Orange Healthcare & Wellness Centre, LLC

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their policy to provide medical records for one of three sampled residents (Resident 1). * Resident 1 did not receive the requested medical records timely. This failure resulted in the violation of Resident 1's right to access his medical records.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure proper medication storage was followed in one of three nurse stations (Nurse Station A), one of two medication rooms (Medication Room A), two of two medication carts (Medication Cart A and Treatment Cart A), and one of two medication refrigerators (Medication Refrigerator A) observe. * Multiple medications were left unattended at Nurse Station A, after the pharmacy delivery. * The facility failed to maintain the recommended medication refrigerator temperatures in Medication Room A. * The facility failed to keep Treatment Cart A free of unnecessary items such as batteries, tools, and insulin syringes. * The facility failed to ensure there were no unlabeled loose medications in Medication Cart A. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by the following: * A stainless-steel blender was stored wet. * Time Temperature Control for Safety (TCS) Foods (food that require time and temperature controls to limit the growth of illness causing bacteria) was not handled safely as the leftover chicken was not maintained at the proper temperature. In addition, there was no documentation of the leftover chicken cooked on the previous day on the cooling down log. These failures had the potential to cause foodborne illness for the residents who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure appropriate infection control practices were followed.* The facility failed to test the water supply, and inspect the HVAC filters per the facility's water management program.* The clean linen cart for transferring clean linen in the laundry room had frayed edges and peeling layered duct tape and a non-cleanable surface. * The facility failed to ensure one of three blood glucose monitors (a portable device to measure blood sugar levels at home using a tiny blood sample) was cleaned and disinfected according to the manufacturer's instructions after the blood glucose monitor was used on Residents 3, 33, and 40. These failures resulted in the risk for the spread of microorganisms potentially contaminated areas throughout the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 104) was safe to self-administer medications. * Resident 104 was observed with one unidentified medication tablet and an unlabeled white bottle containing various medication tablets on his bedside table. Resident 104 had no assessment and physician's order addressing Resident 104's self-administration of the medications. This failure had the potential for the resident to administer the medications inaccurately, and the risk of adverse reactions from the medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests of one of one final sampled resident (Resident 20) reviewed for activities. * The facility failed to provide an ongoing activity program for Resident 20 in accordance with the comprehensive assessment, interests, and physical, mental, and psychosocial well-being to ensure the resident maintained their highest mental, physical, and psychosocial well-being. This failure had the potential for the resident to experience feelings of social isolation.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one final sampled resident (Resident 116) and one nonsampled resident (Resident 120) reviewed for the accident hazards were provided the necessary care and services. * The facility failed to ensure CNA 1 remained awake while providing supervision for Residents 116 and 120, who were on high observation alert due to falls. This failure posed a risk for the residents to sustain further falls and/or injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to obtain the appropriate admission PICC line measurements for one of one final sampled resident (Resident 119) reviewed for the central lines (a long, flexible tube inserted into a large vein in the neck, chest, arm, or groin, ending near the heart, to provide long-term access for delivering fluids, nutrition, and medications). * The facility failed to ensure Resident 119's arm circumference and the PICC line's external catheter were measured upon the resident's admission to the facility. This failure had the potential to delay identifying potential complications of the central line.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for one of one final sampled resident (Resident 11) reviewed for pain management. * The facility failed to accurately record Resident 11's highest pain level for the shift, as well as document the nonpharmacological interventions (NPI) implemented prior to administering the PRN (as needed) pain medication. These failures put the resident at risk of their pain level not being documented accurately and receiving unnecessary pain medication without the NPI in place.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure there was adequate staffing for the 2300 to 0700 hours shift to meet the physical and psychosocial needs for two of 19 final sampled residents (Residents 20 and 118) and two nonsampled residents (Residents 43 and 81). * The facility failed to ensure Resident 20's call light was answered in a timely manner for assistance in toileting and transfers to and from the bed between the hours of 0200 - 0500 hours on 1/4 and 1/5/26. * The facility failed to ensure Residents 43 and 81 received timely staff assistance during the 2300-0700 hours shift. * The facility failed to timely answer Resident 118's call light to address her toileting needs without the resident experiencing distress over the staff's response time. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review and facility P&P review, the facility failed to ensure medications were available, administered, and accounted for appropriately for one of five final sampled residents reviewed for unnecessary medication (Resident 116) and for one of two IV E-kit medication kits. * Resident 116's insulin was not available to be administered as ordered. * The facility failed to ensure the IV E-kit in Medication Room A was replaced timely. * The facility failed to ensure the IV E-kit pharmacy log in Medication Room A was accurately completed when accessed by RN 1. These failures resulted in medication not being available to be administered to the residents as well as inaccurate accounting of the emergency medication supply.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the menu was followed for two nonsampled residents. * The menu spreadsheet was not followed for Resident 62's CCHO (Consistent Carbohydrate Diet/Controlled Carbohydrate) diet. * Resident 68 did not receive a salad listed on the lunch menu. These failures posed the risk for the residents who received food prepared in the kitchen to not have their nutritional needs met.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of one final sampled resident (Resident 100) reviewed for hospice services attained and maintained their highest practicable well-being. * The facility failed to ensure the hospice visit calendar was available in Resident 100's medical record. * The facility failed to integrate Hospice A's plan of care into Resident 100's care and failed to accurately reconcile the physician's orders. These failures posed the risk of the delay in the communication and provision of hospice care between the hospice provider and facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary transfer/discharge services for one of three residents (Resident 7) reviewed for close records. * The facility failed to notify Resident 7 and/or their representative in writing regarding the transfer and reasons for the transfer, and the facility's bed hold policy when Resident 7 was transferred to the acute care hospital. In addition, the facility failed to send the copy of notice of transfer discharge to Ombudsman (a neutral advocate who investigates and resolves complaints for residents in healthcare settings like long-term care facilities). [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop a baseline care plan for one of 19 final sampled residents (Resident 118). * Resident 118's removal of her indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine from the bladder) and interventions in place for monitoring for bladder function were not included in the resident's baseline care plan. This failure had the potential for the resident's plan of care not being communicated to the IDT and a potential delay in identifying a bladder dysfunction.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure for an accurate medical record for one of one final sampled resident (Resident 5) reviewed for dialysis. * Resident 5's blood pressure log inaccurately showed his blood pressure was obtained on his left arm, where the resident had an AV shunt (a surgical connection between an artery and a vein). This failure resulted in inaccurate documentation of the resident's blood pressure measurements site.

Inspectors wroteBased on interview, medical record review, and the facility document review, the facility failed to ensure the Arbitration Agreement (an agreement that allows parties to resolve disputes and lawsuits privately rather than going to the court) was explained in a form, manner, and language the residents or their representatives understood for two of three residents (nonsampled Residents 23 and 72) reviewed for the Arbitration Agreement. * The facility allowed Residents 23 and 72 who had no mental capacity to understand and make medical decisions, to enter and sign the Arbitration Agreement. This failure posed the risk for the residents to not have a clear understanding of the arbitration process.

Inspectors wroteBased on interview and facility document review, the facility failed to implement their QAPI plan and their past Recertification Survey POC for F694. This failure had the potential for ongoing non-compliance and complete data being reviewed by the QAPI committee.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the failed to provide the reasonable accommodations to meet the care needs for two of 13 sampled residents (Residents 2 and 3). * The facility failed to ensure Residents 2 and 3's call lights were answered in a timely manner. This failure had the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care and services to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain an accurate and complete medical record for two of 13 sampled residents (Residents 12 and 13). * The facility failed to ensure the licensed nurses documented their initials on Residents 12 and 13's TARs (indicating the treatments were provided) as per the facility's P&P. This failure had the potential for the residents' care needs not being met as their medical record information was inaccurate and/or incomplete.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure the infection control practices were observed. * LVN 1 failed to follow the EBP infection control practices while performing the wound care for Resident 1. * LVN 2 failed to follow the infection control practices on wearing PPE in the hallway. These failures posed the risk for transmission of disease-causing microorganisms and infections.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to follow the abuse protocol during the facility investigation process for one of eight sampled residents (Resident 1). * The facility failed to suspend CNA 1 from work when Resident 1 reported an allegation of physical abuse against CNA 1 on 6/17/25. This failure had the potential to place Resident 1 and other residents at risk of not being protected against the alleged abuser.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * Treatment Nurse 1 failed to perform hand hygiene before providing the wound care treatment to Resident 2. * Treatment Nurse 2 failed to perform hand hygiene before providing the wound care treatment to Resident 1. * CNA 1 failed to perform hand hygiene and change her gloves in between tasks and before accessing the clean linen cart. These failures had the potential for transmission of disease-causing pathogens and infections.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide oral care every shift for one of four sampled residents (Resident 2). This failure had the potential to negatively impact Resident 2's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent UTI for two of two sampled residents (Residents 1 and 2) reviewed for catheter care. * The facility failed to ensure proper positioning of Residents 1 and 2' s urinary drainage bag to prevent urine from flowing back into the residents' bladder. * The staff member failed to monitor or assess the color of Resident 2's urinary output. These failures posed the risk for Residents 1 and 2 to develop CAUTI.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical records for two of sixsampled residents (Residents 1 and 2) were complete and accurately documented. * The licensed nurses failed to ensure documentation on the TAR for Residents 1 and 2 were complete and accurate. This failure had the potential for the residents' care needs not being met as their medical information was incomplete.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide thorough investigation and reported the results of the investigations for the allegation of possible financial abuse from the resident's family member to the CDPH, L&C Program within five working days of the incident for one of two sampled residents (Resident 2). This posed the risk for potential abuse to remain unidentified and for Resident 2 to go unprotected.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop and implement a plan of care to reflect the individual care needs for one of two sampled residents (Resident 2). * The facility failed to ensure a care plan was developed to address Resident 2's Court Investigator's allegation of possible financial abuse from alleged Resident 2's family member. This failure posed the risk of not providing appropriate, consistent, and individualized care to the resident.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain a homelike environment for one of three sampled residents (Resident 3) and one nonsampled resident (Resident B). * Residents 3 and B's rooms had peeled paint above the headboards of the residents' beds. This failure had the potential to negatively affect the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to complete the assessments, attempt the least restrictive alternative measures, obtain the physician's orders and informed consents, and initiate care plans for the use of side rails for five of six sampled residents reviewed for side rail use (Residents 45, 47, 64, 78, and 601). This failure had the potential to put the residents at risk for serious injuries.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper medication storage in three of three medication storage rooms inspection when: * The facility failed to ensure the discharged resident's syringes with needles were discarded and removed from Medication room [ROOM NUMBER]. * Four bottles of lactulose (medication to treat constipation) solution was stored next to 30 lidocaine patches in Medication room [ROOM NUMBER]. * The temperatures for three of three medication room refrigerators used to store medications in Medication rooms [ROOM NUMBER] were out of range. These failures had the potential for the residents to receive ineffective medication dosages and negatively impact their well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed when: * A food preparation sink did not have a backflow prevention. * A rack used to dry plate covers was not clean. * Resident 64's room was observed with perishable food items brought from the outside. These failures posed the risk for cross contamination which could lead to food poisoning in the 83 residents who consumed food from the kitchen.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable disease and infections. * The facility failed to maintain an accurate infection control surveillance program for the months of January 2024 through August 2024. The facility conducted surveillance only on the residents who exhibited signs and symptoms of an infection and were prescribed antimicrobial medications (medications used to treat infections). The facility failed to ensure the residents who exhibited signs and symptoms of an infection but were not prescribed antimicrobial medications were included in the facility's infection control surveillance log. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to inform the physician of the residents prescribed antibiotics with signs and symptoms not meeting McGeer's Criteria (criteria used by long-term care facilities to determine a true infection) for one of 19 final sampled residents (Resident 87) and three nonsampled residents (Residents 59, 77, and 603). This failure had the potential risk for continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete, and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for six of six residents (Residents 45, 47, 63, 64, 78, and 601) who were reviewed for grab bar use. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure care was provided in a manner which promoted dignity and respect for one of four sampled residents (Resident 76) reviewed for the use of indwelling urinary catheter (flexible tube used to empty the bladder and collect urine in a drainage bag). The facility failed to ensure Resident 76's urinary catheter collection bag was inside the privacy bag. This failure had the potential to negatively impact Resident 76's emotional well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the call light was within reach for three of 19 final sampled residents (Residents 16, 38, and 76) and two nonsampled residents (Residents 39 and 61). This failure had the potential to negatively impact the residents' psychosocial well-being or result in a delay to provide care and services to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the written information regarding the advance directives (legal document of a person's wishes regarding medical care when the person is no longer able to make medical decisions), and obtain and/or maintain copies of the advance directives in the medical records for five of 19 final sampled residents (Residents 17, 45, 76, 351, and 601). These failures had the potential for the residents' decisions regarding their healthcare and treatment not being honored.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for two of two residents reviewed for IV access (Residents 89 and 600). * The facility failed to ensure the PICC line external catheter measurements were performed and documented in the medical record upon admission for Resident 600. * The facility failed to ensure the IV antibiotic medication was properly labeled for Resident 89. These failures had the potential to delay the identification of catheter related complications for the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 19 final sampled residents (Residents 58, and 351) and three nonsampled residents (Resident 69, 75, and 352) were provided with the appropriate respiratory care when: * The facility failed to ensure Resident 58's oxygen nasal cannula (flexible tube to deliver oxygen into the nose) tubing was dated as per the facility's P&P and stored in a set up bag when not in use. * The facility failed to ensure Resident 351's nebulizer mask and tubing were stored in a set up bag when not in use. In addition, the facility failed to formulate a plan of care for the use of the nebulizer therapy. * The facility failed to ensure Resident 352's oxygen tubing was not touching the floor. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to offer or provide adequate and appropriate pain management for one of one resident reviewed for pain management (Resident 600). The facility failed to ensure Resident 600 was monitored for side effects related to the use of the narcotic pain medication. Additionally, the facility failed to consistently provide non-pharmacological interventions for pain prior to the administration of a narcotic pain medication to Resident 600. These failures had the potential for not effectively managing the resident's pain.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs of the residents when: * The facility failed to ensure proper accounting and safeguarding of the controlled medications when the incoming and outgoing licensed nurses were not consistently signing the controlled count each shift for Medication Carts 1 and 3. This failure had the potential for drug diversion.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one for five residents (Resident 17) reviewed for unnecessary medications was free from unnecessary psychotropic drugs. The facility failed to ensure Resident 17's orthostatic blood pressure was monitored as ordered by the physician related to the use of an antipsychotic medication. This failure had the potential for Resident 17 to have adverse complications from the medications.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and the facility P&P review, the facility failed to ensure food preferences were honored for one nonsampled resident (Resident 30). Resident 30 disliked Brussels sprouts and preferred nonfat milk but was served Brussels sprouts and low fat milk for lunch. This had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview and facility P&P review, the facility failed to ensure the facility employees and visitors who brought food from the outside to the facility were educated on safe food handling practices. This failure posed the risk for residents who consumed food brought from the outside to be exposed to unsafe food handling which could lead to food borne illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure essential kitchen equipment was maintained in proper working condition when: * The ice machine located in the kitchen was not clean and the manufacturer guidelines were not followed. * The walk-in freezer floor was not in a cleanable condition. * The facility failed to ensure the low air loss matress for Resident 69 was functioning properly. These failures had the potential for essential equipment to not function in the way it was intended.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to ensure the reconciliation of medications was thoroughly performed and documented in the medical record upon discharge for one of two closed records reviewed (Resident 99). This failure posed the risk for not identifying discrepancies or differences in Resident 99's pre-discharge and post-discharge medication orders, which had the potential to negatively affect Resident 99's well-being.

Inspectors wrote2. Medical record review for Resident 63 was initiated on 9/9/24. Resident 63 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 63's POLST dated 10/8/22, under Section D, showed Resident 63 did not have an advance directive. Review of Resident 63's Advance Healthcare Directive (AHCD) Acknowledgement Form dated 7/5/21, showed on 8/14/21, an advance directive was executed. Review of Resident 63's Progress Notes showed an entry dated 8/14/21 at 0913 hours, documenting an advance directive was executed for Resident 63, and the Ombudsman and a witness at bedside. The note showed a copy of the advance directtive was placed in the resident's chart. On 9/11/14 at 1215 hours, an interview and concurrent medical record review for Resident 63 was conducted with the SSD. The SSD stated the POLST form including Section D was completed by the nursing staff. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the written notification of room changes were provided to the resident and RP for two of two sampled residents (Residents 7 and 8). This failure had the potential for violating the residents' rights.

Inspectors wroteBased on interview, medical record review, and the facility's P & P, the facility failed to ensure the comprehensive care plan for one of four sampled residents (Resident 3) was revised to reflect the current resident assessments. These failures placed the residents at risk for the specific care issues not being addressed for medical and physical needs.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical records for two of four sampled residents (Resident 1 and Resident 3) were accurate. * Resident 1's Elopement evaluation was inaccurate * Resident 3's Fall risk evaluation was inaccurate These failures had the potential for the incidents to be reoccurred.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the visual privacy was provided for one of two non-sampled Residents (Resident 6) during care. This failure posed the risk of negatively affecting the resident's dignity.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were maintained. * The staff failed to perform hand hygiene during care for one of seven sampled residents (Resident 6) and one of two nonsampled residents (Resident 9). * The facility failed to label the basin found on top of a common dresser table found in room [ROOM NUMBER]. These failures had the potential to result in the spread of infection to the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage was properly stored in three of six garbage dumpsters. The failure had the potential to attract pest/rodents that carried disease.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility staff failed to immediately reported an allegation of abuse to the administrator, CDPH L&C Program, Long-Term Care Ombudsman, and local law enforcement within two hours after the allegation was made for one of nine sampled residents (Resident 7). This failure had the potential to delay the investigation of the alleged abuse and for staff to not take prompt and appropriate corrective actions to prevent the abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents (Residents 1 and 3) were provided the treatment and care in accordance with the professional standards of practice, comprehensive person-centered care plan, and resident choices. 1. The facility failed to ensure the medication administration was arranged when Resident 3 was out on pass. Resident 3's order for out on pass did not specify the length of time the resident could be out on pass as per the facility's P&P, nor was a care plan developed to address the out on pass process and how the resident's care needs would be met during the out on pass. 2. The facility failed to ensure Resident 1 received five scheduled evening medications, including Resident 1's insulin and antiseizure medication. These failures had the potential to cause harm to Residents 1 and 3.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the personal property of four of 22 sampled residents (Residents 1, 2, 6, and 7) were protected from theft or loss. * The facility failed to ensure Residents 1, 6, and 7's personal items were labeled with the residents' names and includedin the residents' inventory lists. * The facility failed to show documented evidence of personal property was released to Resident 2 upon discharge. These failures had the potential for the residents' property to get lost or stolen.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensurethe abuse allegation was reported to CDPH L&C Program for one of 22 sampled residents (Resident 5). Resident 5 reported a missing ID, debit card, and cash, and reported the debit card had fraudulent charges. This failure had the potential for the abuse allegation going unreported and uninvestigated.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate the abuse allegations for five of 22 sampled residents (Residents 1, 2, 3, 4, and 5). These failures posed the risk of Residents 1, 2, 3, 4, and 5 to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure five of 22 sampled residents (Residents 12, 17, 18, 19, and 20) were provided necessary care and services to meet their ADL care needs. The facility failed to provide showers to Residents 12, 17, 18, 19, and 20 as scheduled. This failure had the potential to negatively affect the resident's well-being and delay the detection of the new or worsening skin condition.

Inspectors wroteBased on interview, facility document review, employee file review, and facility P&P review, the facility failed to ensure one of five registry CNAs (CNA 16) was provided training on abuse before providing the necessary care and services to the residents at the facility. This failure had the potential to put the vulnerable residents at risk for abuse.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medical records for eight of 22 sampled residents (Residents 1, 7, 9, 12, 13, 14, 16, and 17) were complete. The care related to bowel/bladder elimination was not documented for these residents, creating the potential for resident's care needs not being met as their medical information were incomplete.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the residents needs. * The facility failed to ensure the administration of hydrocodone- acetaminophen (an opioid medication used for moderate to severe pain) for Residents 25, 28, and 51a were accurately documented to ensure accurate reconciliation and prevent the medication administration errors. These failures post the risk for loss or diversion of controlled medications. * The facility failed to ensure the incoming and outgoing licensed nurses assigned were consistently signed the Medication Cart A's controlled medication accountability record. This failure post the risk for loss or diversion of controlled medications. [...]

Inspectors wroteBased on observation, interview, facility P&P, and facility document review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen as evidenced by: * Multiple food items observed in the kitchen were unlabeled, undated, and had expired. * A section of the kitchen wall was damaged. These failures had the potential to cause food borne illnesses in the 82 medically vulnerable residents who consumed food prepared in the kitchen.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of six nonsampled residents (Resident 52) was provided care in a manner that promoted dignity and respect. This failure posed the risk to negatively impact the resident's self-esteem.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to accommodate the needs for one of nonsampled residents (Resident 365). The facility failed to ensure Resident 365 was provided the appropriate type of call light and kept in within her reach. This failure placed the resident at risk for her needs to not be met.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to complete the admission, entry, and quarterly MDS assessments timely for three of 18 final sampled residents (Residents 25, 27, and 51a) and seven of 13 nonsampled residents (Residents 7, 37, 52, 700, 701, 702, and 703). This failure had the potential for the staff not identifying the residents' preferences and goals of care, functional and health status, strengths and needs.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure accurate coding of the MDS for two of 18 final sampled residents (Residents 8 and 27). * For Resident 27, the MDS was coded inaccurately for RNA services. * The facility failed to ensure Resident 8's indwelling urinary catheter use was coded accurately. These failures posed the risk of the residents not receiving appropriate care interventions due to incorrect health assessments.

Inspectors wroteBased on interview, and medical record review, the facility failed to develop a care plan problem for one of 18 final sampled residents (Resident 8) and one nonsampled residents (Resident 365). * Resident 8 was assessed to have moisture-associated skin damage (MASD) problem; however, a care plan problem was not developed to address the MASD. This failure placed Resident 8 at risk of not having her care needs met. * Resident 365 was observed to have bruising to her right arm; however, a care plan problem was not developed and implemented to show the interventions to address the uncontrolled body movements. This failure caused Resident 365 to sustain bruising to her right arm due to her arms repeatedly hitting the sides of the wheelchair.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure injury for one of 18 final sampled residents (Residents 11). Resident 11 was on a low air loss mattress for wound management. The facility failed to ensure the low air loss mattress setting was consistently monitored to ensure the appropriate settings of the low air loss mattress for Resident 11. This failure could result in delayed wound healing for Resident 11 and development of new pressure injuries.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one nonsampled resident (Resident 365). This had the potential to increase the risk of injury to the resident.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one of 18 final sampled residents (Resident 25) with an indwelling urinary catheter. The facility failed to ensure Resident 25's urinary catheter drainage bag was changed weekly as ordered by the physician. This failure had the potential for complications related to indwelling urinary catheter use.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary respiratory care and services for two of 18 final sampled residents (Residents 22 and 515). * The facility failed to ensure Resident 22 was administered oxygen as ordered by the physician. * Resident 515 continued to receive oxygen when it had been discontinued by the physician. These failures had the potential for the residents to receive unnecessary supplemental oxygen.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure appropriate pain management for one of 18 final sampled residents (Resident 25). * Resident 25's pain was not appropriately assessed, communicated to their charge nurse, and managed prior to wound care and catheter care treatments. In addition, Resident 25's pain was not being monitored and documented every shift. These failures could result in the resident's pain not being accurately monitored, assessed, and managed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Residents 34) was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 34's episodes of behaviors for the use of risperidone (antipsychotic medication to treat certain mental or mood disorders) were summarized and made available to the prescriber on a monthly basis to serve as reference for gradual dose reduction. This had the potential of not providing the correct data to the prescriber in order to adjust the dose of the psychotropic medications for the residents.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the medications and biologicals were stored and disposed of properly. * The skin/wound solution bottles and medication drawer for Treatment Cart B had stains and sticky residues. This posed the risk for unsafe storage of medication that could result to cross-contamination of the solutions. * The facility failed to ensure the refrigerator temperatures were checked and maintained within the acceptable range daily for two of three medication rooms (Medication Rooms A and B) Medication Room B's refrigerator temperature log had multiple missing entries. Medication Room A's refrigerator temperature log showed the temperatures below the acceptable range without the follow-up actions to correct the out-of-range temperatures. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the accurate and complete medical records for six of 18 final sampled residents (Residents 4, 8, 11, 22, 25, and 51a). * Resident 22's supplemental oxygen use was not documented in the resident's MAR. * Resident 4's colostomy bag change scheduled for every three days was not documented in the medical record. * Resident 51a's urinary drainage bag weekly changes were not documented in the medical record. * Residents 25's urinary drainage bag weekly changes were not documented in the medical record. In addition, Resident 25's pain medication dose was handwritten over without clarification. * Residents 8 and 11's monitoring for the low air loss mattress setting in the TAR had missing multiple entries. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Resident 35), one nonsampled resident (Resident 26), and one staff member were offered or received the influenza or pneumococcal vaccine (an injection given to protect from severe pneumococcal disease) as per the facility's P&P. This failure put the residents and staff at risk for poor health outcomes.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plans were developed and revised for two of 18 sampled residents (Residents 4 and 25) to reflect changes in the residents' care needs. * The facility failed to revise Resident 4's plan of care to include a reasonable and realistic goal for the resident's chronic pressure injury. * The facility failed to discontinue Resident 25's care plan problem regarding isolation status. These failures placed the residents at risk of their care needs not being met.