Norwalk Skilled Nursing & Wellness Centre, LLC

Inspectors wroteBased on interview and record review, the facility failed to: Initiate a care plan for Resident 1's impulsive behavior that was identified in the first fall dated 1/22/2026. Implement a recommendation that was addressed during the Interdisciplinary Team (IDT: Resident's healthcare team consisting of various specialties that share and combine their knowledge and information to create the best possible care plan for the resident) meeting on 3/1/2026. Implement a care plan for Resident 1's known diagnosis of osteopenia (condition where bone mineral density if lower than normal). This deficient practice increased the potential risk of additional falls for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Notice of Transfer/Discharge (a written notification to the resident or responsible party which includes the reason for transfer or discharge, where the resident will be transferred to, how to contact the Long-Term Care (LTC) Ombudsman (patient advocate), and how to appeal the transfer or discharge if necessary) was sent to the LTC Ombudsman upon transfer to a General Acute Care Hospital (GACH) for two of three sampled residents (Residents 1 and 2). This failure had the potential to result in an unsafe discharge and/or deny Resident 1 the right to appeal the discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Director of Nursing (DON) documented the reason for transfer/discharge and the residents (Resident 1) refusal to sign the Notice of Transfer/Discharge (a written notification to the resident or responsible party which includes the reason for transfer or discharge, where the resident will be transferred to, how to contact the Long-Term Care (LTC) Ombudsman (patient advocate), and how to appeal the transfer or discharge if necessary)upon transfer to the General Acute Care Hospital (GACH) for one of three sampled residents (Resident 1). These failures had the potential to prevent Resident 1 from being properly informed of the basis for the transfer/discharge, which could impede her ability to understand and exercise her right to appeal the discharge.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer intravenous fluids (IVF - fluids administered through the vein) as ordered by the physician for one of one sampled resident (Resident 1). This failure had the potential to result in Resident 1 experiencing hypovolemic shock (not enough blood in the body to support organ function) and decreased urine output.

Inspectors wroteBased on interview and record review, the facility failed to provide medical records within two working days of a written request from an authorized representative ([AR] a person who is legally authorized to act on behalf of) per the facility's policy and procedure (P&P) titled, Resident Access to Protected Health Information (PHI), for two of three sampled residents (Residents 1 and 2).

Inspectors wroteBased on observations, interview, and record review the facility failed to:A. Document one dose of Acetaminophen in the July 2025 Medication Administration Record ([MAR] - a record of mediations administered to residents) for Resident 1B. Maintain accurate accountability records for controlled medication ([CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence), Tramadol on 7/16/2025 and 7/17/2025 for Resident 4 in one of two inspected medication carts (East Station Medication Cart)C. Ensure one of one resident (Resident 44) received lactulose (medication to treat constipation) as needed for no bowel movement in 48 hours. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was free of medication error rate of five percent or greater, as evidence by the identification of three medication errors out of 25 opportunities, to yield a facility error rate of 12 percent (%) for two of two Residents (Resident 4 and Resident 28) by failing to: 1. Ensure for Resident 4, Licensed Vocational Nurse (LVN) 2, LVN 3, and Registered Nurse (RN) 2 failed to follow facility's policies and procedures (P&P) titled, Medication - Administration, by failing to ensure the same nurse that prepared Resident 4's Tylenol (Acetaminophen [APAP], treat mild to moderate pain) Extra Strength Oral Tablet 500 milligrams (mg, unit of measurement by weight) administered the medication, and documented the administration of the medication to ensure the correct resident was administered the correct dose. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policies and procedures (P&P) titled, Medication - Administration, to prevent significant medication errors (medication errors that causes the resident discomfort or jeopardizes the resident health and safety) for two of five sampled residents (Residents 28 and Resident 4), by failing to: (Cross Reference F759) 1. Ensure LVN 2, LVN 3 and RN 1 followed facility's P&P titled, Medication - Administration, to ensure accurate administration of medications by making sure the same nurse preparing Resident 4's Tylenol medication for pretreatment for wound care was the same nurse that administered the medication and documented the administration. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of infectious organisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food) for 81 of the facility's residents who eat food prepared in the kitchen by failing to: 1. Ensure the store prepared 18 cups of juice with a prepared-on date.2. Ensure to place an open-date on a Residents juice that was placed in the fridge. These deficient practices had the potential to result in residents developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure two of three sampled residents' (Resident 2 and Resident 44) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for psychotropics (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was obtained prior to administration. This deficient practice violated Resident 2 and 44's rights to receive all information, in advance, of risks and benefits of proposed care, treatment, treatment alterative, and choose the alterative of choice which includes information for administration of psychotropic drugs.

Inspectors wroteBased on interview and record review, the facility failed to conduct Interdisciplinary Team (IDT- a group of medical professionals from different disciplines who work together to help a resident achieve their goals) meetings quarterly and as needed for one of three sampled residents (Resident 32). This failure resulted in Resident 32 and Resident 32's Responsible Party (RP) to be unaware of the plan of care and experience worry while waiting for mammogram (x-ray of the breast to detect signs of breast cancer) results for three months.

Inspectors wroteBased on interviews and record review, the facility staff failed to inform, and give notice of and information of a room change for one of three sampled resident's (Resident 75) . This deficient practice had the potential to affect Resident 75's self-esteem, self-worth, and cause confusion due to sudden room change.

Inspectors wroteBased on interview, and record review, the facility failed to ensure there was an appropriate indication for the use of antipsychotic (medication used to treat mental illness) medication for one of six sampled residents (Resident 4) when Resident 4 had haloperidol (a medication used to treat certain mental health) on an as-needed (prn) basis without a specific diagnosis or documented justification for administration of haloperidol. The deficient practice had the potential for use of unnecessary medications on Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to accurately document the 's Minimum Data Set (MDS - a resident assessment tool) for one of five sampled residents (Resident 3). This failure had the potential to result in a delay of care or not receiving the appropriate services or treatment.

Inspectors wroteBased on interview and record review the facility failed to develop a person-centered care plan for one of two sampled residents (Resident 4) for the used of antipsychotic medication, haloperidol (a medication used to treat certain mental health illnesses) .This failure had the potential to result in inappropriate medication use, lack of behavioral monitoring, and increased risk of adverse drug effects.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two sampled residents' (Resident 40) care plan for smoking was updated. The deficient practice had the potential to result in poor quality of care and a delay in care and services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one out of three residents (Resident 44) received assistance with toileting hygiene as needed. The deficient practice had the potential increased risk of skin breakdown and loss of dignity.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents with a diagnosis of Diabetes Meletus Type II (DM - a condition wherein the body can not regulate consumption and use of sugar which may result in poor wound healing) (Resident 28)'s:a. Physician was notifiedb. Change of condition (COC) was initiatedWhen Resident 28 had repeated hyperglycemic (level of blood sugar is higher are higher than normal [reference range70-99 milligram/deciliter (mg/dL- a unit of measurement used to express blood glucose levels) mg/dl]) events. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement accident risks and hazard interventions for two of Three sampled residents (Resident 38 and Resident 75) by: 1. Failed to ensure there was no smoking sign for a Resident 38 who is on oxygen.2. Failed to ensure Resident 75's bed was in the lowest position.3. Failing to ensure Resident 75 was placed in a low bed ( a bed frame designed to sit closer to the ground than a traditional bed). This deficient practice had the potential to result in injury .

Inspectors wroteFacility failed to ensure that the urinary catheter bag (a urine drainage bag is a small bag that collects urine when you have a catheter inserted into your bladder) for one of three sampled residents (Resident 8) did not touch the floor. This failure had the potential to result in contamination of the catheter system and an increased risk of urinary tract infection (UTI an infection in your urinary system, which includes your kidneys, bladder, and urethra) or other complications for Resident 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) orders, in accordance with physician orders and facility policy and procedures (P&P) titled, Feeding Tube - Medication Administered, for one of five sampled residents (Resident 28) by failing to ensure: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of three sampled residents (Resident 28 and 53) by not following the facility's own policy and procedure. a. For Resident 28, Facility failed to receive the physician's order for the use of oxygen and date on the nasal cannular (NC- a simple device used to deliver oxygen to the nose) while in use. b. For Resident 53, Facility failed to date on the NC while in use. a. During a review of Resident 28's admission Record, the admission Record indicated the facility admitted Resident 28 on 1/7/2022 and readmitted on [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD-a common lung disease that makes it hard to breathe). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents (Resident 5) received dialysis care and services based on professional standards. The facility failed to:a. Ensure Resident 5's fluid intake was being monitored.b. Ensure Resident 5 was assessed after the resident returned from the dialysis center. These deficient practices had the potential to result in complications from dialysis like fluid overload, infection and low blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 was competent in administering medication via a gastrostomy tube (GT and/or Enteral Feeding Tube, a tube inserted through the abdomen that delivers nutrition and/or medication directly to the stomach) in accordance with the facility's policy and procedure (P&P) titled, Medication Administration with Enteral Formulas Competency Validation. This failure had the potential for the facility not to be able to assess the skills necessary to provide services to assure resident safety.

Inspectors wroteBased on observation interview and record review the facility failed to ensureA. Licensed Vocational Nurse (LVN) 2 failed to perform hand hygiene (hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) for one of five sampled resident (Resident 28) during medication administration observation. This failure placed Resident 28 at risk for the spread of infection between residents and staff and had potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another). B. One of three residents (Resident 62)'s peripheral intravenous catheter IV ( [IV] a flexible tube inserted into a vein for medication administration) was labeled and dated . This deficient practice had the potential to result in the sterility infection at the IV site. Add to Based on:

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who had diagnosis of self-harm, did not inflict self-injury by spraying oven-cleaner (degreaser) over his arms, for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure staff followed Resident 1's untitled Care Plan dated 7/8/2025, for ideations of self-harm to provide the resident with a one-on-one sitter (a caregiver who provides continuous, dedicated support to an individual patient when a patient requires close supervision due to safety concerns such as potential for self-harm) after Resident 1 was readmitted back to the facility on 7/7/2025 from a general acute care hospital (GACH) 1 where he had been admitted for ideations of self-harm. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), whose cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired, and who was assessed at risk for elopement (the act of leaving a facility unsupervised and without prior authorization), was monitored to prevent him eloping from the facility. This deficient practice resulted in Resident 1 eloping from the facility, on 4/1/2025 at approximately 7 p.m. Resident 1 was found by a good Samaritan on 4/2/2025, approximately 14 miles from the facility, he was transferred to a General Acute Care hospital (GACH) for evaluation before being readmitted to the facility on [DATE]. This deficient practice had the potential for Resident 1 to continue to be missing, injury and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident, who was transferred by a mechanical lift (a device used to transfer residents from a bed to a chair or between surfaces), did not fall from the lift during transfer and sustained injuries for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA 1) did not transfer Resident 1 by herself from a bed to a shower chair (a movable or permanently installed seat for the tub or shower) by using a mechanical lift (a device used to transfer residents from a bed to a chair or between surfaces). 2. Ensure CNA 1 did not use a mechanical lift sling (accessory attached to a mechanical lift [device used to transfer residents from one surface to another]) with worn out straps to transfer Resident 1 from bed to shower chair. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 was competent to use the mechanical lift (a device used to transfer a resident from one surface to another) to transfer a resident (Resident 1) from bed to shower chair in accordance with professional standards of practice. This failure resulted in Resident 1 falling from the sling and suffering a head injury when CNA 1 transferred Resident 1 from bed to shower chair without assistance from another staff member.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain and calibrate (the process than ensures the reading and functionality of a device is accurate and in full working order) on 2 of 5 mechanical lifts (a device used to transfer residents from a bed to a chair or other similar places) mechanical lift 1 and mechanical lift 2 for use to transfer residents of the facility from one surface to another in the facility. This deficient practice had the potential to cause injury to any resident if the mechanical lift that was used to determine the weight of the resident was inaccurate. The inaccurate weight of the resident could lead to the wrong sling being used to transfer residents based on the height and weight of the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive care plan indicating two- person assist with using a mechanical lift (a device that helps safely transfer people with limited mobility from one place to another) was followed for one of three sampled residents (Resident 1), This deficient practice resulted in Resident 1 sliding out of the mechanical lift's sling and sustaining a bump on the right parietal (located near the back and top of the head) area of the head.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five sampled resident's (Resident 1) debit and credit cards were documented on their Personal Effects Inventory form, Resident 1 was made aware of the risk involved in keeping her debit and credit cards at her bedside and Resident 1 was offered a place to safely keep her debit and credit cards. This deficient practice resulted in Resident 1 being unaware of her rights as it pertained to her personal valuables and it had the potential for Resident 1's personal belongings to be lost, stolen and for her funds to be inappropriately used by unauthorized persons.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident, who had diagnosis of depression (mental health disorder characterized by persistently low mood or loss of interest in activities, causing significant impairment in daily life ) and a history of suicidal ideation (thinking about or formulating plans for suicide [the act or an instance of ending one's own life voluntarily and intentionally) did not commit suicide for one of three sampled residents out of 38 residents with a diagnosis of depression (Resident 1). The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed nurses notified the physician when a resident with diagnosis of depression (mental health disorder characterized by persistently low mood or loss of interest in activities, causing significant impairment in daily life ) experienced a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive behavioral, or functional status) manifested by sobbing (crying spells) and verbalization that someone wants to kill him by putting poison in his water pitcher for one of three sampled residents (Resident 1). This failure resulted in Resident 1 committing suicide (the act or an instance of ending one's own life voluntarily and intentionally). On [DATE] at 4:40 a.m. Resident 1 was found hanging in the bathroom with a phone charging cord around his neck. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed nurses (Licensed Vocational Nurse [LVN 1] Registered Nurse Supervisor [RNS 2] ) implemented the resident's care plan interventions related to the use of Lexapro (prescription medicine that treats depression [a mental health condition that involves a persistent feeling of sadness and loss of interest in activities, along with other symptoms that affect daily life] and anxiety ( feeling of worry, nervousness or unease) to prevent the resident from committing suicide (the act or an instance of ending one's own life voluntarily and intentionally) for one of three sampled residents (Resident 1). The facility failed to: 1. [...]

Inspectors wroteBased an observation, interview, and record review the facility failed to ensure facility staff including, Social Service Director, (SSD), Registered Nurses (RNs), Licensed Vocational Nurses (LVNs) and certified nursing assistants (CNAs) had competencies needed to care for residents with mental disorders and psychosocial disorders) for 38 sampled residents (Resident 1). The facility failed to: 1. Intervene when Resident 1 was observed sobbing (crying spells) and was accusing CNA 1 of putting poison in his water pitcher on 9/14/2024 at 12:15 a.m. [...]

Inspectors wroteBased on interview, and record review the facility's Quality Assurance Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) failed to identify resident care issues, develop, implement appropriate plans of action, and evaluate measures necessary to provide behavioral health care and services for the treatment of the resident's emotional and mental condition by ensuring: 1. Resident 1 who had a diagnosis of depression and history of suicidal thoughts from previous admission on [DATE] was assessed, monitored closely and primary care physician notified after observed having crying spells, anxiety (feeling of uneasy and worried), fear and verbalized Certified Nursing Assistant (CNA )1 put poison in his water pitcher on 9/14/2024 at 12:15 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a competency and skill set review on four of five sampled staff employees were completed according to the facility ' s policy and procedure. This failure had the potential to put residents at risk for not receiving care in a safe and competent manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) did not receive Seroquel (a psychotropic medication [drug that affects brain activities associated with mental processes and behavior] used for mental and mood disorders) without a diagnosis and indication of used. These failures resulted in Resident 2 to received Seroquel without diagnosis from Resident 2 ' s physician and had the potential for increased risk for Residents 2 to experienced serious adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) of Seroquel including dizziness, drowsiness and irregular heartbeat, that can lead to an overall negative impact on their physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services to meet the residents needs for two of three sampled residents (Resident 1 and 2) when: a. The facility failed to ensure Registered Nurse (RN) 1 did not document in Resident 1 ' s Medication Administration Record (MAR) that Methadone (strong medicine used to treat heroin [an illegal substance] dependence) was administered on 7/27/2024 to Resident 1 because it was not given to Resident 1. b. The facility failed to ensure Resident 1 ' s physician order for Methadone on 7/17/2024 at 12:29 p.m. indicated the medication should not be administered on the day Resident 1 will visit the methadone clinic on Mondays. c. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication error when: a. The facility failed to ensure Resident 1 received Methadone (strong medicine used to treat heroin [an illegal substance] dependence) 55 milligrams on 7/27/2024 at 9 a.m. as ordered. b. The facility failed to ensure Resident 1 ' s physician order for Methadone on 7/17/2024 at 12:29 p.m. indicated the medication should not be administered on the day Resident 1 will visit the methadone clinic on Mondays because Resident 1 will receive a dose in the clinic. The deficient practice of not receiving the methadone on 7/27/2024 placed Resident 1 at risk for drug withdrawals (negative physical and mental symptoms that occur after stopping or reducing intake of a drug). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were dated, properly sealed, refrigerated after opening per manufacturer's recommendation, and discarded before the used by date (expiration dates) for 91 out 93 total residents. This failure placed residents at risk for developing foodborne illness (food poisoning: any illness resulting from the food spoilage from contaminated food with germs) which can cause symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all facility staff were provided with five hours of dementia (diseases that affect memory and thinking) training annually. This failure had the potential to result in residents with dementia being neglected and not provided with resident centered, comprehensive care.

Inspectors wroteBased on observation, interview and record review, the nursing staff member failed to provide reasonable accommodation to meet the resident's needs for five of five sampled residents (Resident 442, Resident 19, Resident 441, Resident 32, and Resident 192 by: A. Failing to adjust the side rails as resident requested on 3/2024 for Resident 442. B. Failing to place call light within reach for Resident 442, 19, 32 and 192. These failures had the potential to resulted in residents not being able to summon staff for assistance with care, and negatively impacting the psychosocial well-being of the residents or result in delayed provision of services.

Inspectors wroteBased on interview and record review, the facility failed to implement the care plan interventions for two of three sampled residents (Resident 293 and Resident 193). The facility failed to: 1. Implement interventions for smoking for Resident 293. 2. Treat and provide pain medication for Resident 193. These deficient practices had the potential for delayed provision of necessary care and services. a. [...]

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure effective pain management for two of five sampled resident (Resident 441 and Resident 193), by failing to: a. Obtain a physician order for pain medication for moderate pain (pain scale rating from zero to ten [pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible]). This deficient practice had the potential to result in insomnia (a sleep disorder with trouble falling asleep, staying asleep, or getting good quality sleep) for Resident 441 b. Administer pain medication in a timely manner as ordered by Resident 193 physician. This failure resulted in Resident 193's to experience unnecessary pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 391) received treatment in accordance with the physician`s order. This deficient practice has the potential for Resident 391 not be free from infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure feeding tube formula, tubing, administration syringe, and water flush bags were changed within 24 hours for one of three sampled residents (Resident 85). This failure had the potential to result in Resident 85's Gastrostomy tube ([G-tube] - tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) getting clogged and placed Resident 85 at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician responded to the consultant pharmacist's recommendation from 6/4/24 to obtain a valproic acid level (a lab value used to ensure certain medications are used safely and effectively) related to the use of divalproex sodium (a medication used to treat seizures) in one of five sampled residents (Resident 5.) The deficient practice of failing to ensure the physician evaluated and responded to medication irregularities (potential issues with a resident's medication regimen) identified by the consultant pharmacist during the Medication Regimen Review (MRR - a monthly report from the consultant pharmacist identifying any medication irregularities in a resident's current medication regimen) increased the risk that Resident 5 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor valproic acid levels (a laboratory test used to ensure medications used to treat seizures are present at a safe and effect level in the blood) related to the use of divalproex sodium (a medication used to treat seizures) in one of five residents sampled for unnecessary medications (Resident 5.) The deficient practices of failing to monitor valproic acid levels related to the use of divalproex increased the risk that Resident 5 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) or seizures related to valproic acid levels being too high or too low leading to medical complications possibly resulting in hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard and replace one expired fluticasone/salmeterol inhaler (a medication used to treat breathing problems) affecting Resident 22 in one of two inspected medication carts (East Medication Cart.) The deficient practice of failing to remove expired medications from the medication carts increased the risk that Resident 22 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on interview and record review, the facility failed to assess mental capacity (ability to make decisions) and provide information to one of three sampled residents (Resident 85) and their responsible parties before signing arbitration agreement (a way of resolving a dispute without filing a lawsuit and going to court). This failure had the potential to result in Resident 85 not fully understanding their right to limit opportunity to initiate judicial proceedings that challenge unfavorable decisions.

Inspectors wroteBased on interview and record review, the facility failed to supervise two of seven sampled residents (Resident 1 and Resident 6). A. The facility failed to ensure Resident 1 did not leave the facility premises unsupervised and without the staff knowledge and this failure had the potential for Resident 1 to be exposed to elements of extreme weather conditions, traffic accident, safety/ fall incident and/or be subjected to any forms assault (physical attack) which could be detrimental to her health and well-being. B. The facility failed to ensure Resident 6 was assisted to use the toilet in a timely manner. This failure left Resident 6 feeling frustrated because she had to crawl her way to the toilet to prevent herself from having an incontinence in her bed.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of seven sampled residents (Resident 1 and Resident 6) were provided psychological (emotional and mental state) assessment and follow-up when: a. Resident 1 left the facility unnoticed and was found by facility staff under a tree with bare minimum clothes and no shoes, and b. Resident 6 crawled on the floor to use the toilet when there was no supervision provided for Resident 6. This failure had the potential to result in the residents' unmet psychosocial needs and concerns which could potentially affect their quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the alarm system located at the rear entrance/exit door of the building was functioning properly. This failure has resulted in the elopement (resident leaving premises without knowledge of staff) of one of seven sampled residents (Resident 1) which could have negatively caused Resident 1 her safety and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 6) was treated with dignity and respect by assisting Resident 6 to use the toilet in a timely manner. This failure left Resident 6 feeling frustrated because she had to crawl her way to the toilet to prevent herself from having an incontinence in her bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to Identify and to intervene for one of three sampled residents (Resident 1) with a history of trauma and triggers which may cause re-traumatization. This failure resulted in Resident 1 feeling anxious and re-traumatized by Resident 2 during smoking breaks at the smoking patio.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility ' s Coronavirus disease Covid-19(respiratory infection) policy by: a. failing to report the COVID-19 outbreak (At least one laboratory confirmed case of COVID-19 resident who has resided in the skilled nursing facility for at least 7 days,)to the California Department of Public Health (CDPH), with one out of three sampled residents (Resident 2) positive for Covid-19 on 10/9/2023, b. failing to document 159 out of 159 facility staff COVID testing from (10/18/2023 -10/25/2023). This deficient practice potentially increased the risk of further spreading Covid-19 to other residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for one of one resident (Resident 1), when Resident 1 filed a grievance (a complaint that may or may not be justified) on 7/12/2023 with the Social Services Director (SSD) alleging Certified Nursing Assistant (CNA)1 inappropriately touched her (Resident 1). This deficient practice delayed California Department of Public Health (CDPH) investigation and had the potential to result in further abuse to go unreported. Findings During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted on [DATE] with the diagnoses including diabetes (high blood sugar in the blood) and morbid obesity (more than 80 to 100 pounds above their ideal body weight). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow professional standards of practice when Licensed Vocational Nurse 1 (LVN 1) administered one of one resident (Resident 1) Docusate Sodium 100 mg (milligrams) tablet (medication to soften bowel movements) without a physician ' s order. This deficient practice resulted in Resident 1 receiving medication without a physician order and had a potential for Resident 1 to experience allergic reactions or medication interactions. Findings During a review of Resident 1 ' s admission record (AR), the AR indicated Resident 1 was admitted on [DATE] with the diagnoses including diabetes (high blood sugar) and osteomyelitis (infection of the bone) of the lower leg. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA 1) did not transfer a resident, who required two persons for physical assistance with transfers between surfaces, by using a mechanical lift (a device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) alone, for one out of two sampled residents (Resident 1). As a result of this deficient practice Resident 1 sustained a nasal (nose) bridge laceration (cut) with a nasal fracture (a break) after being struck in the nose by the bar of the mechanical lift. Resident 1 was transferred to a General Acute Care Hospital (GACH) where he was treated with IV ([intravenous] in the vein) antibiotics (medication to treat bacterial infections) for his nasal laceration and nasal fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two sampled residents (Residents 29 and 39) were treated with dignity and respect by: 1. Failing to provide Resident 29 with privacy after being left naked and exposed in bed while waiting for care to be provided. 2. Failing to ensure staff did not stand over Resident 39 while assisting with meals. These deficient practices had the potential for Residents 29 and 39 to experience embarrassment due to a loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to resolve the following resident grievances in a timely manner for three of nine sampled residents (Residents 33, 61, and 68): 1. Residents 61 and 68 missing clothing items from the laundry room. 2. Resident 33's missing backpack. This deficient practice was violation of the facility's policy to make every effort to have a home-like environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Recognize Resident 31's non-verbal cues for pain and to ensure the resident's pain assessment was accurate. 2. Ensure Resident 31's care plan interventions for pain management were implemented. 3. Ensure Resident 31 received appropriate hospice (care to provide comfort, relieve pain, and offer support for persons near the end of life and their families) services. These deficient practices resulted in inadequate relief from pain for Resident 31 and placed Resident 31 at risk of not receiving the care necessary to prevent pain, discomfort and distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain medication for one of five sampled residents (Resident 31) prior to wound treatment. This deficient practice resulted in Resident 31 experiencing unnecessary pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure nursing staff administered a medication with meals and food, per physician's order, for one of three residents (Resident 61) observed during the morning medication administration (med pass). 2. Ensure a resident (Resident 285) was assessed and received a physician's order for the self-administration of medications, and the medications left at the bedside were labeled and checked for drug interactions from the facility's contracted pharmacy. These deficient practices had the potential for harm to Residents 61 and 285 due to potential adverse effects of the medications and medication duplication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five (5) percent, due to two (2) medication administration errors involving one out of three residents (Resident 61) observed during medication administration (med pass). This deficient practice of a medication administration error rate of six and six one hundredths percent (6.06 %) exceeded the five (5) percent threshold.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one (1) bottle of an over-the-counter medication was not expired, located in one (1) medication storage room, out of three (3) total medication storage rooms at the facility. This deficient practice had the potential for harm to residents due to the potential loss of strength of the medication, and the potential for the residents to receive ineffective medication dosages due to expired medication. 2. Ensure the refrigerator temperature monitoring records did not have an incorrect printed temperature range, located in two (2) medication storage rooms, out of three (3) total medication storage rooms at the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the following for one sampled resident (Resident 44) receiving hospice (type of healthcare that focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life) care: a. Ensure there was a signed agreement between the facility and the Hospice agency. b. Ensure Resident 44's diagnoses qualified the resident to be placed under hospice care. c. Ensure Informed consent and treatment authorization of the Hospice program was completed and signed. d. Implement the facility's Hospice program policy and procedures. e. File weekly assessment nursing progress notes in the Hospice binder or in Resident 44's medical records. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate infection control practices were implemented, by not: a. Ensuring a resident (Resident 3), who was positive and on contact isolation for Clostridium difficile ([C-diff] infectious germ that causes severe diarrhea, watery stool and inflammation of the colon transmitted from person to person by spores) did not share a room with other residents. b. Ensuring staff wore proper personal protective equipment ([PPE] protective clothing, gloves, masks designed to protect from the spread of infection or illness) while handling soiled linen hampers and trash. c. Ensuring kitchen staff used gloves while handling food. These deficient practices had the potential to result in cross contamination, foodborne illnesses and spread of infection among residents and other staff members.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform one sampled resident (Resident 33) during the admission process whether a electric wheelchair for mobility was allowed in the facility. This deficient practice denied the resident of her right to be informed.

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan to prevent one sampled resident (Resident 70) from the recurrence of developing a urinary tract infection ([UTI] infection of the bladder). This deficient practice placed Resident 70 at increased risk for recurrent UTIs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 49) was provided with a smoking apron (protective fabric designed to protect smokers from cigarette burns) during smoke breaks. This deficient practice placed Resident 49 at risk for injury and bodily harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a therapeutic diet (meal plan that controls the intake of certain foods or nutrients/compounds in foods often followed as part of the treatment of a medical condition, and is most times done temporarily to heal and/or to prevent health conditions) prescribed by the physician was followed and food preferences were honored for one sampled resident (Resident 84). This deficient practice had the potential for Resident 84 to experience stomach cramps, pain and diarrhea.

Inspectors wroteBased on interview and record review, the facility failed implement a resident's Minimum Data Set ([MDS] a resident assessment and care-screening tool) assessment to assist in directing care to one of 18 sampled residents (Resident 44) who required a two-person physical assist, by failing to: 1. Implement its policy and procedure (P/P) which indicated a care plan would be initiated according to identified risk factors. 2. Ensure staff were trained how to use the assessment Resident Special Needs List tool. These deficient practices resulted in Resident 44 falling and sustaining a scrape (injury to the skin) to the left knee and soreness to the left hip, and the potential for a fracture (broken bone) or severe injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident 39) was free of unnecessary medications. This deficient practice placed Resident 39 at increased risk for adverse drug side effects due to the resident taking multiple medications in the same drug category.

Inspectors wroteBased on interview and record review, the facility failed to document a reason for not attempting a gradual dose reduction (GDR) for the use of an antidepressant (medication used for the treatment of mood disorders) for one resident sampled (Resident 39). This deficient practice had the potential to result in Resident 39 receiving more medication than was necessary.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Correctly label and date food items in the kitchen. 2. Ensure the ice-maker machine was locked and the interior was free from dirt. These deficient practices placed the residents receiving food and ice from the kitchen at risk for food-bourne illnesses.