident's dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for three of three (Resident 101, Resident 88, Resident 65) residents investigated for antibiotic use by failing to: 1. Remove an intravenous (IV, into or within a vein) saline lock catheter (a small, flexible hollow tube inserted into a vein used to provide fluids and medication into a resident's vein) for Resident 101 after an IV medication therapy was completed. 2. Label the IV insertion site dressing per facility protocol for Resident 88. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two of two sampled residents (Resident 5 and Resident 77) reviewed under the respiratory care area, with necessary respiratory care services consistent with professional standards of practice by failing to: 1. Ensure there was a physician's order to administer continuous oxygen therapy to Resident 5. This deficient practice had the potential to place Resident 5, who required continuous oxygen therapy, at risk for respiratory distress. 2. Ensure Resident 77, who had an order for continuous oxygen therapy, was wearing his oxygen nasal cannula (NC - a device that delivers supplemental oxygen directly into the nostrils) at all times. This deficient practice had the potential to place Resident 77 at risk for respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when: 1. Cooks could not verbalize time and temperature monitoring for thawing foods in the preparation sink. 2. Staff could not verbalize and demonstrate how to check the chlorine concentration following manufacturer's guidelines. These failures had potential to result in harmful bacterial growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food and drinks that are contaminated with germs or chemicals) in 84 of 90 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved appearance, flavor and temperature when: 1. The temperature of the milk measured 42 degrees Fahrenheit ( F, degree of temperature), the juice measured 61 F and the triple fruit crisp measured 98 F. 2. Herb crusted beef roasts were dry. These failures had potential to result in 84 of 90 facility residents including (Resident 13) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. One (1) of three (3) racks in the dry storage area were corroded and rusted.2. There was elbow macaroni, split peas particles on the dry storage room floors. 3. Kitchen equipment and utensils were not free from dirt, dust and food debris. a. Sticker residues on 13 food storage bins in the dry storage area. b. Nine (9) of 9 carts had old tape and sticker residues. c. Drying racks were dusty and dirty when touched. d. Vents by the dishwashing area had dust accumulation and buildup. e. Coffee spout had dirt buildup f. Condiment containers had sugar, salt, pepper and sweetener particles and debris. 4. Seven (7) of 7 dented cans were stored with non-dented cans. 5. Fifty-seven (57) of 57 trays had cracks and lost their glaze. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to enforce its policy of storing brought in by family or visitors in a way to ensure safety and sanitary storage of food when one (1) of 1 sampled resident (Resident 95) brought unpasteurized egg (raw shell eggs that have not undergone heat treatment to destroy potential pathogens like salmonella [a type of bacteria that causes gastrointestinal infections in humans]) and cooked it in the microwave without the staff knowledge. This failure had the potential to result in consumption of undercooked food and food borne illness (a disease caused by consuming food and drinks that are contaminated by germs or chemicals) from salmonella to Resident 95.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Maintain medical records that are complete and accurately documented by facility staff documenting that the peripherally inserted central catheter (PICC - flexible tubing inserted into a large vein near the heart for long term intravenous IV medication) line dressing and bio patch (a small, sterile, antiseptic-coated [kills/stops bacteria growth] foam dressing) were changed on 1/13/2026 and 1/20/2026 when the actual dressing indicated it was last changed on 1/10/2026 for one of three residents (Resident 65) investigated under antibiotic use. This deficient practice resulted in inaccurate documentation in Resident 65's medical record and the potential for infection/irritation at the PICC line site. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control standards when: A medication tube was brought into a resident's room, medication was applied, and the medication tube was placed back into the medication cart without cleaning it for one out of five sampled residents observed during medication administration This deficient practice increased the risk of transmission of infectious microorganisms to other residents in the facility. Resident's Oxygen (O2) nasal cannula (NC - a device that delivers supplemental oxygen directly into the nostrils) was found touching the floor for one of two sampled residents (Resident 77) reviewed under respiratory care area. This deficient practice had the potential for contamination of the resident's care equipment, increasing the risk of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care was provided in a manner that promoted resident dignity and respect for two of three residents (Resident 9 and Resident 77) when: 1. Resident 9, who had a documented preference to wear her own clothing, was observed dressed in a hospital gown (loose fitting garment worn by patients for examination, procedures or while staying in the hospital). 2. Resident 77 was observed wearing only an incontinent brief (adult diaper), leaving the resident exposed. These deficient practices had the potential to negatively affect residents' self-esteem and sense of self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a comfortable environment to one of two sampled residents (Resident 44) reviewed under the environment task by failing to ensure the button of Resident 44's call was not broken. This deficient practice has the potential to cause discomfort to Resident 44's thumb when using the call light to request for assistance.

Inspectors wroteBased on interview and record review, the facility failed to submit a new level 1 Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) when a resident was diagnosed with a serious mental illness diagnoses of bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs) on 12/2/2025 for one of one sampled resident (Resident 44) investigated under the PASARR care area. This deficient practice had the potential to result in Resident 44 not receiving specialized services required by the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 22 sampled residents (Residents 2 and 95) had a comprehensive person-centered care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) when: 1. For Resident 2, the black box warning (the strongest safety alert for prescription drugs) for the resident's prescribed hydrocodone-acetaminophen (an opioid medication used to treat pain) was not included in the resident's care plan. This deficient practice had the potential to increase Resident 2's risk of experiencing adverse effects (harmful, undesired reactions) from the prescribed hydrocodone-acetaminophen. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-centered Care Plan after a fall incident for one of six residents (Resident 66) investigated under the care area of accident. This deficient practice had the potential to result in Resident 66 not receiving the necessary care and services to prevent recurrence of falls.

Inspectors wroteBased on interview, and record review, the facility failed to ensure there was a clear antibiotic treatment plan affecting one of three residents (Resident 88) for antibiotic use, by failing to clarify the resident's antibiotic therapy with the physician to determine whether the order needed to be updated. As a result, there was a lack of clear direction regarding two (2) doses of Resident 88's originally prescribed 20-dose Zosyn (a broad-spectrum antibiotic used to treat pneumonia [a lung infection]) regimen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that is free from accident hazards for two of six sampled residents (Resident 3 and Resident 66) reviewed under the accidents care area by failing to: 1. Ensure Resident 3, who has a seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) has padded side rails (adjustable rigid plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) as indicated in the resident's care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals). This deficient practice placed Resident 3 at an increased risk of injury. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 3) received appropriate treatment and services to prevent a urinary tract infection (UTI- an infection in the bladder/urinary tract) when the resident's indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing had a u-shaped dependent loop causing urine to collect and back up the tubing. This deficient practice placed Resident 3 at an increased risk of developing a UTI.

Inspectors wroteBased on interview and record review, the facility failed to ensure a blood pressure medication was held when a resident's systolic blood pressure (SBP-the force of blood against artery walls when the heart beats, representing the top number in a blood pressure reading) was below 110 millimeters of mercury (mmHg- a special unit that measures pressure shows how high a column of mercury rises) for one of three residents (Resident 4) reviewed for Closed Record. This deficient practice had the potential to cause complications such as hypotension (low blood pressure) that could require hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was properly stored when one of two inspected medication carts (Medication Cart 1) had unlabeled, unpackaged tablets in the bottom of a cart drawer. This deficient practice placed residents at risk of receiving an incorrect or expired medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when a fruit fly (a type of insect) was observed in the residents' dry food storage. This failure had the potential to result in 84 of 90 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. - unit of measurement) per resident in multiple resident bedrooms for 27 out of 42 resident rooms (Rooms 4, 6, 8, 10, 12, 14 a. b., 14 c. d., 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, 29, 31, 32, 35, 37, 39, 41 and 42). Rooms 4, 6, 8, 10, 12, 14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 29, 31, 32, 35, 37, 39, 41 and 42 all have two beds in each room. rooms [ROOM NUMBERS] had 4 beds in each room. This deficient practice had the potential to result in inadequate usable living space for all the residents and inadequate working space for the health caregivers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with a proper functioning bed pad alarm (an alerting device intended to monitor a resident's movement) as ordered by the physician. This deficient practice had the potential to place Resident 1 at an increased risk for further falls, accidents, and injuries.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a thorough Trauma (refers to an emotional, psychological, or physical response to a deeply distressing or disturbing event that overwhelms a resident ' s ability to cope) Care Evaluation was completed for one of four sampled residents (Resident 1). 2. Develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) that addressed past trauma and triggers (something that reminds you of a past traumatic experience and causes a strong emotional reaction, like experiencing the trauma again) for one of four sampled residents (Resident 1). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide privacy to four of seven residents (Resident 54, 35, 58 and 3) observed during medication administration. This deficient practice violated the resident`s right to be treated with dignity and respect which could affect the residents' sense of self-worth and sense of well-being.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Revise the comprehensive person-centered care plan (a care plan is a form where you can summarize a person's health conditions, specific care needs, and current treatments) addressing the residents activity needs for two of three (Resident 15 and 69) residents investigated under the activity care area. This deficient practice had the potential for the residents to not receive the necessary care and services related to their activity needs. 2. Revise the comprehensive person-centered care plan addressing nutritional needs of one of three (Resident 25) residents investigated under the nutrition care area. This deficient practice had the potential for Resident 25 to not receive the necessary care and services related to his nutritional needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Ensure a multi-dose vial (contain more than one dose of medication) of Aplisol (used in a skin test to help diagnose tuberculosis [TB, a contagious bacterial infection that can affect the lungs and other parts of the body)] infection) found in one of three medication rooms (Medication Room A), was labeled with an open date. This deficient practice increased the risk that residents could have received the medication that had become ineffective or toxic and result in health complications and inaccurate test results. b. Ensure one unopened insulin (a medication to treat diabetes mellitus [a chronic condition that affects the way the body processes blood sugar]) pen (an injection device with a needle that delivers insulin) was not stored in Medication Cart 2 for one of one sampled resident (Resident 8). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control guidelines when Registered Nurse 1 (RN 1) was observed leaving a resident's room during a medication pass observation while still wearing an isolation gown and gloves for one (Resident 295) of nine residents who were on enhanced barrier precautions (EBP-a method of using personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments] to reduce the spread of pathogens between residents in skilled nursing facilities). This deficient practice had the potential to increase the risk of spreading infection to other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's Quarterly Minimum Data Set (MDS - a standardized assessment and care screening tool) was completed timely for one (Resident 37) out of 1 sampled resident. This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 37.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of four sampled resident (Resident 58) investigated under accidents. This deficient practice had the potential for Resident 58 to not receive the necessary care and services to prevent potential injury caused by the use of bed rails (adjustable metal or rigid plastic bars that attach to the bed that are available in a variety of types, shapes, and sizes)

Inspectors wroteBased on observations, interview, and record review the facility failed to provide appropriate and consistent activities for one of 21 sampled residents (Resident 52). This deficient practice had the potential to negatively affect Resident 52's physical, cognitive, sense of belonging, and emotional health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards for one of eight sampled residents (Resident 50) reviewed under the accidents care area by failing to ensure Resident 50 did not store medications at bedside readily accessible to other residents. This deficient practice had the potential to result in residents obtaining medication without staff knowledge resulting in accidental ingestion causing harm to residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (EF, also known as tube feeding, a method of supplying nutrients directly in to the gastrointestinal [the body's system for processing liquids and foods] tract) received appropriate care and services to prevent complications of enteral feeding for one out of three sampled residents (Resident 47) by failing to cover the enteral feeding tube with a cap after disconnecting the tubing from Resident 47 once the enteral feeding had been completed. The deficient practice had the potential to contaminate the enteral feeding system and placed the resident at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label the insertion site (areas where intravenous [IV, into or within a vein] lines are placed such as the forearm) of the intravenous catheter (a device used to provide medications) dressing per facility protocol to one out of three sampled residents (Resident 13) who had an IV access. This deficient practice has the potential to fail to identify the signs and symptoms of intravenous site insertion complications such as swelling and redness in the insertion site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was assessed for risk of entrapment from the use of bed side rails (adjustable metal or rigid plastic bars that attach to the bed) as indicated in the facility's policy and procedure for one of one sampled residents (Resident 58). This deficient practice had the potential for inappropriate use of bed rails that could lead to entrapment and result to injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure leftover food brought from outside by resident`s family and visitors was labeled with resident identifier and use by date for one of one (Resident 141) sampled resident. This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) among the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square (sq.) feet (ft.) per resident in 27 of 43 resident rooms (Rooms 4, 6, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, 29, 31, 33, 35, 37, 39, 41, and 42). 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 failed to follow their policy and procedure regarding Weight Change by failing to ensure a resident's physician's progress note addressed a resident's weight loss for one (1) of three (3) sampled residents (Resident 1). This deficient practice had the potential to lead to a delay or lack of delivery of care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide pain medication as ordered by the physician and follow the physician's order for pain medication parameters for one (1) of three (3) sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1's pain not being managed properly and potentially cause the resident to experience prolonged discomfort and pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's Quarterly Minimum Data Set (MDS - a resident assessment tool) assessment accurately reflected a resident's status for one (1) of three (3) sampled residents (Resident 1). This deficient practice had the potential to lead to a delay or lack of delivery of care and services for Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care consistent with the professional standards of practice to help prevent pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three sampled residents (Resident 1) by failing to ensure Resident 1's bilateral (both) heel protectors (device that can help prevent and treat heel pressure ulcer) were place on the resident's heels as ordered by the physician. This deficient practice had the potential for development and worsening of Resident 1's pressure ulcer.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure on Medication Ordering and Receiving from Pharmacy by failing to reorder and refill one of three sampled residents (Resident 1) Alprazolam (a medication used to treat anxiety disorder [a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness]) timely (five days in advance of anticipated need). This deficient practice resulted in delay in the delivery of medication for Resident 1's and may result to Resident 1 having anxiety attacks.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior by one resident towards another) for one of six sampled residents (Resident 1) on 6/19/2024, when Resident 2 struck Resident 1 in the face with his closed fist. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility and had the potential to cause emotional harm which could result to a feeling of embarrassment, low self-esteem, and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to implement its infection control policy and procedures for Isolation (separation of an infected resident from the healthy resident until the infected resident is no longer able to transmit the disease)- Initiating Transmission-Based Precautions (TBP- used to prevent infection transmission) for one of six sampled residents (Resident 5), when on 3/1/2024 upon re-admission of Resident 5, who was positive for Clostridium Difficile (also known as C. Diff, a germ [bacteria] that causes diarrhea [a condition in which feces are discharged from the bowels frequently and in a liquid form] and colitis [an inflammation of the colon]), was cohorted (place infected residents with the same organism in the same room) with Resident 6 who was not on Isolation-TBP and did not have a diagnosis of Clostridium Difficile. [...]

Inspectors wroteBased on interview and record reviewed, the facility failed to implement its policy titled Tuberculosis [TB- a potentially serious infectious bacterial disease that mainly affects the lungs] Infection Control Program by failing to conduct an annual TB Risk Assessment (TBRA- assessment that identifies and evaluates the risk of transmission of TB within the facility) as indicated. This deficient practice had the potential to place the residents at risk for tuberculosis.

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders to hold anti-hypertensive medication (a type of drug used to treat high blood pressure) if pulse rate (PR- a measurement of the heart rate, or the number of times the heart beats per minute) was lower than 60 beats per minutes (bpm - unit of measure) for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for side effects including very slow heartbeats and lightheaded feeling.

Inspectors wroteBased on interview and record review, the facility failed to provide a treatment plan to manage hypoglycemia (a condition in which the body's blood sugar level goes below the standard range; severe cases may trigger a loss of consciousness or seizures [a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness]) for Resident 1 who was receiving insulin (to lower the level of sugar in the blood) for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for delayed interventions of hypoglycemia.

Inspectors wroteBased on interview and record review, the facility failed to document blood sugar (BS - body's primary source of energy) level accurately for one of three sampled residents (Resident 1). On 3/9/2024 at 12:30 p.m., Resident 1's blood sugar level was documented as 1796 milligrams per deciliters (mg/dL- unit of measure) and on 3/11/2024 at 9:00 p.m. Resident 1's BS was documented as 27 mg/dL when the normal fasting (without eating for eight hours) BS level range from 100 to 125 mg/dL. This deficient practice resulted in inaccurate medical record information and had the potential to negatively affect Resident 1's medical treatment plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure residents' insulin was given according to the physician's orders for two of four sampled residents (Resident 46 and 50) investigated for insulin administration by failing to ensure Resident 46 and 50's blood sugar check and insulin were documented immediately after being given. This had the potential to cause confusion for when a resident actually received their insulin. 2. Ensure Station 2 Medication Room did not have an emergency kit (E-kit a box that contains medications that can be given to residents quickly in time of need, i.e. a medication ordered such as antibiotic, or a pain medication) that had expired. This had the potential for a resident to receive expired medications that were less effective. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' insulin (medication used to lower blood sugar) were given according to the physician's orders for three of four sampled residents (Resident 10, 46, and 50) investigated for insulin administration by failing to: 1. Ensure a blood sugar was taken before meals and insulin was administered as ordered for Resident 10 and Resident 46. 2. Ensure Resident 50 received the ordered insulin on 12/24/2023 at 4:30 p.m. and did not receive ordered insulin too early on four instances in 12/2023. This had the potential for the residents to have uncontrolled blood sugars and result in mismanagement of diabetes (chronic condition that affects the way the body processes blood sugar) in residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication and biologicals were stored with currently accepted professional standards for two of three medication carts (Med Cart 1 and 2) investigated during the Medication Storage task by failing to: 1. Ensure one opened bottle of glucometer (medical device for determining the approximate concentration of glucose [sugar] in the blood) Control Solution (solutions used to test the glucometer for proper function) found in Med Cart 1 was not used past 90 days. 2. Ensure one opened bottle of glucometer test strips (works with glucometer to read the blood sugar levels) found in Med Cart 2 was labeled with an open date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a resident's urinal (a container used to collect urine) was labeled with a resident identifier for one of nine sampled residents (Resident 36) investigated for infection control. 2. Ensure a resident's oxygen tubing (device that delivers oxygen) was labeled with the date of when it was last changed for two of nine sampled residents (Resident 58 and 244) investigated for infection control. 3. Ensure a resident's nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was not touching the floor for two of nine sampled residents (Resident 244 and 57) investigated for infection control. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was treated with dignity and respect by failing to ensure Certified Nurse Assistant 3 (CNA 3) knocked and asked permission from the resident before entering the room for one of one sampled resident (Resident 68) reviewed for dignity. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for two of five sampled residents (Residents 70 and 28) investigated for accommodation of needs. This deficient practice had the potential to cause a delay in resident care and for the residents' needs to remain unmet.

Inspectors wroteBased on interview and record review, the facility failed to inform and provide the resident and/or his/her responsible party with written information regarding the right to formulate an advance directive (a written statement of a person's wishes regarding medical treatment) for two of four sampled residents (Resident 38 and 45) investigated for advance directive. This deficient practice violated Resident 38 and 45's and/or his/her representative's rights to be fully informed of the option to formulate an advance directive and had the potential to cause conflict with the residents' wishes regarding his/her health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's room temperature was between 71 to 81 degrees Fahrenheit (F- unit of measurement for temperature), as indicated in the policy and procedure, for one of three sampled residents (Resident 36) investigated under the care area of environment. This deficient practice resulted in the resident's increased level of discomfort and had the potential to negatively impact the resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan (a written document outlining a patient's needs, goals, and care) within 48 hours of admission for one of one sampled resident (Resident 294) who was on anticoagulant (helps prevent blood clots [clumps that occur when blood hardens from a liquid to a solid]) therapy. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 294.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a written document outlining a patient's needs, goals, and care) for two of seven sampled residents (Resident 246 and 38) by failing to: 1. Develop a care plan addressing Resident 246's use of buspirone (medication used to treat anxiety disorders [(intense, excessive, and persistent worry and fear about everyday situations]). 2. Develop a care plan addressing Resident 38's Restorative Nursing Assistant (RNA- specially trained Certified Nursing Assistant who use specialized techniques to maintain and improve each resident's abilities and functions) program. This deficient practice had the potential to result in failure to deliver necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to update and revise a comprehensive person-centered care plan (a written course of action that helps a patient achieve outcomes that improve their quality of life with specific interventions for two of three sampled residents (Resident 69 and 84) by: 1. Failing to ensure Resident 69's care plan for Alteration in Nutritional Status dated 7/10/23 was reassessed and revised after the resident experienced a significant weight gain (a gain of 10 percent [%-unit of measure] of a resident's body weight in a period of six months) of 13% of 10/5/2023. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' low air loss mattress (LAL - mattresses designed to prevent and treat pressure ulcers [skin and soft tissue injuries that can occur when an area of skin is under pressure for a long time or is applied with great force over a short period] by reducing pressure and moisture build-up on the skin) was set to the correct setting according to the residents' weight for two of four sampled residents (Resident 5 and 70) investigated for pressure ulcers. This deficient practice placed the residents at risk of discomfort and development of new pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to obtain a laboratory test in a timely manner as ordered by the physician for one of three sampled residents (Resident 78) by failing to ensure Resident 78's serum digoxin level (measures the amount of digoxin that is in the body) was obtained when ordered. This deficient practice placed Resident 78 at risk for digoxin toxicity (type of poisoning that occurs in people who take too much of the medication) and ineffective medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure food items not in their original containers were labeled and dated. This deficient practice had the potential to place 88 of 93 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square (sq.) feet (ft.) per resident in 27 of 43 resident rooms (Rooms 4, 6, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, 29, 31, 33, 35, 37, 39, 41, and 42). 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 failed to implement their Coronavirus Disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) policy by failing to ensure residents and their residents' representatives were informed of the COVID-19 case status of the facility for three of three sampled residents (Resident 6, Resident 7 and Resident 8). This deficient practice has the potential to violate residents' rights and/or representatives' rights to be informed of the facility's COVID-19 status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control policy and procedures by failing to ensure two staff members (Licensed Vocational Nurse [LVN 1] and Certified Nursing Assistant 1 [CNA 1]) donned (put on) a face shield, gown, and gloves prior to entering a Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) isolation room (a type of room that keeps resident with infectious illnesses away from other residents) for one of three sampled residents (Resident 3). This deficient practice had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff other residents.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility ' s Influenza (also known as the flu, it is an infection of the nose, throat, and lungs) vaccine (medication that prevents infection from influenza) policy by failing to ensure residents were assessed for their current vaccine status and offered the influenza vaccine upon admission for two of five sampled residents (Resident 1 and Resident 3). This deficient practice had the potential for residents to not be aware of the risks and benefits of the influenza vaccine.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for two of five sampled residents (Resident 1 and Resident 2) when on 10/1/2023, Resident 1 hit Resident 2 in the head with a trashcan lid, and Resident 2 hit Resident 1 in the head with a wooden back scratcher. This deficient practice resulted in Resident 1 and Resident 2 being subjected to physical abuse while under the care of the facility, and both Resident 1 and Resident 2 required transfer to the General Acute Care Hospital (GACH) for possible head injuries as a result of the physical altercation.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1105B of the Act by failing to report an allegation of physical abuse (any intentional act causing injury, trauma, bodily harm or other physical suffering to another resident by way of bodily contact) on 9/25/2023 within two (2) hours of being made aware of an allegation of Certified Nurse Assistant 1 (CNA 1) using bed sheet as a physical restraint (any manual method, physical or mechanical device, equipment attached to a resident's body restricting the resident's freedom of movement) for one of five sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect the resident from further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Certified Nursing Assistant ' s (CNA) certification was renewed and active while working at the facility for one of two sampled staff (Certified Nursing Assistant 1 [CNA 1]). This deficient practice had the potential for knowledge, training, and certification deficit leading to inadequate resident care.