Northvine Postacute Care

Inspectors wroteBased on interview and record review, the facility failed to ensure rehabilitative services were provided for one of four sampled residents (Resident 1) when Physical Therapy (PT) was not provided according to the plan of care and physician orders. This failure had the potential to result in the resident failing to attain her highest practicable level of physical and functional well-being. During an interview with the Administrator on 1/27/26 at 10:10 a.m., the Administrator stated that the facility was transitioning to having in-house rehab staff rather than staff from an outside rehab provider. The facility ended the contract with the outside rehab providers at the start of the year. The Administrator stated he hired one Occupational Therapist (OT) from the outside rehab providers to continue to work for this facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of nursing care when one resident (Resident 1) of three sampled residents did not have documented weekly skin assessments in their medical chart and wound care treatments were not implemented to Resident 1's right great toe. This failure resulted in the development of infection and maggots in Resident 1's right great toe, which required hospitalization and subsequent amputation to his right great toe. Cross reference F925. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (a condition characterized by paralysis of one side of the body), and Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). [...]

Inspectors wroteA review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of hemiplegia (a condition characterized by paralysis of one side of the body), expressive language disorder (a communication disorder impacting a person's ability to communicate their thoughts), Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1's History and Physical, dated 11/1/24, indicated Medical Doctor 1 (MD 1) planned for a wound care consult, currently foam dressing to right dorsal [top of foot] foot ulcer every Monday, Wednesday, Friday. MD 1 noted the wound measurement taken on 10/4/24 was, 1 centimeter [cm-a unit of measure] x 1cm x 0.2cm. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program when flies were observed in common hallways and three resident rooms and four resident rooms had torn window screens. This failure decreased the facility's potential to prevent vector (an insect or rodent that transmits bacteria and viruses) borne illnesses for a census of 54 residents. During a concurrent observation and interview on 7/28/25 at 10:30 a.m., Resident 3 was lying in bed. Upon observation a half full and open urinal and partially eaten personal food items had been placed on Resident 3's bedside table. In addition, a strip of fly paper with 3 dead flies attached and a live fly was seen on Resident 3's curtain Resident 3 stated he had seen flies in his room, all the time. Upon inspection, Resident 3's window screen was torn. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, comfortable, and homelike environment when three chairs available for resident use were worn out and tattered in one hallway of the facility. This failure decreased the facility's potential to provide a clean and comfortable environment for residents and their guests. During an observation of the facility's Garden Hall on 7/14/25 at 11:36 a.m., three wooden chairs with seats and arm rests made of pleather (a synthetic material made to look and feel like leather) were cracked, flaky, and worn-out which exposed light brown, discolored, and coarse fabric fibers. These chairs were available for residents and guests to use. One chair was removed by a guest and brought into a resident room. Thereafter, a resident sat in one of the other chairs. During a concurrent interview and observation on 7/14/25 at 1:12 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents from Resident 1's aggressive behavior when facility staff were not able to verbalize Resident 1's care plan for aggression. This failure resulted in Resident 1 becoming physically aggressive with two residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the services necessary to maintain good grooming for three residents (Resident 1, Resident 2, and Resident 3) of three sampled residents when all three had long, jagged (rough, uneven shape, with some sharp points), and dirty fingernails. This failure decreased the facility's potential to prevent skin infections if the residents' scratched their skin with dirty jagged nails.

Inspectors wroteBased on interview and record review, the facility failed to initiate and implement resident-centered nursing care plans for one of three sampled residents, when: 1. A nursing care plan was not initiated when Resident 1 developed a urinary tract infection (UTI- when bacteria enter the urinary tract, which includes the kidneys, bladder, and urethra. Most UTIs are caused by bacteria from the bowel); and, 2. Nursing care plan interventions were not implemented when Resident 1 experienced constipation for three days These failures had the potential to worsen or delay improvement of Resident 1's medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for 57 out of 59 residents who received food from the facility's kitchen, when:1. a grease trap (a plumbing device, type of drain, intended to capture fats, oils and grease from wastewater), located in the dishwashing area under the two-compartment sink, was not maintained in good repair and caused wastewater (includes substances such as food scraps, oils, soaps and chemicals) to back-up on to the kitchen floor. This occurred while a County Department of Health Services (CDHS) Inspector was present on 3/18/25.2. did not ensure that the facility identified and resolved the source of the wastewater backup into the kitchen, despite evidence that staff were aware of wastewater coming up from the grease trap and drain under the grease trap prior to the survey. And,3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety when: 1) Tuna and chicken salad sandwiches did not reach a safe internal serving temperature, 2) [NAME] and dishwasher were not wearing an apron 3) Absence of a touch free garbage can by hand washing sink, 4) Internal food temperatures were not monitored prior to transporting residents' meals to the facility, 5) Pots and pans were not air dried, 6) Three-compartment sink manual dishwashing process was not done correctly, 7) Temperature monitoring for the walk-in refrigerator, freezer and commissary kitchen (a rentable commercial kitchen), were not completed, and 8) Dietary Aide used the food production two-compartment sink to rinse out a dirty pan. [...]

Inspectors wroteBased on interview and record review, the facility's administration (the person/s responsible for the overall operation and management of a skilled nursing facility, ensuring the facility meets regulations and provides quality care for residents) failed to use their resources effectively and efficiently, when corrective actions were not completed following the issuance of the County's Department of Health Services (CDHS) Site Review Inspection Report in October 2024. This failure resulted in the interruption of food services for 57 out of 59 residents who received food from the facility's kitchen when CDHS suspended the facility's Retail Food Permit which required the facility to cease all food production operations effective 3/18/25 at 10:37 a.m. and to remain in effect until the facility can meet CDHS requirements (cross reference with F908).

Inspectors wroteBased on interview and record review, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program, when the facility's QAPI program did not address code compliance corrective actions, related to the physical environment of dietetic services, issued to the facility by the County Department of Health Services (CDHS) on 10/28/24. This failure resulted in the interruption of food services for 57 out of 59 residents who received food from the facility's kitchen when CDHS suspended the facility's Retail Food Permit and required the facility to cease all food production operations effective 3/18/25 at 10:37 a.m. and to remain in effect until the facility can meet CDHS requirements (cross reference with F908).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an effective pest control program when: 1) Evidence of a rodent infestation was at the offsite commissary (a rentable commercial kitchen) and 2) A fly infestation was present in the designated dietetic service space (formerly the facility breakroom). These failures had the potential to cause foodborne illness (any illness resulting from eating contaminated/spoiled foods) for 57 of 59 residents who received food from the facility ' s kitchen.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an abuse allegation was reported to the appropriate agencies within 2 hours after an allegation was made for one out of two sampled residents (Resident 1). This failure could put the resident's safety at risk and potentially hinder the ability to properly investigate and protect the resident due to a lack of time to intervene effectively.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident when a staff member (Unlicensed Staff C) was allowed to continue working on her shift while the investigation for the abuse allegation was in progress. This failure reduced the facility ' s potential to protect Resident 1 from further abuse while the alleged abuse investigation was in progress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests when flies were seen flying throughout the facility. The facility did not adequately address the pest problem, leading to residents being bothered by flies in their room while trying to rest and eat their meal. Flies were seen flying in the kitchen, which could lead to contamination of food being prepared and the spread of disease.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or their responsible party with a summary of the resident's Baseline Plan of Care for four of 18 sampled residents (Resident 45, 48, 54, and 108). This failure had the potential to limit communication with the resident and/or their responsible party on how the facility planned to manage the resident's needed services and treatments while at the facility, which could have led to the resident feeling stressed, uneasy and lack of trust with the staff providing care, leading to negatively affecting the resident's physical and psychosocial well-being.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure: 1.the Restorative Nursing Assistant (RNA, a certified nursing assistant (CNA) who has specialized training in therapeutic rehabilitation) process was followed when one out of two sampled residents (Resident 6) did not have a weekly summary completed by the RNA and there were no monthly summary meetings in Resident 6's electronic medical chart 2. the RNA followed the splint (provide a slow force to stretch the contracture- tightening of muscles that causes the joints to shorten, and improve mobility) order for both hand flexion contracture (shortening and hardening of muscles, resulting to deformity) management for one out of two sampled resident (Resident 6). These failures placed Resident 6 at risk for further contracture, pain and development of wound.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide the necessary behavioral health care and services (a range of treatments and services that address a person's mental and emotional health) for one out of two sampled residents (Resident 27). This failure put Resident 27 at risk for worsening of mental health symptoms, poor physical health, social isolation, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Implement EBP (Enhanced Barrier Precautions: a set of infection control guidelines that use personal protection equipment [PPE: gown and gloves] to reduce the spread of multidrug-resistant organisms [MDROs: a bacteria that has become resistant to an antibiotic [medication that treats a bacterial infection]) for two of 18 sampled residents (Resident 30 and Resident 108) and five unsampled residents (Resident 8, Resident 9, Resident 212, Resident 213, and Resident 214), who had wounds and required dressing changes, and/or indwelling medical devices, such as a foley catheter (a flexible tube that is inserted into the bladder to drain urine or a gastrostomy tube (G-tube: [...]

Inspectors wroteBased on interview and record review, the facility did not report an alleged abuse allegation for one out of two sampled residents (Resident 6) within 2 hours to California Department of Public Health (CDPH, responsible for and enforces some of the laws in the California Health and Safety Codes), the Ombudsman (official appointed to investigate individuals' complaints) and the local Police Department (PD). This failure put Resident 6 and all the vulnerable residents at risk for abuse to continue.

Inspectors wroteBased on interviews and record reviews, the facility failed to: 1.ensure an appropriate notice of discharge (a written document provided to a patient or their representative usually given before or at time of discharge (in an emergency) which explains why the patient is being discharged and provides information about their next steps and ongoing care) was provided to the resident and/or representative and ensure the Ombudsman (an official appointed to investigate individuals' complaints against maladministration) was notified when one out of two sampled residents (Resident 57) was sent to the emergency department (ED, department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) on 8/1/24. [...]

Inspectors wroteBased on interview and record review, the facility did not complete the Minimum Data Set (MDS, a standardized process for evaluating a resident's health and functional abilities in a nursing home) Discharge Assessment (DCA, a required part of the process for evaluating the health of a resident and their discharge plans when they leave a nursing home) for one out of two sampled residents (Resident 28). This failure could potentially lead to improper care planning on Resident 28's new discharge setting which could also potentially put Resident 28's safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to follow through with notifying a resident's physician of the RD's (Registered Dietitian) recommendation for the nutritional supplement, Med Pass (helps provide extra calories and protein to help patients gain weight or recover from illness) for one of eighteen sampled residents (Resident 30), who had lost 16 pounds in one month (8.65% unplanned weight loss), which is severe weight loss. This led to Resident 30 losing more weight, which could prevent Resident 30's right heel ulcer (pressure sore is an injury to the skin and underlying tissue) from healing or cause it to become worse, and could cause an overall decline in Resident 30's physical wellbeing.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect one resident (Resident 1) out of five sampled residents from a staff member (Licensed Staff A) verbally abusing Resident 1. This failure had the effect of causing emotional distress as evidence by Resident 1 crying.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure access to residents when the phones in the facility were left unanswered. This failure resulted in a pharmacy not being able to get in contact with nursing staff to clarify physician ' s ordered medication, and Confidential Complainant not being able to reach staff. This led to Resident 5 not receiving Paxlovid (a medication that helps stop mild-to-moderate COVID-19) for 5 days, and Confidential Complainant unable to discuss an urgent matter with staff.

Inspectors wroteBased on interview and clinical record review, the facility failed to ensure residents were free from significant medication errors for 2 of 3 sampled residents (Resident 5 and Resident 6) when physicians ' order for medication administration were not followed: 1. Resident 5 never received Paxlovid (an antiviral medication) to treat symptoms of COVID-19 which could lead to hospitalization and death and 2. a licensed nurse did not follow physician orders and administered Duloxetine HCI Delayed Release (an antidepressant also used to treat chronic pain ) 60 mg (milligrams) to Resident 6, instead of the physician ordered dose of 30 mg, upon Resident ' s 6 ' s request. These medication errors resulted in to 1. Resident 5 not having a speedy recovery, and 2. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure: 1. The call light (a device used by residents to call for assistance from staff) was always functioning for one out of two sampled residents (Resident 1). 2. A touch pad call light was provided for one out of two sampled residents (Resident 1) who had difficulty using a call button per his request. 3. The call light or an alternative was available for one out of two sampled residents (Resident 7). These failures resulted in: A. Resident 1 worried he could not call staff for assistance if there was an emergency situation and Resident 1 yelling for help instead of using the call light. B. Resident 7 was at risk for staff not meeting his needs and late provision of care.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to implement their smoking policy when one out of two sampled residents (Resident 1) was allowed to vape (an electronic cigarette, to inhale and exhale vapor containing nicotine and flavoring produced by a device designed for this purpose) inside his room, and implement the smoking assessment recommendation for one out of two sampled residents (Resident 1) when Resident 1 was allowed to vape without staff supervision. These failures put Resident 1 ' s roommates at risk for second hand vape exposure (to fine and ultrafine particles that contain nicotine, that might exacerbate respiratory ailments like asthma (narrowing of airways), and constrict arteries (blood vessels tighten) which could trigger a heart attack, and put Resident 1's safety at risk for burns, device/battery explosion and accidents.

Inspectors wroteBased on interviews and record reviews, the facility failed to involve two out of two residents (Residents 1 and 2) in decision making regarding their choice of physician when the facility transferred their care to another physician without their consent. This failure violated residents ' rights to choose their own physician.

Inspectors wroteBased on interview and record review the facility failed to meet professional standards of quality for one of three sampled residents, Resident 6, when a licensed nurse, RN K, did not follow the rights of medication administration (the right patient, the right medication, the right dose, the right time, the right route, right indication) and administered Duloxetine HCI Delayed Release (an antidepressant also used to treat chronic pain ) 60 mg (milligrams) to Resident 6, instead of the physician ordered dose of 30 mg, upon Resident ' s 6 ' s request. This failure led to Resident 6 refusing to take her physician ' s ordered dose of 30 mg, which had the potential to cause withdrawal symptoms for Resident 6 and had the potential for other residents not to receive their medications according to physician orders and professional standards.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the facility ' s policy on death was followed for one out of two sampled resident (Resident 2) when: 1. Resident 2s death was pronounced by a Licensed Vocational Nurse (LVN); and, 2. Staff did not inform the mortuary if an autopsy was to be performed due to Resident 2 ' s unexpected death. These failures may put the residents at risk for missed diagnostic errors and missed opportunities to improve medical treatment.

Inspectors wroteBased on interview and record the facility failed to provide appropriate behavioral health services and treatment when one of one sampled resident (Resident 9) was not provided anti-psychotic medications and mental health treatment services. This failure resulted in Resident 9 being denied his anti-psychotic medication resulting him hitting another resident.

Inspectors wroteBased on observation interview and record review, the facility failed to: 1. Have a consistent leadership of an Administrator, DON (Director of Nursing), and DSD (Director of Staff Development), which led to the lack of training for the nursing staff for both the Licensed Nurses and the Certified Nursing Assistants (CNAs). These failures had the potential for the nursing staff's inability to provide accurate assessments and safe provisions of care to the residents to ensure residents received high quality of care and effective care was being delivered. 2. To assess and treat Resident 11, who had been complaining of his coccyx/buttocks (lower/backside/behind) region feeling chapped and hurting since 5/30/23, until the surveyor had two CNAs turn Resident 11 on his side, after they finished his care on 6/2/23 at 9:45 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, sanitary, comfortable and homelike environment for residents, when: a. there was a strong urine odor (ammonia-like) in the hallway, resident rooms and bathrooms; b. the floors were sticky; c. toilet roll holders were missing in the resident bathrooms, causing toilet paper to be stored out of reach on the bathroom safety handrail or on the back of the toilet (toilet tank lid); d. bathroom walls and cubbies over the toilet bowls had yellow brown splatter; e. a bathroom fan had a loud noise; f. urinals and graduates to collect urine, located in bathrooms, were not labeled, wheelchairs, Hoyer lifts (a mobile tool used to lift, reposition and lower a resident into a wheelchair or bed), and scales were stored in hallways, causing residents to not have access to the safety handrails; g. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure there were sufficient and competent nursing staff to meet the residents needs and assure resident safety, when the facility did not provide adequate staffing based on their facility assessment, for 19 out of 31 days for 3/2023, 15 out of 25 days for 4/2023, 21 out of 31 days for 5/2023, and three out of five days from 6/1/23 up to 6/5/23. The facility did not ensure there were enough night shift Certified Nursing Assistants (CNAs) on duty for 17 out of 30 days on 4/2023, 18 out of 31 days for 5/2023, and three out of six days from 6/1/23 up to 6/6/23. These failures could compromised resident safety, which could result in falls, injuries and increased incidents of abuse.

Inspectors wroteBased on dietetic services observations, dietary and administrative staff interview and administrative document review, the facility failed to ensure a Registered Dietitian (RD) and/or Dietary Manager (DM) comprehensively evaluated the effectiveness of the food service operation, as evidenced by: * Lapses in the delivery of services associated with staff competency (Cross Reference F802); * Meal distribution accuracy, nutritional values of food and physician orders, consistent with the current standard of practice, the approved diet manual and RD approved menu (Cross Reference F804 and F808); * Food safety (Cross Reference F812); * The dietetic services physical environment (Cross Reference F908); and, * Provision of guidance and oversight to the Dietary Manager. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure: 1. the call light (a device used by a patient to signal his or her need for assistance from professional staff) was within the residents' reach for three out of 16 sampled residents, (Resident 22, 47 and 207) and one unsampled resident (Resident 26); 2. the room call light system was working for one out of 16 sampled residents (Residents 157); 3. the residents' bathroom call light could be accessed by a resident lying on the floor for 16 out of 17 bathrooms (Rooms 1 through 9, Rooms 16 through 19, and Rooms 21 through 23); and, 4. the bathroom call lights were in good working condition for nine out of 17 resident bathrooms (Rooms 5, 7, 9 16, 17, 19, 21, 22, and 23). [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to promote care that enhanced dignity and respect for three out of 16 sampled residents (Resident 8, 11, and 47) and two unsampled residents (Resident 7 and 37), when: 1. staff closed the door to drown out Resident 11's pleas for help, and would answer the telephone calls from Resident 11 by saying, Domino's Pizza or Round Table Pizza; 2. staff did not knock on the door, before entering resident rooms and staff would talk in their native language (not English language) within residents' earshot, for Residents 11, 7 and 37; 3. the resident privacy curtain was not pulled for Resident 8, when were not clothed appropriately; 4. a Physical Therapist Aide worked with Resident 8, during transfer to a wheelchair, while Resident 8 was unclothed; 5. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) assessments were completed timely, when the MDS quarterly assessment (used to track the resident's status between comprehensive assessments, and to ensure monitoring of critical indicators of the gradual onset of significant changes in resident status), for seven out of seven sampled residents (Residents 27, 22, 51, 5, 37, 50 and 6), and the MDS Annual assessments (a comprehensive assessment that requires a full MDS with care plan that outlines what needs to be done to manage the residents care needs), for three out of three sampled residents (Residents 25, 9 and 20), were overdue. These failures could result in the nursing home staff's late identification of residents' needs or health problems.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure staff were aware of the Basic Care Plan (BCP, a plan that promotes continuity of care and communication among nursing home staff to increase resident safety) completion time frame and BCP's were completed timely, for seven out of seven sampled residents (Residents 1, 2, 4, 15, 16, 49 and 157). These failures had the potential to put residents' safety at risk and for residents to not receive the care that they need.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an individualized care plan for 4 of 16 sampled residents (Resident 8, 19, 47, and 207), when: 1. Resident 8 was not care planned for ADLs (Activities of Daily Living: Related to personal care, which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) including refusal of showers, not wanting to wear clothes, and needing assistance with toileting; 2. Resident 8 was not care planned for taking the blood thinner Plavix (Clopidogrel Bisulfate: to prevent heart attack and stroke); 3. Residents 8 and 207 were not care planned for Discharge Planning; 4. [...]

Inspectors wroteBased on observation, interview and clinical record review, the facility failed to meet professional standards of quality for three of 16 sampled residents (Resident 8, 19, and 33) when: 1. The facility did not assess Resident 19 for bowel movement (BM) care after Resident 19 did not have a BM for more than three days; 2. Resident 33's Foley catheter (thin, flexible tubing used to drain urine from the bladder by way of the urethra: The tube through which urine leaves the body) leg bag (small bag strapped to one's leg to collect urine and lets one move about more easily when up and about) was not changed to a urine drainage bag (collects a large amount of urine, hangs at the side to the bed, and used when one sleeps at night), which should be positioned lower than the bladder to prevent urine from flowing back into the urinary bladder; and, 3. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide regular scheduled showers for eight out of eight sampled residents (Residents 29, 7, 52, 5, 49, 11, 53 and 46). This failure led to residents feeling frustrated and annoyed and could lead to broken skin, wounds and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide six of 16 sampled residents (Resident 8, 19, 20, 33, 47, and 207), who were dependent on staff for their personal care, their three weekly scheduled showers. This resulted in residents looking unkempt, feeling neglected and unclean, and had the potential to negatively impact the resident's physical and psychosocial wellbeing.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to: 1) ensure residents were provided the needed care and services which were resident-centered and met the professional standards of practice, when an Interdisciplinary Team (IDT, a different types of experts that work together to share expertise, knowledge, and skills to impact patient care) recommendation for a psych consult regarding an abuse allegation was not completed for four out of eight sampled residents (Resident Residents 26, 17, 33 and 53) and an abuse care plan (CP, a document that outlines your assessed health and social care needs and how you will be supported) was not created for two out of eight sampled residents (Residents 165 and 22). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Restorative Nursing Assistant (RNA: Assists residents with therapeutic exercises involving transfers, bed mobility, positioning and range of motion (passive/active) interventions to promote, restore and maintain one's independence) program was being continued as physician ordered, for three of 16 sample residents (Resident 4, 11, and 42) and two unsampled residents (Resident 41 and 52). This failure resulted in a disruption in treatment and had the potential for residents to have a decline in range of motion, strength and endurance, an increase in joint pain and depression, and an overall decrease in Activities in Daily Living (ADLs: Includes eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet.).

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure residents were safe at the facility, when their wanderguard alarm system (a wander management solution for resident safety to protect those at risk of elopement) was broken. This resulted in one resident (Resident 16) leaving the building undetected and placed two out of two sampled residents (Residents 28 and 53) at risk for leaving the facility unassisted, potentially having a fall, an accident, or being struck by a vehicle, possible resulting in injury or death.

Inspectors wroteBased on resident dining observations, medical record review and Registered Dietitian interview, the facility failed to comprehensively assess and implement nutritional interventions for 1 resident (Resident 47) who lost a total of 21 pounds over a period of three months. The facility failed to provide recommended nutritional interventions; the RD failed to implement the current standard of practice of providing a nutrition-focused physical assessment; the interdisciplinary committee failed to provide a meaningful analysis of identified weight loss and follow the facility care plan policy for assessment of weight loss and provision of palliative care. Unintended weight loss is strongly correlated with increased morbidity and mortality in the older adult.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the nursing notes and documentation's were accurate, when there were conflicting progress notes information for three out of eight sampled residents (Residents 20, 26 and 53). This failure resulted in inaccurate documentation which could lead to confusion, potentially impacting continuity of care.

Inspectors wroteBased on dietetic services observation, dietary staff interview and departmental document review, the facility failed to ensure staff competency, when: 1) one cook did not prepare pureed items in accordance to standards of practice; and, 2) one cook was unable to calibrate a thermometer and one cook was unable to properly take food temperatures. Failure to ensure staff competency may result in unsafe food production practices or preparation of food that did not fully meet resident needs, which in turn may result in compromised nutritional status.

Inspectors wroteBased on meal distribution observations, the facility failed to follow the physician-ordered diet when: 1) Residents 22 and 42, with physician-ordered mechanical-soft diets, received potato chips; 2) Residents 4, 15, 18, 19, 20, 26, 29, 32, 41 and 50 did not receive their physician-ordered fortified diets for lunch on 5/30 and 5/31/23. The facility also failed to ensure the physician's diet orders were consistent with the facility-approved menu and current standards of practice for Residents 4, 5, 7, 11, 12, 14, 16, 19, 21, 24, 28, 157, and 158. Failure to ensure accurate meal distribution may put residents at risk for choking, weight loss, and decreased meal satisfaction, further compromising medical status.

Inspectors wroteBased on food production and food storage observations, the facility failed to ensure foods were prepared and/or stored in a safe and effective manner when: 1) there was no time/temperature control documentation for facility prepared tuna salad; 2) the facility retained unlabeled and/or undated food items; 3) staff stored utensils in a manner that may promote contamination of food; and, 4) staff did not cook one poultry item to the proper internal temperature. Failure to ensure systems that support all aspects of food safety may result in practices associated with foodborne illness and contamination of resident food.

Inspectors wroteBased on interview and facility document review, the facility's Quality Assurance and Performance Improvement Program (QAPI, a data driven and proactive approach to quality improvement. It combines two approaches - Quality Assurance (QA) and Performance Improvement (PI). QA is a process used to ensure services are meeting quality standards and assuring care reaches a certain level) failed to identify quality deficiencies as evidenced by: 1) Staff Annual Competency Skills checks for the nurses and Certified Nursing Assistants were not done since 2021; 2) The facility did not provide the residents an environment that was homelike. The floors were dirty and sticky, there were foul odors in the building, and the bathroom toilet and walls in the residents' room did not appear clean and looked as if they were not being cleaned adequately; [...]

Inspectors wroteBased on observation of the dietary department, the facility failed to ensure maintenance the physical environment when there were multiple areas of the kitchen with surfaces that were deteriorated, not smooth or readily cleanable. Failure to maintain the physical environment of dietetic services may promote the growth of pathogenic organisms, create an environment for pest harborage or result in physical contamination of food.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents were receiving their medications timely and were notified of any changes in their medications, for three out of three sampled residents (Residents 11, 7 and 37). This failure was a violation of resident's rights and a safety issue as residents may be receiving medication without a resident's consent. A review of Resident 11's face sheet (demographics) indicated he was 55 years-old, initially admitted to the facility on [DATE]. His diagnoses included Hypertension (high blood pressure), Obesity (abnormal or excessive fat accumulation that presents a risk to health), Major Depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Anxiety Disorder (condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure a resident was free form sexual abuse, for one out of seven sampled residents (Resident 53), when a male resident (Resident 26) grabbed (seized quickly) her breast, touched her breast twice and fondled her breast (caress sexually in a prolonged way), and the facility did not address the risk of this incident occurring again. This failure could put the resident at risk for further sexual abuse and feelings of shock, shame, anger and depression.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to: 1) ensure the 5-day summary report, regarding an abuse allegation, was completed and sent to the state within five working days, for three out of four abuse allegations (for Residents 26 and 20, for Residents 17 and 33 and for Residents 165 and 22), the SOC 341 was completed within two hours after an allegation was made for two out of six sampled residents (Residents 160 and 161) and ensure staff were aware of abuse reporting time frames; and, 2) follow up, investigate and report a possible abuse, for one out of nine sampled residents (Resident 14). These failures could put residents' safety at risk and could result in ongoing abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a sexual abuse allegation was investigated thoroughly for one out of two sampled residents (Resident 6). This failure could potentially put the facility residents' safety at risk and could result in ongoing abuse.

Inspectors wroteBased dietetic services observations, dietary staff interview and departmental document review the facility failed to ensure staff competency when: 1) staff did not prepare the diabetic dessert for the noon meal on 8/22/23, in accordance with the facility spreadsheet; and, 2 ) one staff member (Dietary Staff 4) did not test sanitizer strength in accordance with manufacturer's recommendations.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the provision of daily Registered Nurse (RN) services when an RN was not present at the facility on 4 weekend days in January, 2022. This failure prevented professional RN oversight and assessment of nursing services and general operations that impact the care and treatment of vulnerable residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an effective Infection Prevention and Control Program when: 1. Facility staff (Screener M) gave her used vape pen (battery-powered device that produces vapor from any of a variety of substances, especially liquid containing nicotine or cannabinoids, allowing the user to inhale the aerosol vapor) to Resident 3 to utilize; and 2. The facility did not ensure its emergency water was stored per CDC (Center for Disease Control and Prevention) guidelines or per manufacturer's directions, and did not develop a policy and procedure for treating, monitoring, and accessing its facility-treated emergency water. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure each resident was treated with dignity when: 1) Staff did not prevent two male residents (Sampled Resident 23 and an Unidentified Resident) from wandering to into the rooms of 3 female residents (Sampled Resident 98 and Sampled Resident 41 and Unsampled Resident 99) and did not create care plans to address the female resident's fear resulting from the incidents; and 2) The facility's beautician cut one resident's hair (Resident 2) without notifying, or obtaining permission from, her Responsible Party (RP; family member who was designated as Resident 2's decision-maker). These failures caused Resident 98 to scream, Resident 99 to feel scared and subsequently scream, and Resident 41 to scream and feel unsafe, and for Resident 2's family member to be upset.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure nursing staff utilized professional standards when providing resident care when: 1) 3 of 4 licensed nurses (LN N, LN H, and LN I) administered rapid-acting insulin (medication to treat high blood sugar in diabetics; onset of action is within 15 minutes) too early, or without food; and 2) LN C, LN D, and LN Q documented administration of IV (intravenous) medications for RN's who gave the medication. (LN's C, D, and Q were licensed vocational nurses [LVN's]; giving IV medication was outside the LVN's scope of practice. A registered nurse [RN] is qualified to administer IV medication). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: A. prevent falls (defined as moving downward, typically rapidly and freely without control, from a higher to a lower level) in two (Resident 34 and Resident 148) out of six sampled residents and B.ensure one resident (Resident 3) used the designated smoking area that contained fire prevention equipment (ashtray, fire prevention blanket and fire extinguisher) when Resident 3 smoked. These failures had the potential to cause physical harm, psychological harm and even death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure they had sufficient Healthcare Personnel to meet the residents required care needs and provide adequate supervision to residents at risk for falls when the facility was short-staffed nurses and Certified Nursing Assistant(s) (CNA) on multiple occasions. This failure resulted in staff not being able to attend to resident's needs, such as turning, repositioning, and feeding assistance, provide adequate supervision, and timely medication administration, the scheduled Restorative Nursing Assistant (RNA: person-centered nursing care designed to improve or maintain the functional ability of residents) being reassigned to CNA duties, and Resident 41 being incontinent of urine while waiting for her call light to be answered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate medication administration when the nursing medication error rate was 8%. 3 of 4 licensed nurses (LN N, LN H, and LN I) administered rapid-acting insulin (medication to treat high blood sugar in diabetics; onset of action is within 15 minutes) too early, or without food. These failures caused potential for harm in Residents 98 and 7, who could have experienced hypoglycemia (*) when their rapid-acting Insulin was not given timely. *Hypoglycemia occurs when blood sugar levels fall too low; the most common cause is a side effect of drugs used to treat diabetes (like insulin); symptoms include shakiness, anxiety, and sweating and can progress to blurred vision, seizures, and loss of consciousness. [...]

Inspectors wroteBased on interview, and facility document review, the facility's Quality Assurance and Performance Improvement (QAPI) Program failed to identify quality deficiencies as evidenced by: 1.a) Timely Insulin administration was identified as a concern such as Lispro, a fast-acting insulin medication for diabetes. (cross reference F 759) 1.b) Multiple falls with injuries, 9 falls in October 2021 and 9 falls in November 2021 (cross reference F689) 1.c) Multiple female residents were fearful for their safety while a male resident, unsupervised, wandered in their rooms (cross reference F 550); and 2) The facility did not develop a policy and procedure for emergency water treatment, storage, monitoring and safe accessing/use of the water (cross reference F880). [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the doctor and responsible person for one (Resident 123) out of two sampled residents who suffered an accident. This failure resulted in the doctor not being able to make the decision to transfer the resident to a higher level of care for evaluation and the responsible person not being allowed to participate in plan of care decisions creating frustration and lack of trust in the quality of care being provided.

Inspectors wroteBased on interview and record review the facility failed to keep one resident (Resident 34) free from abuse out of three sampled residents when Resident 34 and Resident 7 were indicated to be sitting on top of the bed fondling each other's private parts. This failure had the potential result of physical and emotional harm to both residents.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of sexual abuse to the officials in accordance with State law through established procedures (including to the Department and Long Term Care Ombudsman Agency) for one sampled resident (Resident 34). This failure had the potential to delay investigation and affect the physical and psychosocial well-being of the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an accurate data entry or code in Minimum Data Set/Resident Assessment (MDS) for one of four residents, Resident 35. The MDS Coordinator (LN L) coded Yes to indicated that Resident 35 had a foley catheter/nephrostomy tube (an elastic tube connected to the kidney to drain the urine located in the lower back). This failure had the potential to result in misinformation and incorrect care planning for Resident 35.

Inspectors wroteBased on observation, interview and record review, the facility's Registered Nurse (RN) Coordinator failed to ensure accuracy of resident's assessment in the Minimum Data Set/Resident Assessment Instrument (MDS/RAI) for one of four residents, Resident 35. This failure had the potential to result in incorrect nursing care plan for Resident 35 by not following the nursing care with foley catheter/nephrostomy tube compared to a nursing care plan for bowel and bladder training for incontinence (loss of control with urine and bowel). Senior [NAME] President Consultant (SVPC), RN, signed and approved the MDS assessment that Resident 35 had a foley catheter/nephrostomy tube (an elastic tube connected to the kidney to drain the urine located in the lower back). Resident 35 did not have a foley catheter nor Nephrostomy tube since 1/13/2021.

Inspectors wroteBased on interviews and record reviews, the facility failed to accurately and completely document in the medical record in accordance with professional standards for one of two sampled residents (Resident 123) when Resident 123 had an accident by sliding out of the wheelchair onto the floor and no nursing assessment was observed in the medical record. This failure resulted the in the facility and the Department not being able to review events surrounding the accident or the potential for delay in injury identification by other staff not being aware that an accident had taken place.

Inspectors wroteBased on interview and record review, the facility failed to ensure the QAPI Plan described a process to identify and correct deficiencies when: a) There were no tracking and measuring performances for falls in residents. b) There was no monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revisions as needed for nursing practice in medication administration such as insulin (medication for high blood sugar). c) There were no records of analyzing underlying causes of systemic quality deficiencies such as a male resident wandering to female resident's rooms. This failure resulted in repeated falls with injuries, unsafe nursing practice of medication administration, and residents experienced increased fear and feeling unsafe from a wandering male resident.

Inspectors wroteBased on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) Program Committee failed to have a minimum required staff attendees during a QAPI meeting when: 1. There was no attendance sheet during a QAPI meeting held on 3/2021. The DON was not able to specify the exact date of the March 2021 meeting. 2. There were no nursing staff attendees during the QAPI meeting held on 7/30/21.