Oc Reading Center LLC

Inspectors wroteBased on observations and interviews, the facility failed to ensure that Residents were provided with a dignified existence on two of two units. Specifically, the facility failed to:1. Ensure that staff members were not using their personal cellphones in Resident areas with Residents present. 2. Ensure that staff members were not speaking a foreign language to each other in front of Residents who do not speak that language.

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were stored according to manufacturer's guidelines in three of three medication carts observed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to identify and assess the use of pillows tucked underneath a fitted sheet and on top of the raised edges of the perimeter mattress on both sides of the bed as a potential restraint for one Resident (#42) out of a total sample of 19 residents.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement an effective baseline person-centered care plan within 48 hours from admission to the facility for one Resident (#76) out of a total sample of 19 residents. Specifically, Resident #76 was admitted to the facility due to a fall, Resident #76 sustained a fall four days after admission, and a falls care plan was not developed or implemented until four days after admissionFindings include: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident with pressure ulcers receives the necessary care and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one Resident (#2) out of a total sample of 19 residents. Specifically, the facility failed to:Ensure weekly skin checks were being completed for Resident #2 who has a stage 2 pressure ulcer 2. Ensure assessment of a pressure ulcer was being completed.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure professional standards for nutrition were implemented for one Resident (#54), out of a total sample of 19 residents. Specifically, for Resident #54, the facility failed to address a significant weight loss in a timely manner resulting in Resident #54 continuing to lose weight resulting in a severe total loss of body weight of 11.97% in approximately 2 months.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for 1 Resident (#17), out of three applicable residents who require renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 19 residents. Specifically, the facility failed to ensure for Resident #17 who had a tunneled femoral hemodialysis line (type of vascular access used for hemodialysis, allowing access to the bloodstream for blood filtration in the thigh area), the facility failed to ensure nursing implemented storage of a clamp at bedside in case of emergency in accordance with the physician's order.

Inspectors wroteBased on interviews and records reviewed, for one of four sampled residents (Resident #2), who was alert oriented and able to make his/her needs know, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when it was reported that during an overnight shift (8/20/25 into 8/21/25) that Certified Nurse Aide (CNA) #2, while interacting with Resident #2, roughly grabbed him/her by wrist, was rude and disrespectful while providing care and when Resident #2 asked CNA #2 for his name, CNA #2 laughed at him/her and walked out of the room.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was found unresponsive by staff, the Facility failed to ensure that Licensed Nursing Staff had adequate training, and the necessary skill set needed to initiate life saving measures in an effective and efficient manner when responding during an emergency situation.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was found unresponsive by staff, and required staff to initiate a Code Blue, the Facility failed to ensure that Licensed Nursing Staff were competent in process of calling and responding in the event of a Code Blue situation.

Inspectors wroteBased on record review and interview, the facility failed to maintain the highest practicable physical, mental, and psychosocial well being for one Resident's (#55) with a history of suicidal ideation (SI) and depression, out of a total sample of 27 residents. Specifically, Resident #55 was not provided with appropriate behavioral health services following verbalization of SI, and attempted to kill him/herself at the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide the appropriate treatment and services for one Resident (#55), with a known history of depression, suicidal ideation, and adjustment difficulty, out of a total sample of 27 residents. Specifically, the facility failed to develop, implement, and update the plan of care, resulting in an attempted suicide after the vocalization of suicidal ideation (SI).

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop a comprehensive person centered care plan and implement the plan of care for two Residents (#55 and #13) out of a total sample of 27 residents. Specifically: 1. for Resident #55, the facility failed to develop a Suicidal Ideation (SI) care plan, after vocalization of suicidal ideation, which resulted in the Resident attempted to commit suicide at the facility and; 2. for Resident #13, the facility failed to develop and implement a plan of care for incontinence.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide necessary treatment, services, interventions to promote healing and prevent new ulcers from developing for one Resident (#4), who was assessed to be at risk for pressure ulcer development, out of 27 total sampled residents. Specifically, for Resident #4: a.) the facility failed to implement physician ordered pressure ulcer prevention interventions to offload heels and ensure correct air mattress settings were implemented consistently resulting in new skin breakdown including the re-opening of a previously healed pressure ulcer on the left upper Achilles heel; b.) the facility failed to obtain wound care orders for the newly re-developed pressure ulcer on the left upper Achilles heel; c.) the facility failed to ensure a right heel pressure related deep tissue injury (DTI) was assessed and measured weekly; [...]

Inspectors wroteBased on interviews, record review, staff education review, and facility assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to ensure licensed nursing staff were trained and demonstrated competency related to wound care.

Inspectors wroteBased on observation, record review and interview the facility failed to provide a dignified existence for one Resident (#13) out of a total sample of 27 residents. Specifically, the facility failed to provide requested incontinence care before meals resulting in Resident #13 repeatedly eating breakfast while sitting in a soiled brief, on multiple days of survey, in a room that smelled strongly of feces.

Inspectors wroteBased on observations, interviews and record review, the facility failed to notify the physician of a significant change in the resident's skin condition and obtain wound treatment orders for two Residents (#4 and #269) out of a total sample of 27 residents. Specifically; 1a.) for Resident #4, the facility failed to notify the provider and obtain wound care orders for the newly re-developed pressure ulcer on the left upper Achilles heel; 1b.) for Resident #4, the facility failed to notify the provider and obtain wound care orders for a skin tear on his/her left hand; and 2.) for Resident #269, the facility failed to notify the provider and obtain wound care orders for a skin condition on his/her buttocks.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one Resident's (#31) grievances were addressed, out of 27 total sampled residents. Specifically, the facility failed to follow their grievance policy when Resident #31 expressed concern multiple times about the staff behavior of sleeping while on duty.

Inspectors wroteBased on record review and interview, the facility failed to follow their abuse policy for one Resident (#38) out of a total sample of 27 residents. Specifically, the facility did not implement the corrective actions after an abuse investigation was conducted.

Inspectors wroteBased on record review and interviews, the facility failed to investigate allegations of neglect for two Residents (1a. discharged Resident #1 and 1b. discharged Resident #2) out of a total sample of 27 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility to ensure that services provided met professional standards for two Residents (#14 and #16), out of 27 total sampled residents. Specifically, 1a.) for Resident #14, the facility failed to transcribe and implement a daily wound dressing according to the physician's order for ten days. 1b.) for Resident #14, the facility failed to implement a daily wound dressing according to the physician's order for two days. 2.) for Resident #16, the facility failed to implement physician orders for heel protection booties.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide Activity of Daily Living (ADL) care to three Residents (#44, #14 and #54), by failing to provide weekly showers, out of a total sample of 27 residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure services to maintain hearing were implemented for one Resident (29), out of a total sample of 27 residents. Specifically, the facility failed to implement the treatment for ear wax removal timely resulting in a delay in the process of obtaining hearing aids.

Inspectors wroteBased on record review and interview, the facility failed to update the plan of care or complete a falls assessment after falls for two Residents (#38 and #27) out of a total sample of 27 residents. Specifically, 1. for Resident #38, the facility failed to review and revise the plan of care after multiple falls resulting in a fall with a fracture; and 2. for Resident #27, the facility failed to update the plan of care following a fall with fracture.

Inspectors wroteBased on interviews and record review, the facility failed to provide care and services consistent with professional standards including ongoing communication and collaboration with the dialysis facility for one Resident (#31), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working), out of 27 total sampled residents. Specifically, the facility failed to ensure complete and accurate communication with the dialysis facility for Resident #31's dialysis appointments.

Inspectors wroteBased on record review and interview, the facility failed to review and address pharmacy recommendations for one Resident (#38) out of a total sample of 27 residents.

Inspectors wroteBased on observations, interviews, and record review for one Resident (#9) out of four residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. One out of three nurses observed made two errors out of 31 opportunities resulting in a medication error rate of 6.45%. Specifically, Nurse #3 administered the incorrect calcium carbonate without clarifying a missing dosage and administered ferrous sulfate without clarifying a missing dosage.

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were stored in the original, labeled containers.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain accurate medical records for three Residents (#14, #6, and #44), out of a total sample of 27 residents. Specifically, 1. for Resident #14, the nurses documented a physician's order for his/her bilateral lower extremity wounds as implemented when it was not; 2. for Residents #14, #6 and #44 the facility failed to complete daily documentation; Findings Include: 1. Resident #14 was admitted to the facility in June 2024 with diagnoses including diabetes, venous ulcers, and chronic respiratory failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/18/24, indicated Resident #14 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. The MDS further indicated Resident required substantial assistance for bathing/showering tasks. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan related to resident's concerns of not receiving showers.

Inspectors wroteBased on observations and interviews, the facility failed to implement the infection prevention and control program. Specifically, 1.) the facility failed to ensure a nurse performed appropriate hand hygiene after removing gloves during wound care; and 2.) the facility failed to ensure a nurse performed appropriate hand hygiene after contact with body fluids during tracheotomy (a surgically created opening in the neck that provides an alternative airway for breathing) care.

Inspectors wroteBased on records reviewed and interviews, for 21 of 21 sampled Residents who were alert, orient, and able to communicate with staff, (Resident's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) the Facility failed to ensure they were issued and provided with a written notice of a room change and/or the receipt of a new roommate prior to making the changes.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications such as topical and treatment items were not stored with oral medications on 3 out of 3 medication carts.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a dignified dining experience for 1 Resident (#14) out of a sample of 27 Residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one Resident (#18) was assessed for the ability to self-administer medications, out of a total sample of 27 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to obtain psychotropic consents from the legal representative for 1 Resident (#54) out of a sample of 27 Residents.

Inspectors wroteBased on record review, interview and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for Covid 19 infection for one Resident (#225) out of a total sample of 27 residents. Specifically, for Resident #225 the facility failed to implement Covid-19 monitoring until 5 days after admission

Inspectors wroteBased on record review and interview, the facility failed to 1) address and implement recommendations made by the behavioral health Nurse Practitioner for one Resident (#8) and 2) transcribe wound treatment correctly, as recommended by the wound physician, for one Resident (#10) out of a total sample of 27 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide activities of daily living, specifically removing chin hair, for 1 Resident (#9) out of a total sample of 27 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to 1. document a bruise on a skin check and complete a skin incident report for 1 Resident (#47) and 2. failed to review and implement hospice recommendations for 1 Resident (#53) out of a total sample of 27 residents.

Inspectors wroteBased on record review and interview, the facility failed to implement recommendations made by the eye doctor for 1 Resident (#63) out of a total sample of 27 residents.

Inspectors wroteBased on observations, record review and interviews the facility failed to follow a wound physician's recommendations for prevention of a pressure ulcer for one Resident (#10) out of a total sample of 27 residents. Findings Include: Review of facility policy titled 'Pressure Ulcer Prevention' last revised December 2022, indicated the following but not limited to: Policy: *The facility will implement interventions to minimize and/ or eliminate contributing factors for pressure ulcer development on patients/residents at risk. *Use pillows or specialty devices and support surfaces to float or off-load heels. Resident #10 was admitted to the facility in July 2023 with diagnoses including acute osteomyelitis of right ankle and foot (bone infection). [...]

Inspectors wroteBased on record review and interview, the facility failed to complete a fall risk assessment before and after a fall, according to facility policy, for 1 Resident (#53) out of a total sample of 27 residents.

Inspectors wroteBased on record review, interview and policy review, the facility failed to identify and address a significant weight change and provide weekly weights as ordered for one Resident (#63) out of a total sample of 27 Residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to 1. follow physician's orders for oxygen management for 1 Resident (#9) and 2. failed to obtain an order for oxygen for 1 Resident (#58), out of a total sample of 27 residents.

Inspectors wroteBased on record review and interviews, the facility failed to provide behavioral services in a timely manner to 1 Resident (#2) out of a total sample of 27 residents.

Inspectors wroteBased on record review, policy review and interview, the facility failed ensure that PRN (as needed) psychotropic medication was limited to 14 days, and that the physician evaluated the appropriateness to extend the use and document the rationale and the duration for the PRN medication for one Resident (#51) out of a total sample of 27 residents.

Inspectors wroteBased on observations, record reviews, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Two out of three nurses observed made five errors in 31 opportunities on two of three units resulting in a medication error rate of 16.13%. These errors impacted two Residents (#42 and #35), out of 4 residents observed. Findings Include: Review of the facility policy titled ' Medication Administration-General Guideline' dated 10/1/2019 indicated the following but not limited to: Policy: Medications are administered and prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedures: *Five rights- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. 1. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow a fluid restriction for a 1 Resident (#47) out of a total sample of 27 residents.

Inspectors wroteBased on record review and interview, the facility failed to inform 2 out of 3 Residents, or their representatives of potential liability for payment for non-covered services including estimated cost of services.