Oceana Healthcare Center

Inspectors wroteBased on interview and record review the facility failed to provide a copy of requested resident records upon written request for one of three sampled residents (Resident 1). This deficient practice violated the rights of Resident 1's legal representative to obtain requested copies of Resident 1's records.

Inspectors wroteBased on interview and record review the facility failed to implement its policy and procedure (P&P) by failing to ensure prompt physician notification of one of one of three sampled residents, Resident 1 when Resident 1 refused ordered medication Asperflex lidocaine 4% patch (a topical medication used to provide temporary relief for minor muscle, joint, and nerve pain) on multiple occasions. This deficient practice had the potential for significant medication errors and timely medication review and intervention by the physician.

Inspectors wroteBased on interview and record review, the facility staff failed to record accurately by failing to document the ordered medication Asperflex lidocaine 4% patch (a topical medication used to provide temporary relief for minor muscle, joint, and nerve pain) as administered and removed when a resident refused Asperflex lidocaine 4% patch medication more than twice for one of three sampled residents Resident 1. This deficient practice resulted in Resident 1's electronic medication administration records to be inaccurate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers according to predetermined and scheduled dates for two of three sampled residents, Resident 1 and Resident 3 according to the facility's policy and procedures (P&P) titled Activities of Daily Living, Quality of Care, Routine Resident Monitoring, and Scope of Services revised 7/11/2025. This deficient practice resulted in Resident 1 and Resident 3 missing at least two showers in the last month or two and had the potential to negatively impact Resident 1 and Resident 3's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident received necessary physical and occupational therapy (PT/OT) services by not facilitating a resident's secondary insurance coverage for one of three sampled residents, Resident 1 according to the facility's policy and procedures (P&P) titled Specialized Rehabilitative Services revised 7/11/2025. This failure resulted in delay of medically necessary therapy services and had the potential for Resident 1 to decline in activities of daily living (ADL).

Inspectors wroteBased on interview and record review, the facility failed to ensure that Certified Nursing Assistant (CNA) 4 was not assigned to provide care to two out of five sampled residents (Resident 4) on 2/17/2026 on the 11pm to 7 am shift according to f the facility 's policies and procedures (P&P) titled , Abuse Reporting and Prevention date 7/11/2025, and Rules of conduct dated 01/2026. The facility was aware that Resident 4 had requested that CNA4 not be assigned to Resident 4. This deficient practice resulted in:A loud argument and possible physical altercation between Resident 4 and CNA4. Resident 5 complaining that he did not like how CNA4 turned him when providing care to him.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to accommodate the residents' needs and request according to the facility's policy and procedures (P&P) titled, Staffing reviewed on 7/11/2025 for seven of ten sampled days (on 2/8/2026, 2/10/2026, 2/11/2026, 2/12/2026, 2/15/2026, 2/16/2026 and 2/17/2026). This deficient practice resulted in residents not receiving needed services timely and efficiently and had the potential to affect the quality of life and treatment given to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement facility's policy and procedures (P&P) titled, Scabies - Prevention and Control, when one of three sampled residents (Resident 5) was noted with signs and symptoms (s/sx) of scabies (a contagious skin disease marked by itching and small raised red spots, caused by the itch mite that burrow into the skin) by failing to:1. Properly identify possible cases of scabies infection as soon as possible.2. Develop contact list (tracing) and to notify and educate facility's employees, family members and visitors. This deficient practice had the potential to further spread infection to the residents, visitors, and the community.

Inspectors wroteBased on interviews, observation and record review, the facility failed to maintain a safe, functional and comfortable environment for residents, staff, and visitors by failing to ensure three of five sampled rooms (room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]) were free of water leaks according to the facility's policies and procedures (P&P) titled, General Maintenance, reviewed on 7/11/2025, and Physical Environment, reviewed on 7/11/2025. This deficient practice had the potential to cause incidental accidents and have the potential for the residents' physical discomfort for residents staff, and visitors.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure one of four sampled residents (Resident 1), received care consistent with professional standards of practice to promote healing of pressure ulcers/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), prevent infection and prevent new ulcers from developing by failing to:Ensure Resident 1 was repositioned every two hours according to Resident 1's comprehensive plan of care and facility's policy and procedures (P&P) titled Activities of Daily Living, Quality of Care, Routing Resident Monitoring, and Score of Services, reviewed on 7/11/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 8) who was identified as at risk for falls did not experience a fall by failing to: Ensure Resident 8 was properly assessed and monitored after Resident 1 slipped out of the wheelchair on 1/16/2026 according to facility's policy and procedures (P&P) titled, Falls by a Resident, reviewed on 7/11/2025. Ensure Resident 8's Fall Risk Assessments were accurately documented by licensed nurse according to facility's P&P titled, Fall Risk & Prevention of Injury to include pathological Fractures, reviewed on 7/11/2025, and P&P titled Falls by a Resident reviewed on 7/11/2025. These deficient practices placed Resident 8 at risk for further falls and/or injuries.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedures (P&P) titled Change of Condition - SBAR [situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents] -Assessment reviewed by the facility on 7/11//2025, for one of three sampled residents (Resident 1). By failing to notify Resident 1's physician on 2/10/2026, when the resident was assessed as a high risk for elopement (the act of leaving a facility unsupervised and without prior authorization). This deficient practice resulted in Resident 1 not receiving orders for a wander guard (an electronic safety technology used in care facilities to prevent residents with dementia or cognitive impairment from wandering off or eloping [leaving]) and eloping from the facility without staff knowledge on 2/11/2026. [...]

Inspectors wroteBased on observation, interview, and record review the facility to develop and implement and individualized and comprehensive care plan to meet the individual needs for one out of three sampled residents (Resident 1), who was identified to be at high risk for elopement (the act of leaving a facility unsupervised and without prior authorization) risk. As a result, on 2/11/2026 Resident 1 eloped (left) from the facility unsupervised without staff knowledge and the resident's whereabouts unknown for 17 hours. Placing Resident 1 at risk for serious injury, harm, or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of21 sampled residents (Resident 75 and Resident 115), received care, treatment, and services in accordance with the physician's order and policy and procedure by failing to:Follow doctor's orders to perform oral care with Chlorhexidine Gluconate Mouth/Throat Solution 0.12% (a solution used to treat gingivitis (inflammation of the gum), reduce gum swelling, redness, and bleeding by decreasing mouth bacteria (germs) and provide 5 milliliters (ml - unit of measurement) of water every shift; per doctor's orders. Initiate a Situation, Background, Assessment, Request (SBAR-a formal written communication tool used to provide essential, concise information during crucial medical situations) Form when Resident 115 complained of abdominal pain. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide competent Restorative Nursing Assistant (RNA, nursing assistant program that help residents to maintain their function and joint mobility) nursing staff when:1. The facility failed to complete annual competencies for putting on and taking off splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and braces (an external device to support, align, or correct a movable part of the body) for two sampled RNAs.2. Restorative Nursing Assistant (RNA) 1 did not follow and perform RNA treatment as ordered by a physician during an RNA treatment session on 2/4/2026 with Resident 74. These deficient practices had the potential to cause injury and harm to residents who require splints during RNA and to Resident 74 during the RNA program.

Inspectors wroteBased on interview and record review, the facility failed to provide accurate and complete medical records and documentation based on professional standards for three of 22 sampled residents (Residents 23, 32, and 8) when:1. For Resident 23, Restorative Nursing Assistant program (RNA, nursing assistant program that help residents to maintain their function and joint mobility) documentation indicated Resident 23 received RNA treatment on 2/4/2026 when Resident 23 did not receive RNA treatment.2. For Resident 32, a Certified Occupational Therapy Assistant (COTA) 2 signed on behalf of the Physical Therapist (PT) 1 on a physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) treatment encounter note.3. For Resident 8, a Certified Occupational Therapy Assistant (DOR/COTA) 1 signed on behalf of PT 1 on a PT treatment encounter note. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control procedures to help prevent the development and transmission of communicable diseases (illnesses caused by organisms that can be passed from person to person) and infections by failing to ensure:1. Provide hand soap and hand sanitizer supplies in Resident 56 and 74's room.2. Properly sanitize and disinfect a cloth gait belt (an assistive device that is secured around a person's waist to assist in moving a person) between multiple resident use. 3. Staff handled soiled linen in a sanitary manner per facility's policy and procedures titled, Infection Control Policy - Laundry Services. These deficient practices had the potential to spread infections and illnesses between residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the licensed nursing staff failed to offer the pneumonia vaccine as required or appropriate to one of five sampled residents (Resident 13 and Resident 32). This deficient practice placed Resident 13 and Resident 32 at increased risk of acquiring and transmitting pneumonia to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident or their representative was notified timely in writing the reason for the transfer/discharge to the hospital for one of eight sampled residents, (Resident 38). This deficient practice resulted in resident 38 and/or their representatives not being provided with their options and rights by the facility staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' Minimum Data Set (MDS- a resident assessment tool) assessments were transmitted to Centers for Medicare and Medicaid Services (CMS - is a federal agency within the U.S. Department of health and Human Services (HHS) that provides health coverage to over 160 million people through Medicare, Medicaid, the children's Health Insurance Program (CHIP), and the Health Insurance Marketplace) within 14 days after completion for one-of-one sampled residents (Resident 75). This deficient practice resulted in the delay to transmit MDS report to CMS for 61 days or Resident 75.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- a resident assessment tool) related to antipsychotic use was accurately documented to reflect the resident's use of antipsychotic medication for one of five sampled residents (Resident 2). This deficient practice had the potential to result in resulted in lack of or delay in fully addressing in the care plan Resident 2's potential for elopement risk.

Inspectors wroteBased on, interview, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR-a tool used to help ensure that individuals are not inappropriately placed in nursing homes for long term) for one of 33 sampled residents (Resident 29). This deficient practice had the potential to result in inappropriate placement of Resident 33 in the facility by failing to: Evaluate the Resident for serious mental illness (SMI) and/or intellectual disability (ID)Offering the Resident the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings). Provide the Resident with the services they need in those settingsFindings: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Restorative Nursing Assistant program (RNA, nursing assistant program that help residents to maintain their function and joint mobility) treatments as ordered by a physician for one of 22 sampled residents (Resident 74) when Resident 74 had missed RNA treatments in November 2025, December 2025, and January 2026. This deficient practice had the potential to cause a functional decline in Resident 74.

Inspectors wroteBased on observation, and interview, the facility failed to label the gastric (stomach) tube feeding with a date for one of eight sampled residents (Resident 38) according to their policy and procedure (P&P) titled Closed Enteral Feeding System Policy, revised 7/11/2025. This deficient practice had the potential to cause infection and/or possible hospitalization for Resident 38.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 45) was administered the following medications as prescribed per physician's orders dated 8/1/2023, 5/31/20, 12/12/2025, and facility's policy and procedures (P&P) titled Medication Administration, revised on 7/11/2025:Hydrocodone-Acetaminophen (a prescription combination medication used for moderate to severe pain relief) Oral (by mouth) Tablet 10-325 milligrams (mg -unit of measure in weight) give 1 tablet by mouth every 12 hours for pain management .Levothyroxine (replaces a missing hormone thyroxine in people with an underactive thyroid [a small, butterfly-shaped gland in the lower front of your neck. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident's medication order included the indication for its use according to their policy and procedure (P&P) titled Physician Services and orders, revised 7/11/2025 for one of eight sampled residents (Resident 14). This deficient practice had the potential to result in a medication error and affect Resident 14's safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to label and date food items in the patient refrigerator per facility policy. This deficient practice had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 2 of 3 medically compromised residents who had food stored in the patient refrigerator.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide full length curtains around the bed for two of 22 sampled residents (Residents 56 and 74). This deficient practice prevented Residents 56 and 74 from having full privacy in Resident 56 and Resident 74's room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of 22 sampled residents (Resident 74) with an appropriate closet with doors and drawers in Resident 74's room. This deficient practice prevented Resident 74 from having a private closet with doors and furniture with enough storage in a homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that call buttons were within reach for one of eight sampled residents Resident 11. This deficient practice had the potential to result in delay of necessary care including emergency response for Resident 11.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and comfortable environment for one of 22 sampled residents (Resident 74) when there was a large patch of paint peeling next to Resident 74's window and there were a brown circular stain and bubbling paint on the ceiling to the right of Resident 74's window. This deficient practice caused Resident 74 to reside in an uncomfortable environment.

Inspectors wroteBased on interview and record reviews, the facility failed to meet professional standards of quality for two of five sample residents (Resident 1, Resident 2) by failing to:Ensure Resident 1 was not allowed to self-administer medications and treatment as indicated in Resident 1's Self Administration of Drugs Assessment which indicated that Resident 1 was not safe to self-administer drugs. Ensure the physician's orders for skin treatments were carried through and documented properly for Resident 1 and Resident 2. These deficient practices placed residents at risk of infection and failure in the delivery of necessary care and services for Resident 1 and Resident 2.

Inspectors wroteBased on interviews and record review, facility failed to ensure staff obtained consent (communication process between the clinician and the patient that's ensures that the patient is fully informed about the nature of the procedure or intervention, the potential risks and benefits, and the alternative treatments available) to COVID -19 and influenza informed consents were properly obtained from a resident with cognitive impairment according to the facility policy and procedures (P&P) titled, Coronavirus Vaccine Policy (COVID-19 Vaccine Policy) reviewed on 7/11/2025, for one of four sampled residents (Resident 8). This deficient practice resulted in the facility violating the rights for Resident 8.

Inspectors wroteBased on observations, interviews and record review, facility failed to ensure staff adhered to infection control practices by failing to:1. Ensure four of five sampled residents (Residents 5, 6, 7, and 8) received Coronavirus disease 2019 (COVID-19 - an illness caused by a virus which causes severe acute respiratory syndrome), pneumonia (an infection in one or both lungs that may be caused by bacteria, viruses, or fungi) and influenza (an infection of the nose, throat and lungs, which are part of the respiratory system) vaccines2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff followed proper infection prevention and control practices when attempting to provide care to one of three sampled residents, Resident 2. A Certified Nursing Assistant (CNA) 2 was observed dropping a clean towel onto the floor and then mixing the towel with clean linen and gown attempting to use the same towel on a resident. This deficient practice had the potential to place Resident 2 at risk of cross contamination and exposure to infectious agents from environmental surfaces.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Notify a physician that one of two sample residents (Resident 1) was experiencing itching in both eyes since 2023.2. Develop a policy and procedures for eye/vision care. These failures resulted in Resident 1 to continue rubbing and experience itching in both eyes and develop dark discoloration (change in the color or pigmentation of the skin) in both eyes.

Inspectors wroteBased on interview and record review, the facility failed to notify Resident 1's Family Member 1 (FM 1) when Resident 1's room was changed on 5/7/2025 and 5/8/2025. This deficient practice violated the residents' rights of notification according to facility's policy and procedure titled, Transfer Room to Room and Resident's Rights.

Inspectors wroteBased on interview and record review the facility failed to protect one of four sampled residents (Resident 1) from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of property and personal belongings. This deficient practice resulted in Resident 1's missing cochlear hearing aid (a small electronic device that can provide a sense of sound to people who are deaf or hard-of-hearing) and significantly impacted Resident 1's ability to hear, potentially leading to social isolation and safety concerns.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan (CP) that met the care/services based on the resident's individual assessed needs for one of six sampled residents (Resident 1) behavior of removing mittens and pulling on tracheostomy (a surgical procedure where a hole, called a stoma, is made in the neck to access the windpipe [trachea]) and gastrostomy tube (g-tube - a tube surgically inserted through the skin and directly into the stomach). This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice for one of three sampled residents, Resident 1 by failing to: A. Implement Resident 1 ' s blood sugar check (BSS - measures the glucose levels in the blood) according to physician ' s order and care plan (CP). B. Implement facility ' s policy and procedure (P&P) titled, Death of a Resident, Documentation when Resident 1 expired on [DATE]. These deficient practices placed Resident 1 in incomplete assessment and documentation required per facility ' s policy and procedure upon death.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide effective pain management for one of six sampled residents (Resident 2), who had a left shoulder fracture (break in a bone), bladder surgery, and left hip fracture all sustained from a motorcycle accident, by failing to: 1. Administer the as needed pain medication, hydromorphone (Dilaudid- a strong pain reliever to treat moderate to severe pain) when Resident 2 complaint of a lot of pain on 5/24/2025 morning. Resident 2 received a dose of hydromorphone 4 milligrams (mg) on 5/24/25 at 4 PM. 2. Administer the as needed pain medication (hydromorphone) when Resident 2 complaint of pain on 5/27/2025 at 1:15 PM. Hydromorphone is not available. 3. Accurately assess and document the pain level (a pain scale or pain rating scale). 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor one of the four sampled residents (Resident 5) rights by failing to treat her with dignity and respect by leaving resident exposed while changing Resident 5 ' s incontinence diaper. This deficient practice had the potential to cause embarrassment for Resident 5 Cross reference F726, F755.

Inspectors wroteBased on interviews and record review, the facility failed to ensure: 1. Licensed Vocational Nurse (LVN) 2 had the skills and knowledge to safely prepare and administer medications for one-of-one sampled resident (Resident 4) by crushing all morning medications on 5/15/2025 without a physician ' s order. 2. Certified Nursing Assistant (CNA) 1 treated one-of-one sampled resident (Resident 5) with dignity and respect by failing to provide privacy and leaving resident exposed while changing Resident 5 ' s incontinence diaper. This failure had the potential to result in medication side effects such as low blood pressure for Resident 4 and embarrassment for Resident 5.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to implement procedures to ensure safe dispensing and administration of medications for one out of one observed residents (Resident 4) by failing to: 1. Properly identify Resident 4 when preparing her (Resident 4) morning medications. 2. Crushing medications without a physician ' s order 3. administering all medications as ordered by the physician. This deficient practice had the potential to increase the risk of medication adverse reactions. Cross reference F726.

Inspectors wroteBased on observation, interview, and record review, the licensed nursing staff failed to maintain complete and accurate medical records in accordance with the accepted professional standards for three of four sample residents (Resident 1, Resident 2, Resident 3). The facility failed to ensure Medication Administration Record (MAR) was completed with identifiable information of licensed staff initials and signature. This deficient practice had the potential to result in medication administration errors and delays in communication between staff leading to care interruptions.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a clean and homelike environment in room [ROOM NUMBER]. This deficient practice had the potential for accidents and resulted in the room to be cluttered and disorderly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the Case Manager (CM) have the specific competencies and skill sets necessary to ensure that the admission process is seamless and efficient according to facility's policy and procedure (P&P) titled, Nurse admission Policy: Duties and Responsibilities. This deficient practice resulted in a negative effect to residents' plan of care and delivery of necessary care and services.

Inspectors wroteBased on interviews, and record reviews the facility failed to implement its' abuse policy and procedures (P&P) when the facility did not report to the California Department of Public Health (State Agency) of an alleged abuse of one of four sampled residents (Resident 1). This deficient practice resulted in a delay of the onsite investigation by the State Agency and the potential to place Residents 1 to be exposed to continuous sexual abuse from the alleged abuser causing mental anguish and emotional distress. [...]

Inspectors wroteBased on observation, interview, and record review, for two of six sampled residents (Residents 21 and 101), the facility failed to ensure: 1. Residents clothes received back the exact number and color of clothes after the cclothes were washed, 2. Residents did not wear other residents clothes. These failures resulted in Resident 101, and 21 loosing their clothes, Resident 101's T-shirt was bleached from black color to biege color, and another resident wearing Resident 101's T-shirt.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of his/her individuality for two (2) out of the 18 sampled residents (Resident 34 and Resident 69) by: 1. Staff standing over Resident 34 while assisting her to eat a meal. 2. Failing to describe what food was on the food tray and where each food item was located on the food tray. Resident 69 is visually impaired (is a partial or total inability to see). This deficient practice had the potential to affect Resident s self-esteem, self-worth, and dignity.

Inspectors wroteBased on observation, interview, and record review, Certified Nursing Assistant (CNA) 1 failed to protect the resident's rights by not closing the privacy curtain to ensure a resident is visually exposed to the roommates while the performing personal care for one of 24 sampled residents (Resident 13). This deficient practice violated the Resident 13's right for privacy.

Inspectors wroteBased on observation, and interview, the facility failed to ensure a safe, comfortable, and clean homelike environment for one out of three sampled residents (Resident 101) by failing to: 1. Repair the window frame was broken and the window glass that had detached from the window frame was repaired. 2. Trash was not left on the floor. 3. The floor was not partially cleaned. These failures resulted in cold air to continuously enter Resident 101's room making the residnt feel uncomfortably cold at night, and was ashamed of her living area.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) for physical restraints one of 24 sampled residents (Resident 30). This deficient practice had the potential for Resident 30 to not be provided with effective personalized care.

Inspectors wroteBased on interview and record review, the facility failed to provide restorative nursing assistance program (RNA -a program/person that helps patient regain their ability to perform daily activities after an illness or injury) according to the physician's orders for one of five sampled residents (Resident 38). This deficient practice resulted in Resident 38 not receiving therapy for two out of 31 days in 11/2024 placing Resident 38 at increased risk for decline in physical function and possibly contractures.

Inspectors wroteBased on interview and record review, the facility failed to fully identify, evaluate, and implement accident risks and hazard interventions for one out of 18 sampled residents (Resident 51) to prevent Resident 51 from falling. These deficient practices resulted in Resident 51 falling on 5/9/2024. Resident 51 was transferred a general acute care hospital (GACH) on 5/9/2024 where the resident was diagnosed with acute on chronic right frontal convexity subdural hematoma measuring approximately 11 millimeters (mm-unit of measurement) in depth with associated 4mm of leftward midline shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label tube feeding (nutrition in a liquid form) according to facility policy and procedure for one of ten sampled residents (Resident 44). This deficient practice had the potential to cause infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure outside staff food was not stored in the kitchen refrigerator #3. This deficient practice placed the residents at increased risk to suffer foodborne illness (food poisoning).

Inspectors wroteBased on observation, interview, and record review, for two of 18 residents (Residents 69 and 44), the facility failed to: 1. Provide hand hygiene to Resident 69 prior to meals. 2. Label tube feeding (nutrition in a liquid form) according to facility policy and procedures for Resident 44. These deficient practices had the potential to cause infection and cross contamination with infectious agents such as blood, body fluids, secretions and excressions (visible and invisible) for Residents 69 and 44.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) before administering an influenza vaccine (flu vaccine -an injection that helps prevent the flu and its complications) for one of five sampled residents (Resident 41). Resident 41 received the Influenza vaccine on 11/4/2024 and the consent for Influenza vaccine was obtained on 11/8/2024. This deficient practice violated the responsible party's (RP) right to be notified in order to make an informed choices for Resident 41 to receive or not to receive the influenza vaccine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from resident to resident physical abuse for one of two sampled residents (Resident 1). The facility was aware for a couple of months, that Resident 2 had been asking Resident 1 to marry Resident 2. As a result, on 10/20/2024 at 1:50 PM, Resident 1 got upset with Resident 2 after Resident 2 sneezed on Resident 1's shoulder. Also, Resident 2 hit Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate resident to resident physical abuse and harassment for one of two sampled residents (Resident 1). The facility was aware that for a couple of months, Resident 2 had been asking Resident 1 to marry Resident 2. This deficient practice resulted in two months continuous verbal abuse and harassment to Resident 1 by Resident 2 which resulted in Resident 1 and Resident 2 hitting each other on 10/20/2024.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sample residents (Resident 1), had an order for Rehabilitation Services evaluation carried out. This failure had the potential to result in Resident 1 ' s functional decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff provided adequate supervision and monitoring to prevent elopement (the act of leaving a facility unsupervised and without prior authorization) for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 eloping from the facility on 10/04/2024 at 9:36 AM., placing the resident at increased risk to suffer accidents, falls with injuries, physiological (referring to the body and its systems) harm, hospitalization, and death. Resident 1 went to family member 1's (FM 1) residence and never returned back to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor residents' personal foods that were placed in a residents' refrigerator and ensure the refrigerator was unaccessible by other residents and/or family member per facility ' s policy and procedure. This deficient practices had the potential to result in missing residents ' own food and food-borne illness and compromised infection control for all residents who received food from outside sources.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Resident Council Meetings were conducted regularly at least monthly for per facility's policy and procedure titled, Resident Council. This deficient practice resulted in unresolved residents' grievances related to residents' care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident, (Resident 2)'s clinical record was updated per facility's policy and procedure by failing to: 1. ensure Resident 2's clinical records were updated regarding Physician Orders for Life-Sustaining Treatment (POLST - is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency). This deficient practice had the potential to cause conflict with resident's wishes regarding health care. Cross Reference F656.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of three sampled residents (Resident 2) by failing to ensure that a comprehensive (CP) was implemented, This deficient practice had the potential to result negative impact on residents' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure two of five sampled residents (Resident 3 and Resident 4) was free from significant medication error by failing to ensure Resident 3 and Resident 4's medications were given on time and as ordered by the physician and according to facility's policy and procedure. These deficient practices have the potential to result in residents' unintended complications related to the management of medications. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for two of five sampled residents (Resident 3 and Resident 4) by failing to ensure that a comprehensive care plan (CP) was implemented for administering medications. This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on interview, and record review, the facility failed to provide sufficient staffing to accommodate the residents needs and request by not administering medications to one of five sampled residents (Resident 4). This deficient practice resulted in Resident 4 not receiving needed services timely and efficiently and had the potential to affect the quality of life and treatment given to the residents.

Inspectors wroteBased on interview and record review the facility failed to protect one of six sampled residents (Resident 2) from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of property and personal belongings. This deficient practice resulted in Resident 2 ' s missing mobile phone and chargers.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy regarding reporting of residents ' allegation of physical abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of six sampled residents (Resident 1). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further physical abuse for Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) who are smokers was not allowed to keep and use a marijuana in their possessions according to facility ' s policy and procedure. This deficient finding placed Resident 1 at risk for smoking related accident.

Inspectors wroteBased on observation, interview and record review, facility failed to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to one of one sampled resident (Resident 1) by failing to address behavioral health care needs and implementing a person-centered care plan when Resident 1 had episodes of aggressiveness toward staff. This deficient practice had the potential to negatively affect the delivery of behavioral health care and services to Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 2) who is on an airborne precaution (a set of measures used to prevent the spread of infectious agents that can be transmitted through the air) for coronavirus (COVID-19 - an infectious disease that can cause respiratory illness in humans) was placed into a private single room. 2. Ensure two of two sampled residents (Resident 3, Resident 4) who were exposed to COVID-19 infections were placed into a contact precaution room according to facility ' s policy and procedures (P&P). These deficient practices had the potential to transmit infectious diseases and increase the risk of infection to the residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to enhance a resident's dignity and respect by failing to provide personal hygiene such as showering to one of four sampled residents (Resident 1). This deficient practice had the potential to negatively affect the residents' psychosocial wellbeing.

Inspectors wroteBased on interview, and record review the facility failed to ensure the facility ' s policy and procedures were followed for a resident leaving against medical advice (AMA) for one of six sample residents (Resident 1). This failure resulted in an incomplete AMA form and the potential for serious complications due to Resident 1's diagnoses and medical condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the door alarm on one of four exit doors in working order. This failure had the potential to result in residents that were at risk for elopement (a resident leaving a safe area or premises without authorization or necessary supervision) to leave the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality of care and services by failing to ensure timely medication administration was provided to one of three sampled residents (Resident 4). This failure had the potential to negatively impact the delivery of care services provided to Resident 4. Cross Reference F755.

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely administer medications per facility policy to one of three sampled resident (Resident 4). This failure had the potential to result in medication ineffectiveness and risk for unsafe, and improper medication administration use. Cross Reference F658.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient nursing staff was available to provide nursing and related services to meet the resident's needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being for four of eight sampled residents (Residents 4, 6, 7 and 8) by failing to: 1. Ensure the call light was answered timely for Resident 4. 2. Ensure scheduled showers were provided to Resident 6, 7 and 8. This deficient practice resulted in Residents 4, 6, 7 and 8 not receiving assistance from staff with activities of daily living (ADLs-bed mobility, walk in room/ corridor, transfer, toilet use, bathing, personal hygiene, etc.) in a timely manner and had the potential to affect the quality of life for Residents 4, 6, 7 and 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to daily post in a visible and prominent place the updated actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift on 7/1/2024. This deficient practice had the potential to prevent residents and visitors from knowing the accurate and final Direct Care Services Hours Per Patient Day (DHPPD) and had the potential to cause inadequate staffing.

Inspectors wroteBased on interviews, and record review, the facility failed to follow its policy and procedures (P&P) titled, Abuse Prevention/Investigation/Reporting and Resolution, which indicated the facility will protect the rights, safety, and wellbeing of each resident, by failing to prevent one of three sampled residents (Resident 2) from hitting Resident 1. This deficient practice resulted in Resident 1 sustaining a laceration (cut) and contusion (a bruise which is when blood leaks into the surrounding area due to an injury) to the forehead and was transferred to the general acute care hospital (GACH) for evaluation and treatment of the head.

Inspectors wroteBased on interview, and record review the facility failed to provide supervision while smoking for one of three sampled residents (Resident 1). This deficient practice resulted in a fight between Resident 1 and Resident 2 on 6/8/2024. Resident 2 hit Resident 1 on the forehead. Resident 1 sustained a laceration (cut) to the forehead and was transferred to the general acute care hospital (GACH) on 6/8/2024. GACH diagnosed Resident 1 with contusion (a bruise [This happens when small blood vessels get torn and leak blood under the skin], a result of a direct blow or an impact) of the head.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff was available to provide nursing and related services to meet the resident ' s needs safely and in a manner that promotes each resident ' s rights, physical, mental and psychosocial well-being for three of six sampled residents (Residents 1, 3 and 4) by failing to ensure sufficient staffing was provided to all three residents at all times. This deficient practice resulted in Residents 1, 3 and 4 not receiving assistance from staff with activities of daily living (ADLs-bed mobility, walk in room/ corridor, transfer, toilet use, bathing, personal hygiene, etc.) on a timely manner and had the potential to affect the quality of life and treatment for Resident 1, 3 and 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 2) was treated with respect and dignity by failing to ensure Registered Nurse 3 (RN3) provided good customer service to Resident 2. RN3 stated to Resident 2 that, No one wanted to take care of you. This deficient practice has the potential to affect resident ' s sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) was provided with a well-planned discharge planning process on a timely manner. This deficient practice has the potential for a delay of discharge to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 2) received treatment and care in accordance with professional standards of practice by failing to ensure Registered Nurse 3 (RN3) provided good customer service to Resident 2. RN3 stated to Resident 2 that, No one wanted to take care of you. This deficient practice has the potential to affect resident ' s sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the employee file containing current/active certificate, license, background check, verification of references for six sampled staff. This deficient practice had a potential for staff not to safely and competently provide the necessary care to meet the resident's needs and prevent the residents from abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1) ensure medication storage room was locked. 2) ensure key to the medication storage room was not left hanging out of the keyhole. 3) ensure medication storage room was kept in a clean, safe, and sanitary manner. 4) ensure medication storage room was not used for charting. 5) ensure medication storage room was not used by staff to store personal belongings, and food. 6) ensure medication storage room was not used to keep space heater running. These deficient practices had the potential to result in unsanitary storage room and to cause harm to residents when key to the medication storage room was not kept safe; when access to the medication storage room was not limited to specific staff; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an orderly and homelike interior for five of eleven sampled resident rooms by failing to: 1. Ensure the sliding screen door or window in 5 of the 11 sampled rooms were present and/or free from holes and damages. 2. Repair ceiling water damage in 1 of the 11 sampled rooms (Resident 2's room) These failures resulted in an unhomelike environment and uncomfortable interior including the potential for pest to get into the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan to meet the care/services based on resident ' s individual assessed needs for one of seven sampled residents (Resident 6) by failing to ensure a care plan was developed and implemented for Resident 6 ' s inappropriate behavior. This deficient practice had the potential to result negative impact on Resident 6 ' s health and safety, as well as the quality of care and services received.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of care and practice for one of seven sampled residents (Resident 6) by failing to ensure that a change in condition was done when Resident 6 had an inappropriate behavior towards Physical Therapy Assistant 1 (PTA1). This deficient practice had the potential to negatively impact the delivery of care service provided to Resident 6.

Inspectors wroteBased on interview and record review, the facility failed to provide reasonable accommodations of resident needs and preferences for one of two sampled residents (Resident 1) by failing to: 1. Ensure facility staff followed up Resident 1 ' s transportation when Resident 1 had a surgery appointment. Resident 1 had to wait for his transportation back to the facility for almost five hours. 2. Ensure Resident 1 was assisted back to bed from the wheelchair. Resident 1 waited for almost four hours prior to getting assistance back to bed. These deficient practices had the potential not to meet Resident 1 ' s needs and preferences and had the potential to delay care for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of care and practice for one of six sampled residents (Resident 2) by failing to ensure physician (MD) order was followed when MD ordered Resident 2 to be transferred to general hospital (GACH) via GACH ' s regular transportation. Facility staff arranged a different type of transportation and failed to notify MD, Resident 2 and/or Resident 2 ' s family, change the order and document the necessary change of transportation. This deficient practice had the potential to negatively impact the delivery of care service provided to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff available at all times to provide nursing and related services to meet the resident ' s needs safely and in a manner that promotes each resident ' s rights, physical, mental and psychosocial well-being for one of two sampled residents (Resident 1) by failing to ensure Resident 1 was assisted back to bed from the wheelchair. Resident 1 waited for almost four hours prior to getting assistance back to bed. This deficient practice resulted in Resident 1 not receiving assistance from staff with activities of daily living (ADLs-bed mobility, walk in room/ corridor, transfer, toilet use, bathing, personal hygiene, etc.) on a timely manner and had the potential to affect the quality of life and treatment for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to properly document albuterol sulfate/ipratropium bromide (Combivent-an inhaler medication used to treat and prevent symptoms of chronic obstructive pulmonary disease [COPD-group of lung diseases that block airflow and make it difficult to breathe] such as wheezing [whistling sound or coarse rattle sound when airway is partially blocked during inhalation] and shortness of breath) via medication administration record (MAR) after as needed (PRN) dose was administered to one of six sampled residents (Resident 2). This deficient practice had the potential to result in medication administration error and risk for unsafe, improper medication administration use.

Inspectors wroteBased on interview and record review, the facility failed to provide professional standards of care and practice to one of three sampled residents (Resident 1) by failing to ensure proper documentation of refusals of showers and appropriate education provided to Resident 1. This deficient practice had the potential to negatively impact the delivery of care service provided to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic (medication that fight bacterial infection) Stewardship by ensuring completion of the Surveillance Data Collection Form (SDCF-form that facility was using to monitor antibiotic medication in the facility) for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that pain management was provided consistent with professional standard of practice for two of two sampled residents (Resident 2 and 9) by failing to assess and document pain assessment per facility policy. This deficient practice had the potential to negatively affect Resident 2 and 9 ' s physical comfort and psychosocial well-being when not being assessed properly. Cross Reference F755.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Controlled Drug Record (CDR-accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for two of two sampled residents (Residents 2 and 9). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). Cross Reference F697.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, comfortable, and homelike environment by failing to ensure residents ' rooms were kept clean and sanitary for two of eight sampled residents (Resident 2 and 5). This deficient practice had the potential to negatively impact the resident ' s quality of life and placing Residents 2 and 5 at risk for accident, physical discomfort, and possibly spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality of care and services by failing to: 1. Ensure timely medication administration was provided to one of four sampled residents (Resident 8). 2. Ensure treatment order of colostomy (opening of the large intestine [abdominal area] to the outside of the body for passing of stool and gas) care for one of one sampled resident (Resident 2) was provided and documented properly under treatment administration record (TAR). 3. Ensure Rehabilitation Department documented the plan of care or progress notes to one of one sampled resident (Resident 1) when orthosis (device to improve and encourage proper joint alignment and/or protect existing limb) was needed prior to start of a rehabilitation therapy for Resident 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper storage of medication for one of four sampled resident (Resident 2) when opened Polyethylene glycol (laxative medication) bottle was observed at Resident 2 ' s bedside. This deficient practice had the potential to compromise Resident 2 ' s safety when being administered inappropriately.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%) due to three (3) errors observed out of 30 total opportunities (error rate of 10%). The medication errors were as follows: 1. Resident 206 received a dose of fish oil (a medication used as a dietary supplement to provide support to the heart and brain) that was different than the one ordered by Resident 206's physician, 2. Resident 206 did not receive Rena Vite (a medication used as a dietary supplement to provide essential vitamins for people with chronic kidney disease) and thiamine (a medication used to treat thiamine [vitamin B1] deficiency [lack of] in those with liver disease) as ordered by Resident 206's physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure eight licensed vocational nurses (LVNs) did not administer expired insulin (a medication used to regular blood sugar levels) to two of five sampled residents (Resident 85 and 94) observed for medication availability. As a result, Residents 85 and 94 received a total of 14 doses of expired insulin. These practices had the potential to cause Residents 85 and 94 to experience serious health complications due to uncontrolled blood sugar levels, including possible hospitalization or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Remove and discard from use of one expired insulin (medication used to regulate blood sugar levels) Lispro (fast-acting insulin) Kwikpen (an injection device containing insulin) for Resident 94, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart [NAME] 1.) 2. Label one insulin Toujeo (long-acting insulin) Max (higher volume of insulin) Solostar (an injection device containing insulin) pen for Resident 205, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart [NAME] 1.) 3. Store one insulin Lispro Kwikpen for Resident 26 at room temperature, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart [NAME] 2.) 4. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain current food handler certifications for two of three sampled cooks (CK- Ck1 and Ck2). This deficient practice could have led to unsafe food handling related to a lack of knowledge of current food handling regulations and requirements. Findings A review of CK 1's Food Handler certificate of training indicated an issue date of 4/15/2021 and valid for three years (expired on 4/15/2023). A review of CK 2's Food Handler certificate of training indicated an issue date of 10/4/2018 and valid for three years (expired on 10/04/2021). During an interview on 11/29/2023 at 2:48 p.m. the dietary supervisor (DS) stated the certifications had to be renewed every three years. During an interview on 11/30/2023 at 9:09 a.m. [...]

Inspectors wroteBased on interview and record review the facility failed to submit payroll-based journal (PBJ) staffing data to the Center for Medicare and Medicaid Services (CMS - the federal agency that provides health coverage) timely. This deficient practice had the potential to result in inaccurate reflection of the facility's staffing data.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was answered timely and within reach for 2 of 6 residents (Resident 23 and 45). This failure had the potential to delay meeting residents needs for assistance and could lead to falls and accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 6 sampled residents (Resident 39) were treated with dignity and respect, by failing to sit next to the resident while feeding the resident. This failure had the potential to affect Resident 39's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of eight sampled residents (Resident 16 and Resident 55), who were dependent on staff for the activities of daily living (ADLs), were repositioned every two hours according to its policy. This deficient practice had the potential for the residents to develop complications including bed sores and contractures.

Inspectors wroteBased on Observation, interview, and record review, the facility failed to ensure the safety of 1 of 6 sampled residents (Resident 45), by failing to supervise Resident 45 while smoking cigarettes as indicated in the resident's Smoker's Risk Assessment (a tool used to identify resident's requiring staff supervision and assistance with smoking). This failure had the potential to cause harm to Resident 45 when smoking cigarettes unsupervised.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of eight (8) sampled residents (Resident 101) was provided pain medication as ordered. This deficient practice had the potential for Resident 101 suffering unnecessary pain.

Inspectors wroteBased on interview and record review the facility failed to complete a comprehensive assessment completed and developed a treatment plan for a diagnosis of post-traumatic stress disorder (PTSD- a disorder that develops in some people who have experienced a shocking, scary, or dangerous event) for ensure one of three sampled residents (Resident 86). This deficient practice had the potential for Resident 86 to have experience increased anxiety (intense, excessive, and persistent worry and fear about everyday situations disorder), depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) and recurrence of reliving PTSD.

Inspectors wroteBased on interview and record review the facility failed to implement the facility's policy and procedures (P&P) for psychotropic (a drug capable of affecting the mind, emotions, and behavior) medications for one of three sampled residents (Resident 86) by not monitoring Resident 86 for anxiety (intense, excessive, and persistent worry and fear about everyday situations disorder). This deficient practice had the potential for Resident 86 to have increased anxiety, increased depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) and inaccurate assessment of current mood.

Inspectors wroteBased on observation and interview the facility failed to store food in accordance with professional standards for food safety, by failing to label three boxes of ice cream in the unit freezer with open date. This deficient practice had the potential to lead to food borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to label personal food items in the facility's residents' refrigerator according to the facility policy and procedures (P&P). This deficient practice had the potential to cause food borne illness. Findings During a review of the facility's Fridge Clean Log dated 11/26/2023 indicated housekeeper 1 (HK 1) cleaned the residents refrigerator located in the activity room for residents' food brought in from outside. During an observation and inspection of the residents' refrigerator located in the activity room for residents' food brought in from outside, and concurrent interview with the dietary supervisor (DS) on 11/30/2023 at 11:13 a.m., the DS looked through the refrigerator and the following were identified: 1. One tin foil tray was covered with foil. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to observe infection control measures for one of three sampled residents (Resident 256) by failing to wear appropriate personal protective equipment (PPE equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when entering Resident 256's room. This deficient practice had the potential to transmit microorganisms (a complex structure of elements that can only be seen under a microscope [a tool used to see very small objects]) throughout the facility and increase the risk of infection for all residents and staff members.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of the sampled residents (Resident 1) received his mail/package he had ordered himself online per their policy. This deficient practice resulted in the violation of Resident 1 ' s rights to receive his mail privately.