Pacific Palms Healthcare

Inspectors wroteBased on record review, and interview, the facility failed to monitor, document and record the intake and output ([I&O] the measurement and recording of all fluids entering and leaving the body over a specific period)for one of three sampled residents (Resident 1), who was readmitted to the facility on [DATE] with an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). This deficient practice resulted in the inability to determine if Resident 1's was hydrated appropriately and had the potential for fluid overload and/or infection to go unrecognized.

Inspectors wroteBased on record review, and interview, the facility failed to ensure Registered Nurse (RN) 1 accurately documented one of three sampled resident's (Resident 1) blood glucose (the main sugar found in the bloodstream) results. This deficient practice resulted in an inaccurate portrayal of Resident 1's clinical status and the potential to result in unnecessary treatment and care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of four sampled residents (Resident 1) medication as ordered by his physician when Resident 1 did not receive Refresh Liquigel Ophthalmic Gel 1 % (a thick, gel-like eye drop solution, often called artificial tears) in both eyes at bedtime for dry eyes. This deficient practice resulted in Resident 1 not receiving Refresh Liquigel Ophthalmic Gel 1 % as ordered and had the potential for Resident 1 to experience dry eyes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light devices were within reach for three of 26 sampled residents (Residents 7, 100, and 121). This deficient practice had the potential for residents not being unable to summon health care workers for assistance as needed. a. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) affecting left dominant side, stiffness of left shoulder, elbow, and hand, and history of falling. During a review of Resident 7's Minimum Data Set (MDS: a resident assessment tool) dated [DATE], the MDS indicated Resident 7 was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a consent form for the use of an abdominal binder (belt used to support the abdomen after surgery, improve physical function), complete the restraint assessment, and monitor the use of abdominal binder for one of 26 sample residents (Resident 121). These deficient practices resulted in unnecessary restraint and placed the residents at risk of physical harm, skin injuries, or entrapment. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive resident specific care plan for two out of seven sampled residents (Resident 9 and Resident 13). This deficient practice had the potential for Resident 9 and Resident 13 to not receive person-centered care.

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for two of two sampled residents (Resident 11 and Resident 125) reviewed for unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and impaired blood sugar control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 10 sampled residents (Residents 101, 55, and 113) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to:1a. Provide Resident 101 with a Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) evaluation and assessment prior to increasing the wear time for both knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) from 30 minutes to two to four hours during Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment.1b. Objectively measure Resident 101's ROM in both legs during the PT Evaluation dated 7/13/2025.2a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the urine (liquid waste product made by the kidneys, stored in the bladder, and expelled from the body through the urethra) output for two out of two sampled Residents (Resident 15 and Resident 121) who had indwelling urinary catheters (a thin tube inserted into the bladder to drain urine continuously into a collection bag). This deficient practice had the potential to cause a delay in addressing Resident 15 and Resident 121's overall hydration status (the process of replenishing water in the body), kidney function (how well the kidneys are working), and fluid balance (the body's regulation of fluid intake versus output to maintain stable hydration and electrolyte levels for essential bodily functions) issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT - an opening to the stomach from the abdominal wall made surgically for the introduction of food) feeding formula was provided and documented as physician ordered for two of three sampled residents (Resident 28 and Resident 2). This failure had the potential to result in Resident 28 and Resident 2 receiving inaccurate amounts of GT feeding formula that could lead to unintended weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two resident's (Resident 20) Bilevel positive airway pressure ([BIPAP] type of noninvasive ventilation that helps you breathe) machine was maintained as indicated in facility policy and indicated in the BIPAP User Guide. The deficient practices had the potential to result in serious health risks such as bacterial growth and infection and potential damage to the device.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of one sampled Certified Nursing Assistant (CNA) 3 was competent and knowledgeable with a pureed (foods that are blended, mashed, or whipped to a smooth, lump-free, pudding-like consistency, which is easier to swallow and does not require chewing) texture diet when passing the meal tray to Resident 13. This deficient practice had the potential for Resident 13 to aspirate (when something other than air gets into your airways) or for Resident 13 to lose weight because she was provided with a diet not consistent with her physician's orders.

Inspectors wroteBased on interview and record review, the facility failed to ensure [NAME] (CK) 1 was competent in preparing pureed (foods that are blended, mashed, or whipped to a smooth, lump-free, pudding-like consistency, which is easier to swallow and does not require chewing) scrambled eggs and oatmeal. As a result of this deficient practice 27 residents who were on a puree diet were placed at risk for receiving eggs and oatmeal that were not completely smooth and without lumps which could lead to aspiration (when something other than air gets into your airways).

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food that was at the correct temperature to one of three sampled residents (Resident 131). This deficient practice had the potential to result in loss of appetite and cause unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of six sampled residents (Resident 13) was provided with a puree diet as ordered by the physician. This deficient practice had the potential for Resident 13 to aspirate (when something other than air gets into your airways) or for Resident 13 to lose weight because she was provided with a diet consistent with her physician's orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food under safe and sanitary conditions in one of one kitchen, by failing to:a) Ensure no staff personal belongings were in the kitchen preparation area.b) Ensure the sanitizer bucket was not in the food preparation sink while food was being prepared. c) Ensure the pancake, breakfast meat, and waffles holding temperature (temperature at which food is kept) on the steam table (specifically made for holding prepared foods at a consistent temperature) were checked prior to meal service.d) Ensure the ice machine was clean.e) Ensure two of three residents' (Resident 101 and 112) refrigerated personal food items were dated on when it was opened or procured. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for three of nine sampled residents (Resident 13, Resident 101, and Resident 113) when:a. Restorative Nursing Aide (RNA 1) documented he provided RNA feeding program (staff provide feeding assistance) assistance to Resident 13 for two meals, when he did not. b. RNA 1 documented Resident 101 wore both knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for two hours during Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment on 11/18/2025 when Resident 101 wore both knee splints for 40 minutes to one hour.c. RNA weekly documentation did not accurately reflect Resident 113's ambulation distance from 8/3/2025 - 10/4/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to: a. Perform hand hygiene when entering and exiting Resident 5's room.b. Replace Resident 96's tube feeding line when it was found on the floor without a cap. c. Implement and document control measures per water management policy and procedure.d. Monitor, document, and implement contact isolation precautions (infection control measures used to prevent the spread of germs by direct contact) for Resident 131. These deficient practices had the potential to transmit infectious microorganisms (living organisms that are too small to be seen with the naked eye) and increase the risk of infection for the residents.

Inspectors wroteBased on interview and record review, the facility failed to:a. 1. Administer the coronavirus vaccination for one of five sampled residents (Resident 5). b. 2. Offer and educate coronavirus vaccinations for staff per facility's policy for three of five sampled employees. These failures had the potential to place all residents at risk for exposure to infection of coronavirus.

Inspectors wroteBased on interview and record review, the facility failed to inform one of two sampled residents (Resident 11) of the risks associated with repeated subcutaneous (beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injections administered in the same anatomical site. This deficient practice had the potential to limit Resident 11's ability to make informed decisions regarding treatment.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when Resident 113's ambulation (walking or moving from one place to another) distance declined. This failure had the potential to result in a delay of care and further decline of ambulation.

Inspectors wroteBased on interview and record review, the facility failed to ensure the use of mirtazapine (a medication used to treat mental illness) was used to treat a medical condition diagnosed and documented in the medical record between 7/7/25 and 11/9/25 for one of five residents sampled for unnecessary medications (Resident 9.)The deficient practice of using psychotropic medications (medications that affect brain activities associated with mental processes and behavior) to treat medical conditions without sufficient documentation of their diagnosis increased the risk that Resident 9 may have experienced adverse effects (unwanted or dangerous medication-related side effects) related to the use of mirtazapine. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) assessment accurately reflected one of three sampled Residents (Resident 74). This failure had the potential to negatively affect Resident 74's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to revise a comprehensive care plan for one of two sampled residents (Resident 11), who preferred not to have subcutaneous (beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection sites rotated, to include individualized goals and interventions addressing resident preference and associated risks. This deficient practice placed Resident 11 at risk for skin tissue damage and inconsistent insulin absorption due to unmet care needs related to the absence of a revised, individualized care plan.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of two sampled Residents (Resident 13) on the restorative nursing assistant (RNA) feeding program (staff provide feeding assistance) was supervised during two meals. This deficient practice had the potential for Resident 13 to aspirate (when something other than air gets into your airways) or for Resident 13 to lose weight if she was not encouraged to consume the meal.

Inspectors wroteBased on observation, interview, and record review the facility failed to discontinue an intravenous (IV, in the vein) catheter (flexible tube inserted into a vein to deliver fluids and medications into the blood stream) for two of two sampled residents (Resident 15 and Resident 121) per the facility's policy and procedure (P&P) titled Removal of a Peripheral IV (Over the needle, Peripheral Short) Catheter. As a result of this deficient practice, Resident 15 and Resident 121 were placed at risk for discomfort and infection at the IV site.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 113) was assessed by a neurologist and wound doctor as ordered by the physician. This deficient practice had the potential to result in delay in the delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to monitor the valproic acid level (a lab value used to determine the effectiveness of certain medications used to treat seizures) related to the use of Depakote (a medication used to treat seizure disorder) per the physician's order in one of five residents sampled for unnecessary medications (Resident 9.)The deficient practice of failing to monitor valproic acid levels for the use of Depakote according to the physician's instructions increased the risk that Resident 9 could have experienced seizures or adverse effects related to the use of Depakote possibly leading to medical complications resulting in hospitalization. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve regular texture toast to one of three sampled residents (Resident 98). The deficient practice had the potential to result in loss of appetite and cause unplanned weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure the binding arbitration agreement (a contract in which a person agrees to settle future disputes with the facility outside of court, through a private, neutral decision-maker instead of a judge or jury) was explained in a language that a resident could understand for two of three sampled residents (Resident 78 and Resident 82). This deficient practice had the potential to limit Resident 78 and Resident 82's understanding of the binding arbitration agreement and their legal rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 2) who was under hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) was visited by hospice licensed nurses weekly per hospice care agreement. This failure had the potential to result in Resident 2 did not receiving hospice care as they agreed upon.

Inspectors wroteBased on observation, interviews, and record reviews, the facility did not adequately provide pharmaceutical services to meet the needs of both sampled residents (Resident 1 and Resident 2) by failing to: a. Follow the order as prescribed when the physician discontinued a Hydrocodone-Acetaminophen (used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated) 10-325miligram (mg-unit dose) and ordered 5-325mg dose for Resident 1. b. Follow the facility's policy requiring the controlled substances to be stored in the medication room in a locked container, separate from non-controlled medications. Instead, a bottle of Lorazepam Intensol (knowns as Ativan, is used to treat anxiety disorders) for Resident 2 was found stored unlocked in the refrigerator. c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions ([EBP] involve gown and glove use during high contact resident care activities for residents at risk for Multidrug-Resistant Organisms ([MDRO, bacteria that have become resistant to certain antibiotics]) for one of three sampled residents (Resident 1), who had a left thigh wound and required daily dressing (sterile pad or material placed directly on a wound to protect it from infection and to promote healing ) changes. The facility failed to: 1. Ensure the Treatment Nurse (TN) had the proper understanding of EBP and 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 conducting Resident 1 ' s dressing change. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' medical records were up to date as per the facility's policy and procedure (P&P) regarding advance directives (a legal document indicating resident preference on end-of-life treatment decisions) for two of seven sampled residents (Residents 18 and 83). These deficient practices violated the residents' right to be fully informed of the option to formulate an Advance Directive and had the potential to cause conflict with the residents' wishes regarding health care in the event residents became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff.

Inspectors wroteBased on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS], a federally mandated resident assessment tool) assessment for two of three sampled residents (Resident 81, and Resident 83). This deficient practice had the potential to result in inaccurate care and services for the residents due to inappropriate MDS assessment and care screening tool practices.

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to update and revise a fall risk care plan for two of three sampled residents (Resident 106 and 170). This deficient practice had the potential to place Residents 106 and 170 to be at risk for recurrent falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow through Registered Dietitian (RD-a health professional who has special training in diet and nutrition)'s recommendations in a timely manner and failed to assess, monitor, and evaluate interventions to prevent two of nine sampled residents (Resident 42 and 79) from further weight loss by: A. Failing to ensure to monitor and assess Resident 42's weekly weights and intake of supplements, and obtain an order for Megestrol Acetate (a medication to treat loss of appetite and weight loss) in a timely manner as recommended by the RD. B. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency related to their duties when: 1. Dietary Aid (DA2) and Dishwasher (DW) did not know the concentration strength of the chlorine sanitizer used in the dish machine (chlorine sanitizer a product that is used to reduce or eliminate pathogenic agents on surfaces). 2. Cook1 did not follow standardized recipes when preparing pureed diet and did not prepare enough zesty meat sauce to meet facility residents need. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 10/6/2024 when: 1. Facility failed to ensure 16 residents on puree diet (The pureed diet provides foods that do not require chewing and are easily swallowed. All foods should be smooth and pureed to the consistency of pudding.) received spaghetti texture in form that meet their needs when the texture of the puree spaghetti was lumpy, not smooth and had large pieces of pasta present requiring chewing before swallowing. 2. The facility failed to follow lunch menu and portion sizes as written for residents on pureed diet. 16 residents on pureed diet received ½ cup of pureed meat sauce instead of 2/3 of cup per the food portion and serving guide. Residents on pureed diet did not receive the pureed garlic bread per the menu. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. There was no soap available in the handwashing sink. 2. One plastic bag of sliced raw meat, and two logs of ground beef thawing on the rack with no thaw date. One open container of cottage cheese and one container of juice with no open date and previously prepared house shake stored in a large one-gallon milk container. 3. Food brought to residents from outside of the facility, were stored in the resident food refrigerator with no use by date. There were four tv dinners with manufactures instruction to store frozen was stored in the refrigerator with no use by date. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship program policy for four of five sampled residents (Resident 39,96, 37 and 42) when an antibiotic (a substance used to kill bacteria and to treat infections) did not meet McGeer Criteria (criteria used to determine appropriate use of antibiotics) for administration. This deficient practice had the potential to increase antibiotic resistance and provide antibiotics to the residents without justification. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure following up with an optometrist (health care providers who examine, diagnose, treat, and manage diseases and disorders of the visual system, the eye and associated structures as well as diagnose related systemic conditions) visit in six months as recommended by the optometrist and referring to ophthalmologist (a specialist who can treat complex medical issues related to your eyes, and can perform corrective procedures or surgeries including cataracts [tissue that forms over the eye, causing vision loss) and glaucoma [built up pressure in the eye that causes gradual vision loss]) for one of six sampled residents (Resident 55). This failure had the potential to result in Resident 55 not receiving proper care to maintain and/or improve his vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for one dose of a controlled medication (medications with a high potential for abuse) affecting Residents 10 in one of two inspected medication carts (West Station Cart 1.) This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and the risk that Resident 10 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician responded to the consultant pharmacist's recommendation from 8/3/24 to consider a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) related to the use of Depakene solution (a medication used to treat mood swings) in one of five sampled residents (Resident 65.) The deficient practice of failing to ensure the physician evaluated and responded to medication irregularities (potential issues with a resident's medication regimen) identified by the consultant pharmacist during the Medication Regimen Review (MRR - a monthly report from the consultant pharmacist identifying any medication irregularities in a resident's current medication regimen) increased the risk that Resident 65 could have experienced adverse effects (unwanted, [...]

Inspectors wroteBased on interview and record review, the facility failed to discontinue hydroxyzine (a medication used to treat itching and allergies) per the physician's order due to non-use in one of five residents sampled for unnecessary medications (Resident 40.) The deficient practice of failing to discontinue the use of hydroxyzine when Resident 40 was simultaneously using another medication to treat itching effectively could have increased the risk that Resident 40 may have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to the use of hydroxyzine possible resulting in a decline in her quality of life.

Inspectors wroteBased on interview and record review, the facility failed to perform a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) related to the use of Depakene solution (a medication used to treat mood swings) or document a clinical rationale as to why an attempt would be contraindicated in one of five sampled residents (Resident 65.) The deficient practice of failing to perform or consider an GDR increased the risk Resident 65 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to Depakene therapy possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on interview and record review, the facility failed to assess the mental capacity (ability to make decisions) of one of three sampled residents (Resident 65) to sign a legaly binding document before indicating the Arbitration agreement (a contract indicating any disputes would be resolved within the facility rather than in court) was signed by Resident 65. This failure had the potential to result in Resident 65 not fully understanding their rights, to limit opportunity to initiate judicial proceedings that challenge unfavorable decisions. [...]

Inspectors wroteBased on interview and record review the facility failed to protect one of one resident (Resident 1) from misappropriation of property (deliberate misplacement exploitation, or wrongful, temporary, or permanent use of a resident ' s belongings or money without the resident ' s consent) when Housekeeper 1 (HK 1) was running several personal errands procuring personal items, bringing the items to Resident 1, and cashing personal checks from Resident 1. This deficient practice placed Resident 1 at risk for misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to ensure, the resident, who was assessed as being a moderate risk for falls, did not fall for one of one sampled resident (Resident 89). The facility failed to: 1. Ensure a Certified Nurse Assistant (CNA 6) did not leave Resident 89 unsupervised when Resident 89 needed his soiled incontinence brief changed and left the resident's room to collect items for incontinence care. 2. Ensure CNA 6 followed the facility's policy and procedure (P&P) titled Answering the Call Light to summon other staff help by using the call light for assistance to get incontinence care items when CNA 6 was in the Resident 89's room. 3. Ensure Resident 89's room was changed closer to the nursing station for a closer observation/visibility as care planned. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: A. call light was functioning properly for one of five sampled residents (Resident 76). B. Call light was within reach for Resident 52 while up in Geriatric Chair(([Geri Chair]- a large, padded chair that is designed to help seniors with limited mobility) C. care was provided in a manner that maintain or enhanced a resident's dignity and respect for Resident 63. This deficient practice had the potential for Resident 76 and Resident 52 not receiving necessary assistance when needed, experience loss of dignity, and loss of self-esteem due to inability to summon help with call lights. This deficient practice has the potential to affect Resident's 63 sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately assess and monitor one of one sampled resident (Resident 73) during the use of a pommel cushion (blue cushion placed on a wheelchair) to prevent the resident from sliding. This deficient practice had the potential to result in entrapment and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR is guided by federal regulations that require all individuals being considered for admission to a Medicaid-certified nursing facility (NF) be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness) ) screening was completed for two of five sampled residents (Resident 14 and Resident 22) who were diagnosed with mental disorder (MD). This deficient practice had the potential for Resident 14 and 22, not receiving appropriate behavioral services

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 14, and Resident 57) were provided with a communication board and language translating service were readily available. These deficient practices lead the potential Resident 14 and 57 not communicating her needs effectively with staff and delay in care and services being rendered for Resident 14 and 57.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure five vials of pens of insulin (a type of medication used to treat high blood sugar) requiring refrigeration were stored according to the manufacturer's requirements affecting Residents 5, 14 and 17 in one of two inspected medication carts (West Station Cart 2.) The deficient practices of failing to store medications per the manufacturers' requirements increased the risk that Residents 5, 14 and 17 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Cooked eggs, cooked bacon and ready to eat tofu were stored on the same shelf next to raw eggs and a carton of raw liquid eggs. Raw chicken was stored to thaw on shelf above raw marinated ground beef. This had the potential to cross contaminate food and result in food borne illness in 100 residents who received food from the kitchen. 2. Kitchen wash cloths/towel were stained and discolored, and dishware were chipped. Staff using discolored and stained wash cloths to clean food contact surfaces. 3. Cook1 did not wash hands after removing soiled gloved and returned to food prepare vegetables and rice. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the electric hi-low therapy mat (therapy mat, electric and adjustable padded mat table used for therapy treatments) was in safe, operating condition. This deficient practice had the potential to cause injury to any resident or staff member who used this equipment as part of therapy treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Certified Nursing Assistants (CNAs) were provided mandatory (required by law or rules) minimum 12 hours per year in-service training of Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) Care and Abuse (treat a person with cruelty or violence, especially regularly or repeatedly). This failure had the potential to result in the residents being subject to abuse, and residents who had dementia improperly cared for.

Inspectors wroteBased on interview, and record review, the facility failed to ensure advance directives (written statement of a person's wishes regarding medical treatment made to sure those wishes are carried out should the person be unable to communicate) was discussed and written information was provided to the residents /or responsible parties for one of five sampled residents (Resident 22). This deficient practice violated the resident's right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 96) was reviewed for changes in Medicare (federal health insurance for people 65 or older) coverage were provided with the Notice of Medicare Non-Coverage (NOMNC) appeal process in a timely manner. This failure had the potential to result in Resident 96 and/or responsible party not being able to exercise their right to file an appeal.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 57) was reviewed for Preadmission Screening and Resident Review (PASARR) in a timely manner. This failure had the potential to result in the resident not receiving appropriate care or delay in treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a care plan for one of three sampled residents (Resident 13) who has decreased hearing. This deficient practice had the potential to negatively affect the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to update and implement the comprehensive care plan for one of one sampled resident (Residents 73) who sustained a fall from his wheelchair. This failure resulted in Resident 73 sustaining an injury from the actual fall.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician's order for foot care for one of one sample resident (Resident 97). This deficient practice had the potential for placing the resident at risk for complications such as infection or bleeding of the feet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for the use of one dose of a controlled substance (medications with a high potential for abuse) affecting Resident 17 in one of two inspected medication carts (West Station Cart 2). This deficient practice increased the risk that Resident 17 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to enter or clarify a prescriber's order to reduce the dose of Seroquel (a medication used to treat mental illness) between 9/20/23 and 10/5/23 for one of five sampled residents (Resident 52.) As a result of this deficient practice, Resident 52 received a higher than necessary dose of Seroquel between 9/20/23 and 10/5/23 which increased the risk that he could have experienced adverse effects (unwanted side effects of medication therapy like drowsiness or constipation) related to the use of Seroquel leading to a decline in his quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 55 was assisted and provided with additional nutritive packets to have a therapeutic diet (a prescribed meal plan that controls certain aspects of nutrients and/or foods as part of a treatment plan) as ordered by the physician during Restorative Nurse Assistant (RNA) feeding program (a feeding assistant program to restore residents to a former capacity or to improve their level of independence and thereby promote improved nutrition status) for one of three sampled residents (Resident 55). This failure had the potential to result in preventing Resident 55 from receiving benefit of a therapeutic diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper adaptive eating utensils (AE, eating equipment such as forks, knives, and spoons that are modified to increase independence with eating) for one of seven sampled residents (Resident 69) by failing to: 1. Follow physician's orders for AE. 2. Perform an assessment to determine the AE provided to Resident 69 was suitable and effective. [...]