Pacific Gardens Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice for eight of 21 sampled residents (Resident 1, Resident 55, Resident 72, Resident 102, Resident 127, Resident 150, Resident 155, and Resident 167) when:1. Resident 1's oxygen therapy (a colorless, odorless, tasteless gas essential to living organisms) was set at 2 liters per minute (L/min - a unit of measurement for oxygen flow rate) and not 1 L/min as indicated on the physician order (a set of instructions written by a doctor for clinicians to follow when caring for a resident).2. Resident 55's oxygen flow rate (the quantity of oxygen that is passing through a cross-section of a pipe in a specific period) was being delivered at 4 LPM (liters per minute - a unit of measurement) instead of the ordered 2 LPM.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to have an adequate system for reconciling controlled drugs (substances that have an accepted medical use and have a potential for abuse and may also lead to physical or psychological dependence), when the facility did not have an effective system in place for the Director of Nursing (DON) to accurately account for all controlled substances awaiting destruction in the facility. This failure had the potential for diversion (the illegal transfer, therft, or misuse of prescription drugs), mismanagement, or unaccounted medication, and the potential not to meet the needs of the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Resident 3, Resident 79 and Resident 150), were free from unnecessary drugs when:1. Resident 3 was administered magnesium oxide (a mineral supplement used to treat low magnesium levels) medication and magnesium levels were not monitored.2. Resident 79 was administered amiodarone (medication used to treat and prevent severe, life-threatening irregular heartbeats (arrhythmia) by slowing down overactive electrical signals in the heart) and thyroid stimulating hormone (TSH- blood test that measures level of thyroid hormone) levels were not monitored.3. Resident 150 was administered levothyroxine (medication used to treat an underactive thyroid (hypothyroidism) by replacing the missing thyroid hormone) and TSH levels were not monitored. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent for five residents (Resident 135, Resident 167, Resident 9, Resident 46 and Resident 117), when:1. Resident 135 was not administered their prescribed dose of levothyroxine (medication used to treat an underactive thyroid by replacing the missing thyroid hormone) and the medication was left with the resident. This failure had the potential to result in Resident 135's thyroid levels dropping, resulting in symptoms like cognitive decline (gradual loss of thinking skills), persistent fatigue (extreme tiredness or lack of energy) and weakness.2. Resident 167's oxycodone- acetaminophen tablet (prescription opioid medication used to treat moderate to severe pain) was administered without a pain assessment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with the facility policy and procedures (P&P) when:1. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure menus were followed for 20 of 66 sampled residents (Residents 8, 65, 84, 92, 71, 60, 98. 33, 57, 109, 102, 119, 172, 145, 78, 106, 116, 51, 21, and 58) when they were not provided mashed sweet potatoes according to the menu during the lunch meal service on 4/21/26. This failure had the potential to result in not meeting the micronutrients (referred to as vitamins and minerals, are vital to healthy development, growth, disease prevention, and well-being) in the physician's prescribed therapeutic diets which could compromise nutritional and medical status of Residents 8, 65, 84, 92, 71, 60, 98. 33, 57, 109, 102, 119, 172, 145, 78, 106, 116, 51, 21, and 58. During a review of the lunch menu for 4/21/26 indicated, baked honey glaze ham, baked sweet potatoes, and French style green beans for the following diets: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 12) was informed in advance, by the physician or other practitioner of the risks and benefits of proposed treatment when Resident 12 did not have a signed physician informed consent (a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) prior to the use of bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered) position. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 61), was assessed to self-administer and store mediations at bedside when Resident 61 had an expired bottle of [brand name polyethylene glycol 400 0.25% (over the counter eye drop medication used to treat dry eyes)] eye drops stored at bedside for self-administration with no order or Medication Self-Administration Assessment Form (MSA- an assessment form to determine if a resident is clinically appropriate to safely and securely store and self-administer their own medication at bedside). This failure resulted in Resident 61 self-administering and storing expired medication at bedside without oversight which could lead to duplicate therapy, medication interactions, and adverse effects.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure two of five sampled residents (Resident 3 and Resident 32), were free from unnecessary psychotropic (drugs that affect brain activities with mental processes and behaviors) medications when: a. Resident 3 was prescribed quetiapine fumarate (prescription drugs that alter brain chemistry to affect mood, thoughts, behavior, and perceptions) with inappropriate indication of neurocognitive disorder (decline in mental function-such as memory, attention or language, caused by brain disease, injury or damage). b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) was developed and implemented for four of 14 sampled residents (Resident 12, Resident 15, Resident 120 and Resident 139) when:1. Resident 12 had two bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed and can be placed in a guard [raised position that is intended to prevent an individual from inadvertently rolling out of bed] or lowered position) on each side of the bed in the guard position. Resident 12 did not have a plan of care developed and initiated for getting out of bed unassisted and prior to the use of the bed rails. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL's- routine activities such as grooming, bathing, dressing and toileting a person performs daily to care for themselves) was not provided for one of three sampled residents (Resident 178), when Resident 178's fingernails on both hands were long, jagged (sharp, uneven edges), and dirty with brownish to blackish dirt built up underneath her nails. This failure had the potential for Resident 178 to obtain skin-related injuries including cuts, scratches, and infections. During a concurrent observation and interview on 4/22/26 at 1:03 p.m. with Resident 178 in Resident 178's room, Resident 178 was observed having a Peripherally Inserted Central Catheter (PICC -a long, thin tube that's inserted through a vein in the arm) line placed to her right upper arm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one resident (Resident 12) when when weekly weights were not implemented to track and monitor the effectiveness of interventions that were put into place such as snacks, nutritional shakes and daily intake. This failure resulted in a weight loss of 4.49 % (percent) in a month from 11/19/25 to 12/17/25, 13.48 % in three months from 11/19/25 to 2/18/26, and 9.14% in three months from 12/17/25 to 3/18/26 for Resident 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled Residents (Resident 12) was assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered) prior to installation and had a consent form (form signed by resident or family explaining the risks of side rail use), physician order, indication for use, and care plans prior to the use of side rails when, Resident 12 had bed rails on the right and left side of her bed in the guard position (a position that is intended to prevent an individual from inadvertently rolling out of bed). These failures had the potential to cause entrapment, serious harm, injury, or death to Resident 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors, when one resident (Resident 34) was administered expired latanoprost ophthalmic solution (a medication for glaucoma-eye diseases that damage the optic nerve, often due to high fluid pressure inside the eye, leading to irreversible vision loss or blindness) for over one month. This failure put Resident 34 at risk for infection due to bacteria or fungi growth from the expired medication and at risk of uncontrolled glaucoma, leading to permanent vision loss over time.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents' food was prepared and processed appropriately to meet residents' needs for two of three sampled residents (Resident 86 and Resident 73) when large pieces of broccoli were not in proper form of minced and moist on their lunch meal tray on 4/23/26. This failure to properly process the minced and moist food can result in choking (when the airway is obstructed by food, drink, or foreign objects) for Residents 86 and 73 on a minced and moist diet at the facility. During a review of the lunch menu for 4/23/26 indicated, for the MM5 (minced and moist level 5 diet) the following: Japanese Vegetable Blend. soft mashed broccoli, sweet and sour pork SBMM (soft and bite and minced and moist), rice, puree bread. During an observation of the lunch meal service on 4/23/26 at 12:39 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's food preference was provided for one of 20 sampled residents (Resident 26) when Resident 26's lunch tray did not include double protein (one of the many substances found in food such as meat, cheese, fish, or eggs, that is necessary for the body to grow and be strong) on 4/21/26. This failure had the potential for Resident 26 not to receive her food preference which can result in undernutrition that could compromise her medical and nutritional status. During a review of the lunch menu for 4/21/26 indicated, for the house (regular diet) the following: .Baked Honey Glazed Ham 4.4 oz (ounces- a standard unit of weight), Baked Sweet Potato1 each, French Style [NAME] Beans 1/2 (half) cup. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served in accordance with professional standards for food safety when:1. Gloves were not changed by Dietary [NAME] (DC) 2 after handling non-food items (a box made of cardboard) while making sandwiches for the residents' lunch meal on 4/22/26. This failure had placed residents at an increased risk of acquiring food-borne illnesses (an illness that comes from eating contaminated food [refers to food or beverages containing harmful microorganisms (bacteria, viruses, parasites), toxins, or foreign physical/chemical substances that make them unsafe for human consumption]).2. Incorrect thermometer usage in residents' freezer. Residents' freezer contained an oven thermometer (used to measure high heat to ensure accurate baking and identify hot spots). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program to help prevent the development and transmission of infections for two of seven sampled residents (Resident 18, and Resident 43) when:1. Resident 18 was placed on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities) and Certified Nursing Assistant (CNA) 2 and CNA 3 did not put on the appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) prior to providing high contact care to Resident 18.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality and the standard of practice according to the facility's policy and procedure (P&P) titled, Charting and Documentation for five of five sampled residents (Resident 1, 2, 3, 4, and 5), when:Licensed Vocational Nurse (LVN) 1 did not document the wound (any physical injury that disrupts the anatomical structure and functional integrity of skin, mucous membranes, or other body tissues) care for Resident 1 on 12/27/25 during the day shift. LVN 2 did not document the wound care for Resident 2 on 12/4/25 during the night shift. LVN 2 did not document the wound care for Resident 3, 4, and 5 on 1/21/26 during the night shift. This failure had the potential to result in infection and delayed wound healing for Resident 1, 2, 3, 4, and 5.

Inspectors wroteBased on interview and record review, the facility failed to follow the policy and procedure (P&P) titled, Admission, Transfer, Discharge and Bed-Holds, for one of three sampled residents (Resident 1) when Resident 1 (a veteran - someone who has served in a nation's armed forces) was denied admission for rehabilitation services based on payment source. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide required treatment and services to one of five residents (Resident 20), when Resident 20 did not receive restorative nursing assistant (RNA - helps patient regain physical skills through therapeutic care including mobility exercises, dressing, eating and bathing) services ordered by the physical therapist (PT-a person qualified to treat disease, injury or deformity by physical methods such as massage, heat treatment and exercise) once PT was discontinued on 3/6/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform and provide written information on how to formulate an advance directive (a legal document that outlines a person's wishes regarding their medical care in the event they become unable to make decisions for themselves due to illness or injury) for four of 163 residents (Resident 12, Resident 30, Resident 57 and Resident 306) when the facility did not document information on how to obtain an advance directive in residents charts. This failure violated the rights of Resident 12, Resident 30, Resident 57 and Resident 306, which could have potentially prevented these residents' wishes from being followed if they were unable to make decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment for: 1. Two of 156 residents (Resident 34 and Resident 57) when Resident 34 and Resident 57 were cold at night and staff did not ensure the temperature range was between 71-81-degree Fahrenheit (a measurement of temperature on a standard in which 32 degrees is the temperature at which water freezes and 212 degrees that at which it boils) This failure resulted in an uncomfortable homelike environment for Resident 34 and Resident 57, which had the potential risk for causing hypothermia (a medical emergency that occurs when your body loses heat faster than it can produce heat) in an already vulnerable population due to their decreased ability to regulate heat. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store, and label drugs and supplies in accordance with acceptable standards of practice when: 1. Two inhalers did not have an open date and expiration date for two of 16 sampled residents (Resident 507 and Resident 36). 2. Two of four sampled refrigerators' temperatures were not within parameters that stored three residents (Resident 558, Resident 138, and Resident 506) medications. These failures had the potential to place Residents at risk of receiving spoiled, expired, and ineffective medications and placed Residents at risk for experiencing adverse reactions (define) from spoiled, expired and ineffective medications.

Inspectors wroteBased on observation, interview, and record review the facility cook staff failed to accurately measure milk and margarine when preparing the pureed rice recipe for 12 of 12 sampled Residents (Resident 64, 505, 78, 95, 9, 96, 111, 123, 65, 93, 74, 85) with a pureed diet order. This failure had the potential to result in 12 Residents (Resident 64, 505, 78, 95, 9, 96, 111, 123, 65, 93, 74, 85) to receive reduced or excess amount of nutrients in their food potentially leading to unexpected weight loss or weight gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe and sanitary food preparation and storage practices when: 1. A box of potatoes was not labeled with a received date or use-by date. 2. A dietary aide failed to wash their hands after scratching their ear and continued to place clean cups in a clean crate. 3. Thawing frozen beef kabobs were not labeled with the prepared by or use-by date, was found in the walk-in refrigerator. 4. Dust was identified on the ceiling above the fan in the food storage room. These failures had the potential to cause food borne illness to a highly susceptible population of 163 residents who received food from the kitchen.

Inspectors wrote6. During a concurrent observation and interview on 2/3/25 at 8:51 a.m. with Resident 505 in the resident's room, Resident 505 was sitting upright in bed wearing glasses, a dark blue sling cradled her right arm, and an oxygen nasal cannula and oxygen tubing were lying on the floor. Resident 505 was alert and oriented, able to state her name, date, location and was able to understand and answer questions. Resident 505 stated she did not use oxygen continuously and was not aware the tubing was on the ground. During a record review of Resident 505's admission Record (AR), dated 2/6/25, the AR indicated, Resident 505 was admitted to the facility on [DATE] with diagnoses: fall with a left broken thigh bone surgically repaired with an artificial hip joint, uneven broken right collarbone, and difficulty breathing. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure corridors were equipped with firmly secured handrails on each side of the corridor. This failure put residents at increased risk for falls when utilizing the handrail for assistance with walking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was provided for two of 11 sampled residents (Resident 3, and 305) when: 1. Resident 3's foley catheter (a soft, flexible tube inserted into the bladder to help drain urine into a bag) drainage bag was without a dignity bag (a bag used to the cover and hold the catheter drainage and collection bag so it is not visible), leaving the urine visible to anyone who walked into Resident 3's room This failure resulted in Resident 3 not being provided his right to have a dignified existence while in the facility. 2. Resident 305's foley catheter drainage bag was without a dignity bag. This failure violated Resident 305's privacy and had the potential to affect the self-esteem, self-worth, and quality of life of Resident 305.

Inspectors wroteBased on interview and record review the facility failed to provide residents and residents' responsible party (RP- a person designated to make decisions for a resident) written information regarding the bed hold policy for two of six sampled (Resident 3 and Resident 455) when: 1. No written notices about the facility's bed hold policy was provided to Resident 3 or their RP when he was transferred to the hospital on 2/2/25. This failure violated Resident 3 and his RP's right to be notified in writing of the facility's bed hold policy. 2. Resident 455 was not provided a bed hold policy prior to being transferred out of the facility due to being a non-Medi-Cal member. This failure had the potential to result in loss of bed availability, confusion, disputes, and quality of care concerns for Resident 455.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) for 7 of 36 sampled residents (Residents 20, 26, 34, 37, 54, 86, and 409) when: 1. Resident 37 did not have a CP developed for an indwelling foley catheter (a thin, flexible tube that is inserted into your bladder to drain urine). This failure of developing a CP for Resident 37's foley catheter had the potential to place Resident 37's safety at risk and her specific needs not being met. 2. Resident 26's CP interventions were not implemented to meet his visual needs. This failure resulted in Resident 26 not wearing his glasses for five days which had the potential to lead to injury or decreased participation in activities of daily living (ADLs). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a comprehensive person-centered care plan for one of three sampled residents (Resident 120), when Resident 120's care plan had active treatment interventions (actions to address resident identified needs) for a stage two pressure ulcer (partial-thickness loss of skin, presenting as a shallow open sore or wound) that had already healed. This failure had the potential for Resident 120's care to not be centered and could cause unclear communication amongst the healthcare team.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice for two of nine sampled residents (Resident 112 and Resident 306) when: 1. Resident 112 was receiving 2.5 liters per minute (LPM- a unit that expresses flow rate define) of oxygen when the continuous oxygen ordered was for 2 LPM. 2. Resident 306's oxygen flow rate was set at 3 L/min and not 2 L/min as indicated on the physician order (a set of instructions written by a doctor for clinicians to follow when caring for a resident). These failures had the potential to result in serious health conditions for the resident including oxygen toxicity that could cause damage to lung tissue and respiratory issues. 3. Resident 306's oxygen tubing was not labeled with the date the tubing should be changed. This failure put Resident 306 at risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled Residents (Resident 28), received toenail care consistent with professional standards of practice when Resident 28's toenails were long and jagged. This failure resulted in Resident 28's toenails to become long, jagged, and caused discomfort which had the potential to lead to ingrown toenails, infection, and injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of six sampled residents (Resident 37), was free from accidents when: 1. Resident 37's foley catheter (helps drain urine from your bladder) tubing was wrapped around her prosthetic (artificial leg that replaces the part of the leg below the knee joint) right lower leg while sitting in her wheelchair. This failure had the likelihood to cause a fall or injury to Resident 37 via the catheter tripping her during a transfer (movement from wheelchair to bed and vice versa) or being pulled from her bladder as a result of being caught on her prosthesis (artificial leg).

Inspectors wroteBased on observations, interview, and record review the facility failed to post the total number of licensed and unlicensed staff and actual hours worked when the posting did not represent the actual hours worked by direct care staff daily. This failure resulted in all residents and their family members to not have access to view the actual direct care staff hours and total number of direct care staff providing care daily and possibly not meeting the needs of the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a drug regimen which was free from unnecessary drugs for one of six sampled residents (Resident 3) when Resident 3 was administered mirtazapine (a medication used to treat depression [a condition characterized by extreme sadness]) from 11/2/24 to 2/6/24 without any documented attempts at a gradual dose reduction (GDR- a system used to slowly stop the use of medication over time). This failure had the potential of causing Resident 3 to receive unwanted side effects such as dry mouth, dizziness, constipation, drowsiness, and headaches as a result of being given the mirtazapine unnecessarily.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 556), were free of any significant medication errors when Resident 556's potassium chloride (a type of salt that gives the body potassium that gives the body minerals needed for the muscle and heart) 20MEQ (milliequivalent- a unit of measure) was not given according to manufacturer's instructions. This failure had the potential to cause poor absorption of the medication (meaning the body could not use it properly) and stomach upset for Resident 556.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate and complete medical records in accordance with professional standards of practice were maintained for one of five sampled residents Resident 306, when the Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was not complete. This failure had the potential for Resident 306's decisions regarding treatment options and end of life wishes to not be honored.

Inspectors wroteBased on interview and record review, the facility failed to provide services which meet professional standards of practice for one of three sampled residents (Resident 1) when License Vocational Nurse (LVN 1) did not perform necessary assessment of her assigned residents and continued to document on Resident 1's clinical record Resident 1's vital signs, pain assessment, feeding tube assessment, enteral feeding intake, and provided non-pharmacological pain interventions care she did not provide from 12/25/21 to 12/30/21 during the time Resident 1 was admitted in general acute care hospital (GACH) from 12/25/21 to 12/30/21. These failure resulted in an inaccurate Resident 1's clinical record which did not reflect Resident 1's current medical status and the lack of resident assessment could negatively impact the care of other residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure license nurse perform residents assessment and document accurately according to the care provided when License Vocational Nurse (LVN 1) did not perform necessary assessment of her assigned residents and continued to document on Resident 1's clinical record Resident 1's vital signs, pain assessment, feeding tube assessment, enteral feeding intake, and provided non-pharmacological pain interventions care she did not provide from 12/25/21 to 12/30/21 during the time Resident 1 was admitted in general acute care hospital (GACH) from 12/25/21 to 12/30/21. These failure resulted in an inaccurate Resident 1's clinical record which did not reflect Resident 1's current medical status and the lack of resident assessment could negatively impact the care of other residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions was maintain in the kitchen when: 1. [NAME] to golden-colored buildup behind the stove and floor behind the stove had accumulation of debris. 2. The floor in the corner next to water inlet, behind the ice machine, between the pantry and kitchen had soiled napkins, straw, beverage cup, wrapper, and food debris. 3. The pantry floor had dark granular substance and a dark glob (a round clump of soft substance or thick liquid). 4. The floor underneath the pantry wire storage rack had scattered debris such as utensils, jelly cups, brown paper bag, napkins, hairnet, and saltine crackers in plastic wrap. 5. In the pantry a one-foot length of vinyl base board molding peeled off and was on the floor. 6. The pantry storage counter holding a five-gallon water jugs had black substance buildup. 7. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program as evidenced by presence of multiple dead cockroaches in the kitchen ' s floor beneath the food preparation area, the three-compartment sink, and on the floor behind the two-hallway ice machine. These failures had the potential to cause foodborne illnesses (illness caused by food contaminated with bacteria, viruses, and parasites) in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) did not develop pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) when Resident 1 was assessed as a moderate risk for developing pressure ulcers and the nursing care plan of daily and weekly skin assessments was not implemented from 1/6/24 to 1/19/24 for early recognition of skin changes and implementation of appropriate interventions to prevent pressure ulcer. [...]

Inspectors wrote2. A review of Resident #208's admission Record indicated the facility admitted the resident on 11/19/2023, with diagnoses that included acute respiratory failure with hypoxia and obstructive sleep apnea. Review of Resident #208's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2023, revealed Resident #208 resident received oxygen. Review of Resident #208's care plan, initiated 11/21/2023 revealed the resident had oxygen therapy related to acute respiratory failure. Interventions indicated the resident received continuous oxygen at a rate of two liters per minute. Review of Resident #208's Order Summary Report, with active orders as of 11/29/2023, revealed an order dated 11/21/2023, for continuous oxygen at two liters per minute by way of nasal canula for acute respiratory failure with hypoxia. [...]

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to assess a resident prior to self-administration of medication for 1 (Resident #114) of 28 sampled residents.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide a comfortable environment and a building in good repair for 2 (Resident #97 and Resident #114) of 3 sampled residents reviewed for the environment.

Inspectors wroteBased on the interviews, record review, and policy review, the facility failed to ensure 1 (Resident #72) of 4 sampled residents reviewed for nutrition was provided assistance with their meals.