Pacific Villa, Inc

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures for 82 of 82 sampled residents. The facility failed to:1. Implement and document regular monitoring of water temperature for their water management plan ( a written safety plan that identifies, monitors, and controls water systems to prevent the growth of legionella bacteria[bacteria commonly found In water that can cause a severe type of pneumonia known as Legionnaires disease {[serious lung infection caused by legionella bacteria that grow in warm water}] ) designed to minimize growth and transmission of Legionella in the facility water systems. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services in a timely manner for two of five sampled residents (Resident 32 and Resident 59). The facility failed to:1. Ensure appropriate follow up for Resident 59's denture needs.2. Provide a dental check up and evaluation for Resident 32, who was admitted with missing and broken teeth. These failures had the potential to result in discomfort and impaired chewing ability, which could lead to decreased appetite and weight loss for both Resident 32 and Resident 59.

Inspectors wroteBased on observation interview and record review the facility failed to ensure food items kept in the refrigerator and freezer were labeled and dated. These failures had the potential to result in foodborne illnesses (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) for all residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 12) attempted a Gradual Dose Reduction ([GDR] an attempt to decrease or discontinue psychotropic [acting on the mind] medication three months after starting on the psychotropic medication) for Resident 12. This failure resulted in Resident 12 receiving Remeron (an antidepressant) 0.5 milligrams ([mg] unit of measurement) for depression and Risperdal (an antipsychotic medication used to treat schizophrenia) 0.5 mg for schizoaffective disorder without a documented gradual dose reduction.

Inspectors wroteBased on observation, interview and record review the facility failed to implement its abuse policy and procedure for one of 20 sampled residents (Resident 9). The facility failed to:1. Follow facility's policy and procedure (P&P) titled, Abuse, Neglect, and Injury Reporting Policy, undated, which indicated injuries of unknown origin will be promptly evaluated and reported in accordance with federal and California regulations. This failure had the potential to result in undetected abuse and compromised resident safety, affecting Resident 9 and other residents in the facility.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to report an injury of unknown origin (the cause of injury was not observed by any person or could not be explained by the resident) to the California Department of Public Health (CDPH) for one of 20 sampled residents (Resident 9) when Resident 9 sustained a right humeral fracture (a break in the upper arm bone between the shoulder and elbow, typically associated with falls or direct impact) on 2/23/2026. This failure had the potential to delay an investigation to determine whether abuse or neglect contributed to Resident 9's injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to investigate an injury of unknown origin (cause of injury was not observed by any person or could not be explained by the resident) for one of 20 sample resident (Resident 9). The facility failed to:1. Investigate Resident 9's injury of unknown origin. Resident 9 was admitted to the facility on [DATE] with no documented fracture (broken bone) to the right shoulder, as confirmed by X ray (imaging that create images of structures inside the body) results dated 1/2/2026 and 1/6/2026. While under the facility's care, Resident 9 developed a humeral fracture (a break in the upper arm bone connecting the shoulder and elbow) on 2/23/2026. This failure had the potential to prevent the facility from determining whether Resident 9's injury resulted from abuse or neglect.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of one sampled residents (Resident 78) was assisted with eating during meals. This failure had the potential to place Resident 78 at risk for weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to provide one of 18 sample residents (Resident 63) with activities or regular room visits as part of an ongoing program to support the resident's chosen activities. This failure had the potential to negatively impact on Resident 63's sense of self-worth and psychosocial well being, including feelings of usefulness, social connection, and personal satisfaction.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 48) was offered functional hearing aids available for use. This failure resulted in Resident 48 not being able to hear adequately and communicate appropriately for care, safety needs and basic services for hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide effective pain management for one of four sampled residents (Resident 9). The facility failed to:1. Ensure Resident 9 was provided with pain medicine based on his assessed pain level. This failure had the potential to result in Resident 9 having unrelieved pain or overmedication (receiving too much medication and taking excessively high doses).

Inspectors wroteBased on interview and record review, the facility failed to ensure staff competency in cardiopulmonary resuscitation (CPR- emergency lifesaving procedure that is performed when someone's stopped breathing or heartbeat has stopped) for one of three reviewed staff members (CNA 2). The facility failed to:1. Ensure CNA 2 demonstrates the knowledge and skills necessary to perform CPR by obtaining Basic Life Support (BLS-verifies training in essential, life-saving techniques for healthcare professionals and first responders focusing on CPR ) certification that includes an online training and in-person skills demonstrations. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients) for one of five sampled residents (Resident 48) who was prescribed an antibiotic drug without meeting the McGeers Criteria (a set of clinical definitions used for surveillance to define the resident symptoms and other clinical criteria that are used to meet infection surveillance definitions). This failure had the potential to result in Resident 48 developing antibiotic resistance (when bacteria develop defenses against the antibiotics designed to kill them) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Activity Assistant accurately documented on Activity Attendance Record provided for one of five sampled residents (Residents 63) in 2/12/2026,2/13/2026,2/14/2026 and 2/2/24/2026. This deficient practice had the potential for confusion in the care and services provided to Resident 63 and placed the resident at risk of not receiving appropriate care due to inaccurate and incomplete medical information.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Antibiotic Stewardship Program ( process for improving how antibiotics [medication used to treat infection] are prescribed and used by residents) was implemented for one of three residents (Resident 90). The facility failed to monitor antibiotic use and review the appropriateness of the prescribed antibiotic. This failure had the potential to put Resident 90 at risk for antibiotic resistance (ability of bacteria and other microorganisms to withstand the effects of antibiotics, rendering them ineffective) or inappropriate use of antibiotic.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that the attending physician was notified of a change in condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death ) for one of three sampled residents (Resident 1), after Resident 1 reported being struck and expressed fear, indicating a psychosocial change ( shifts in a person's thoughts, feelings, behaviors, and relationships) in condition. This failure had the potential to delay or prevent medical and mental health evaluation, resulting in unaddressed psychosocial distress, continued fear, lack of appropriate interventions, and increased risk to resident safety and well-being.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the comprehensive care plan (a personalized, written guide detailing a patient's health status, specific needs, goals, and the nursing actions [interventions]) was developed and implemented for one of three sampled residents (Resident 1) following a change in condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death), when Resident 1 reported being struck and expressed fear, indicating a psychosocial change ( shifts in a person's thoughts, feelings, behaviors, and relationships) in condition. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was not subject to abuse when Resident 2, who has history of schizophrenia (a mental illness that is characterized by disturbances in thought), and sudden mood changes threw water on Resident 1. This deficient practice resulted in Resident 1 feeling like she was drowning when the water that Resident 2 threw on her, covered her face, went into her mouth and down her throat.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for one of two sample residents (Resident 1), when Resident 1 told Certified Nursing Assistant (CNA) 1, that Resident 2 threw water on her (Resident 1). This deficit practice resulted in the inability of the California Department of Public Health (CDPH) to conduct a timely investigation and had the potential for information to be lost and/or forgotten.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow enhanced barrier precautions ([EBP] an infection control intervention designed to reduce transmission of multidrug- resistant organisms that employs targeted gown and gloves use during high contact resident care activities) for one sampled resident (Resident 4) when Treatment Nurse (TN) 1 did not wear a gown while providing care to Resident 4's wound. This deficient practice resulted in an increased risk for Resident 4's wound to become infected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that window blinds were intact and provided adequate visual privacy for 5 of 18 sampled residents. This deficient practice resulted in residents' exposure to the parking lot and sunlight and a potential violation of residents' rights to visual privacy in five resident rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment for one of three sampled residents (Resident 1). This deficient practice had the potential to expose residents to unsanitary conditions and increase the risk of transmission of disease-causing organisms.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin (an injury whose source was not observed by any person or cannot be explained by the individual) to the State Department per the facility ' s policy and procedure (P/P) titled Abuse, Neglect and Exploitation for one of three sampled residents (Resident 1) when Resident 1 who was complaining of right hip pain and was experiencing decreased range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point), was found to have right hip fracture (broken bone). As a result of this deficient practice, Resident 1 had the potential for delay in care and investigation into the cause of Resident 1 ' s fractured right hip.

Inspectors wroteBased on interview and record review, the facility failed to investigate an injury of unknown origin (an injury whose source was not observed by any person or cannot be explained by the individual) for one of three sampled residents (Resident 1) when Resident 1 was found to have right hip fracture (broken bone). As a result of this deficient practice, Resident 1 had the potential for delay in care and investigation into the cause of Resident 1 ' s injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 was competent and reported a Change of Condition (COC) for one out of three sampled residents (Resident 1) who experienced new right hip pain and decreased right hip range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) to the director of nursing (DON) for further assessment. As a result of this deficient practice, Resident 1 had the potential for delays in care and on 5/4/2025 Resident 1 was found to have a right hip fracture (broken bone).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident was free from physical abuse and was not punched on the face multiple times by another resident for one of three sampled residents (Resident 1). The facility failed to: 1. Supervise Resident 1 and Resident 2 who were smoking on the patio and having an argument on 4/12/2025 at 3:45 a.m. as indicated in both residents' Smoking Assessment Form. 2. Assess and monitor Resident 2 when he was restless and had an escalating behavior manifested by yelling and demanding staff for a cigarette to smoke, pacing (to walk in one direction and then back again) back and forth at the facility's nursing station and hallways on 4/12/2025, from 12:00 a.m. to 3:30 a.m. 3. Ensure Certified Nursing Assistant (CNA) 1 knew the whereabouts of Resident 1 and Resident 2 while she was assigned to care for them on 4/12/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents who were smoking on the patio were supervised and monitored for two of three sampled residents (Resident 1 and Resident 2). The facility failed to: 1. Ensure Resident 1 and Resident 2, who were assessed as needed supervision at all times, were supervised while smoking on the patio on 4/12/2025, at around 3:45 a.m. in accordance with the facility's policy and procedure titled, Smoking Policy-Residents and Resident 1's and Resident 2's Smoking Assessment Forms. 2. Ensure Resident 2's aggressive behavior was monitored and addressed on 4/12/2025. Resident 2 had been manifesting aggressive behavior and asking staff for a cigarette all night before the incident happened on 4/12/2025 at 3:35 a.m. These failures resulted in Resident 1 and Resident 2 unsupervised smoking on 4/12/2025 at 3:35 a.m. [...]

Inspectors wroteBased on interview and record review the facility failed to monitor resident for signs and symptoms of neurological decline (brain and nervous system are not working correctly which can lead to problems with thinking, memory, movement or change in level of consciousness[loc-person ' s awareness and responsiveness to their surroundings]) for one of three sampled residents (Resident 4) after being struck on the face by Resident 5. This deficient practice had the potential to lead to serious life-threatening effect that could go unnoticed without a neurological assessment (assessment of a patient ' s mental status , level of consciousness, changes in pupil size and reaction to external stimulus , motor strength, sensation and movement of arms and legs).

Inspectors wroteBased on interview and record review, the facility ' s Quality Assurance (Q A)/ Quality Assurance and Performance Improvement (QAPI) (a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee failed to address , maintain, and develop an effective plan to correct identified problems after the deficient practices were identified related to abuse and accident on 4/28/2025 during an investigation of a facility reported incident (FRI- process by which a healthcare facility documents and reports an event that occurred within the facility and potentially affected the safety of residents, staff or the facility itself). This failure resulted into a repeated deficient practice about abuse and supervision which could affect the health and safety of the residents.

Inspectors wroteBased on observation, interview and record review , the facility failed to observe infection control practice by failing to ensure four of ten sampled staff members wear a mask when the facility was in a Covid outbreak( two or more linked cases of the same illness caused by Covid 19 virus[infectious and contagious disease caused by coronavirus]). This failure had the potential to spread and transmit infection to the residents and other staff.

Inspectors wroteBased on observation and interview, the facility failed to ensure three of three outside grey garbage dumpsters were covered. This deficient practice had a potential to harbor and attract flies, insects, mice, rats, and other animals to the garbage containers. This deficient practice also had the potential for those pests to enter the facility which could lead to the spread of infectious diseases to the residents, staff, and visitors.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of six sample residents (Resident 1) was not physically assaulted by another resident while under the facility ' s care. This deficient practice resulted in Resident 1 being assaulted by her roommate (Resident 2) when during an unprovoked attack, Resident 2 hit Resident 1 with her fist then her shoe. Resident 1 sustained a contusion (a bruise) to her left upper and lower eyelid. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 2/4/2025 for evaluation and treatment where an ice pack was applied.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the food in the refrigerator are not outdated when: a. chicken stored in the refrigerator in a clear plastic container with a cracked lid dated 10/13/2024, b. seasoned hash brown potatoes stored in the refrigerator with an expiration date of 11/26/2024, c. potato salad stored in the refrigerator with an expiration date of 12/9/2024, d. macaroni salad stored in the refrigerator with an expiration date of 12/14/2024, e. tomatoes stored in the refrigerator a plastic container covered with plastic wrap dated 12/14/2024, f. bread stored in the refrigerator in a plastic container covered with foil dated 12/16/2024, g. lettuce stored in the refrigerator in a plastic container covered with plastic wrap dated 12/16/2024 and h. freezer burned meat stored in the freezer were discarded. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately document an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) for five of seven residents (Residents 5, 21, 36, 65, and 68). These failures had the potential to result in causing a conflict with Resident 5, 21, 36, 65, and 68's wishes regarding their health care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a preadmission screening and annual resident review (PASARR) was accurately documented for five of eight residents (Resident 19, 21, 45, 65, and 84). This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident's 19, 21, 45, 65, and 84.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to three of nine residents (Resident 5, 20, and 68) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to: 1. Provide Resident 5 with passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) to both arms from 12/1/2024 to 12/19/2024 in accordance with the physician's order and care plan. 2. Provide PROM to Resident 5's ankles on 12/19/2024 in accordance with the physician's order and care plan. 3. Provide PROM to Resident 20's elbows, wrists, hands, knees, and ankles in accordance with the physician's order and care plan. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices for four of six sampled residents (Resident 20, 27, 54, and 73) by failing to: 1) Ensure the humidifier was changed for Resident 73. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's call light was within reach for one of 20 random sampled residents (Resident 42). This deficient practice had a potential for the resident not able to call for assistant as needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident 81 bed was not broken for 1 out of 3 Residents. This deficient practice had the potential to put Resident 81 at risk for accidents while in bed.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person focused care plan for two of three sampled residents (Resident 6 and 339) by failing to: 1. develop a comprehensive care plan that will address Resident 339's fabrication (making something up) of stories. 2. develop and implement care plan for skin redness and swelling of the right eye and right cheek for Resident 6. These failures placed Resident 6 and Resident 339 at risk for a delay of care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident was provided care and services to maintain good grooming and personal hygiene by failing to clean and cut Resident 29 fingernail for one of three sampled residents (Resident 29). This deficient practice resulted in Resident 29 not receiving fingernail care and can potentially impact Resident 29's self-esteem

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident 6 who had redness on the right side of the cheek was monitored and received treatment for one of 22 sampled residents. This failure had the potential for Resident 6 not receiving necessary care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) staff were competent to provide range of motion ([ROM] full movement potential of a joint [where two bones meet]) exercises and apply splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to three of nine residents (Resident 5, 20, and 68) with limited ROM and mobility (ability to move) in accordance with the facility's undated job description titled, Restorative Aide. This failure had the potential for Resident 5, 20, and 68 to develop further ROM limitations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Administer risperidone (a medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), calcium (a supplement used to treat low level of calcium) and vitamin D (a vitamin used to treat low level of vitamin D) in accordance with physician's orders affecting one of four sampled residents during medication administration (Resident 54). 2. Clarify dose and frequency of physician's order for docusate sodium (a medication used to relieve constipation) affecting one of four sampled residents (Resident 440). 3. [...]

Inspectors wroteBased on interview and record review the facility failed to monitor one of three sampled resident's (Resident 439) behaviors while prescribed with psychotropic medications (medications can alter brain chemistry, impact body functions, and modify a person's thoughts, moods, feelings, awareness, and perceptions). This failure had the potential to result in unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for one of four sampled residents (Resident 54) by failing to provide risperidone (a medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), calcium (a supplement used to treat low level of calcium) and vitamin D (a vitamin used to treat low level of vitamin D) in accordance with physician's orders. This deficient practice of medication administration error rate of 7.14% exceeded the five (5) percent threshold.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure storage and/or labeling of brimonidine tartrate ophthalmic solution (a medication in form of eye drops used to treat high intraocular pressure [a term used to describe fluid pressure inside the eye]), bisacodyl (a medication used to treat constipation) suppositories (a medication designed to be inserted into the anus), and removal of expired Lantus ([generic name - insulin glargine] a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) Solostar Pen from medication refrigerator, in accordance with manufacturer requirements affecting at least two residents (Resident 34 and 51) in one of two inspected medication rooms (Medication Room). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) treatment records for one of nine sample residents (Resident 12) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) was complete for the month of 10/2024. This failure resulted in incomplete RNA records for the provision of passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) for Resident 12.

Inspectors wroteBased on interview and record review, the facility failed to record dates on the Minimum Data Set ([MDS] a resident assessment tool) to indicate the start and end of therapy services since most recent entry (admission) to the facility for three of nine sampled residents (Resident 14, 21, and 26) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move). This failure resulted in incomplete information submitted to the Federal database.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was transferred to a General Acute Care Hospital (GACH) on 9/5/2024 for evaluation and treatment related to abnormal laboratory (labs) results, was refused readmission to the facility after Resident 1 was treated and stabilized at the GACH on 10/1/2024. This deficient practice resulted in Resident 1 remaining at the GACH for 11 days after Resident 1 was deemed appropriate for transfer back to the facility but was denied readmission by the facility. Resident 1 was subsequently transferred to a different facility (10/1102024), placing the resident at risk for confusion, disorientation related to displacement from a place that was considered Resident 1's home.

Inspectors wroteBased on interview and record review, the facility failed to report a resident-to-resident altercation not later than two hours to the Ombudsman (public advocate who tries to resolve complaints) and the California Department of Public Health (CDPH) after the abuse allegation was made according to mandatory reporting requirements for two of four sampled residents (Resident 1 and 2). This deficient practice had the potential to impede the safety of the residents and place the residents at risk for elder abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure by failing to submit a five-day investigative report for one of three sampled resident ' s (Resident 1). This deficient practice resulted in an incomplete investigation and incomplete conclusion of the alleged abuse in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement resident-centered care plan for one of three sampled residents (Resident1). This deficient practice had the potential to result in a delaying delivery of care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices for 88of 88 residents according to the facility's policy and procedure and manufacture' s instructions by failing to: 1. Ensure stored foods were labeled with an open date. 2. Ensure monitoring and documentation for sanitization bucket log. 3. Ensure oasis multi-quat sanitizer strips (to sanitize hard, non-porous food contact surfaces such as tables, counters, utensils and food processing equipment) and sanitation range testing kit (ensures the sanitizer agents are of the correct pH, strength and temperature to ensure equipment is sanitized effectively) were available. [...]

Inspectors wroteCross referenced to F600 Based on observation, interview and record review, the facility failed to implement its abuse policies and procedure for three of four sample residents (Resident 27, Resident 70 and Resident 74 by failing to: 1. Intervene, report, and investigate resident to resident altercation between Resident 27 and 70. 2. Report and investigate Resident 70'[s verbal and mental abuse after reporting it to CNA 1 and after request of room change to Director of Social Service

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of an allegation of abuse were reported to Department of Public Health (DPH) no later than 24 hours for three out of 19 sampled residents (Resident 27,70 and 74). This failure had the potential to delay the investigation by the State agency and had the potential to place Resident 27, 74 and 70 at risk for further occurrence of abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure by failing to investigate and separate Resident 70 from Resident 9 to prevent further potential verbal and mental abuse. These failures resulted in Resident 70 being verbally and mentally abused by Resident 7 for four months and felt depressed (a mood disorder that causes a persistent feeling of sadness and loss of interest) and stressed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of 19 sampled residents ( Resident 74, 21 and 68) received Restorative Nursing Aide (RNA- assist the resident in performing task that restore or maintain physical function) services as ordered by the physician by failing to: 1. Provide active range of motion exercises ([AROM] occurs when a person use their muscles to help move their body) to upper and lower extremities (limbs) five days a week as ordered by the physician to Resident 74. 2. Resident 21 has hand rolls on both hands as ordered by the physician. 3. Resident 68 received Restorative Nursing Aide as ordered by the physician. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide supervision and monitor residents who are on smoking list for three of 19 sampled residents (Resident 15, Resident 72 and Resident 11). This deficient practice resulted to superficial right middle fingers burn to Resident 15, and Resident 11 and Resident 72 at risk for accidental burn due to unsupervised smoking.

Inspectors wroteBased on observation, interview and record review the facility failed to: 1. Follow physician written orders and instructions regarding oxygen therapy (the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of low oxygen) for one of 19 sampled residents (Resident 39). This failure resulted in Resident 39 receiving too much oxygen and potentially leading to complications such as headaches, lethargy (state of sleepiness or deep unresponsiveness), drowsiness, confusion, coma, and death. 2. Replace empty oxygen humidifier for Resident 15. This deficient practice had the potential for respiratory infections for Resident 15.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Account for four doses of controlled medication ([CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for four out of four sampled residents (Resident 31, 44, 58 and 60) in one of two inspected medication carts (Medication Cart South). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of not greater than five (5) percent (%) or below medication error rate, as evidenced by two medication errors out of 29 opportunities for error, which yield a 6.9 % medication error rate. The medication errors were as follows: 1. Resident 38 received a dose of artificial tears (eye drops used to moisturize dry eyes) different from the one ordered by Resident 38's physician. 2. Resident 182 did not receive vitamin D3 (medication used as a dietary supplement to promote bone health) as ordered by Resident 182's physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Twenty-five Licensed Vocational Nurses (LVNs) and one Registered Nurse Supervisor (RNS) did not administer expired insulin (a medication used to regular blood sugar levels) to one of seven sampled residents observed (Resident 10.) 2. Five LVNs and one RNS did not administer lorazepam oral concentrate (a medication used to treat anxiety and restlessness) stored at room temperature to one of seven sampled residents observed (Resident 232.) These failures resulted in Residents 10 received a total of one hundred-one doses (units) of expired insulin and Resident 232 received a total of twenty-one doses of inappropriately stored Lorazepam. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Removed and discard one expired insulin (medication used to regulate blood sugar levels) Novolog (fast-acting insulin) vial for Resident 10, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart South.) 2. Store two insulin Basaglar (long-acting insulin) Kwikpens (type of insulin injection devise) for Resident 10, two insulin Humulin R (short-acting insulin) vials for Resident 58 and 74 at room temperature, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart South.) 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow up necessary dental services for two of 19 sampled residents (Resident 15 and Resident 74). This failure had the potential to put Resident 15 and Resident 74 at risk for development of tooth decay and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician when one of 19 sampled residents (Resident 232) was complaining of painful urination (feel pain or a burning sensation when urinating). This failure resulted in a delay of treatment and had the potential to put Resident 232 for unrelieved bladder discomfort.

Inspectors wroteBased on interview, and record review, the facility failed to protect residents right to be free from verbal and mental abuse including racial slurs (words or phrases that refer to members of racial and ethnic groups in a derogatory manner ), calling him names (insult someone verbally) and being yelled at for one of 19 sampled residents (Resident 70). The facility failed to: 1. Ensure Resident 9 did not continue to use racial slurs, yell and called Resident 70 names after Certified Nursing Assistant (CNA) 1 witnessed the incident and Resident 70 informed CNA 1 in December. 2. Report Resident 70 verbal and mental abuse after reporting it to CNA 1 and after request of room change to Director of Social Service 3. Investigate Resident 70 verbal and mental abuse from Resident 9 for the four months. 4. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of 19 residents (Resident 68) received the proper assistive devices to maintain vision abilities by not assisting in providing of reading glasses. Resident 68 was recommended eyeglasses on 10/2/2023 and by 1/2/2024, the Director of Social Services (DSS) had not followed up in the delay of the reading glasses. This failure resulted in Resident 68 not having his reading glasses and being unable to read or see small objects for three months.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care and services to one of 19 sampled residents (Resident 10) to prevent complications of enteral feedings (method of supplying nutrients directly into the gastrointestinal tract) via gastrostomy tube ([G-tube] an artificial opening into the stomach to deliver medication, nutrition, and hydration) by failing to change the tube feed (liquid form of food that is carried through your body through a flexible tube called G-tube) and administration set (tubing used to deliver the enteral feeding) per facility's policy and procedure. This failure had the potential to result in administering expired enteral formula which could lead to diarrhea, intolerance, dehydration, and weight loss to Resident 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure regarding Trauma Informed Care (an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or response to behavioral health) for one of five sampled residents (Resident 60) by failing to screen Resident 60 for history of trauma on admission. This failure had the potential to place Resident 60 at risk for not receiving adequate care and implement trigger specific interventions to meet Resident 60's psychosocial needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 31) did not receive Ativan (a psychotropic medication [drug that affects brain activities associated with mental processes and behavior] used for anxiety, and categorized as a controlled medication {CM-medications which have a potential for abuse and may also lead to physical or psychological dependence}) without a physician order to renew after 14 days of initial order on 11/16/23 and medication bubble pack (a medication packaging system that contains individual doses of medication per bubble) of Ativan was removed from the medication cart (Medication Cart South.) These failures resulted in Resident 31 to received Ativan beyond the date prescribed by Resident 31's physician and had the potential for increased risk for Residents 31 to experienced serious adverse effects (unwanted, [...]

Inspectors wroteBased on interview and record review the facility failed to offer the pneumococcal vaccine (vaccine that helps prevent pneumonia (an infection that inflames the air sacs in one or both lungs) to one of 19 sampled residents. This failure had the potential to result in Resident 19 acquiring and transmitting pneumonia to other residents, staff, and visitors.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of 19 sampled residents (Resident 68) had a functioning call light. This failure resulted in Resident 68 not being able to use his call light to get help or call for assistance from the nursing staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (Resident 1) who had an appointed conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) 1 was informed in advance, of the risks and benefits of psychoactive medications (a medication which changes brain function and results in alterations in perception, mood, consciousness or behavior) for one of three sampled residents (Resident 1). This deficient practice violated the conservator ' s (CON 1) right to make an informed decision regarding the use of psychoactive medications for Resident 1 and placed Resident 1 at risk for making health care decisions she was not able to understand.

Inspectors wroteBased on interview and record review, the facility failed ensure a resident (Resident 1) who had an appointed conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) request to change psychiatrist (a medical doctor [MD] who specializes in mental health [emotional, psychological, and social well-being]) was honored for one of three sampled residents (Resident 1). This deficient practice resulted in the request for change in MD not being granted per the CON 1 ' s request and violated CON 1 ' s rights to change Resident 1 ' s MD.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of medical records upon written request from an authorized conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) for one of three sampled residents (Resident 1) within two working days per the facility ' s policy and procedure (P/P) titled, Release of Medical Records. This deficient practice violated Resident 1 and the conservator ' s (CON 1) rights to obtain a copy of the resident ' s medical record.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who had a diagnosis of diabetes mellitus (DM) type 2 [a chronic disease characterized by elevated levels of blood glucose (or blood sugar) in a bloodstream], who was receiving Insulin (a hormone which lowers the level of glucose [a type of sugar in the blood]) every morning at 9 a.m., and blood glucose monitoring before meals and at bedtime, primary care doctor (MD 1) and appointed conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) was informed immediately after Resident 1 ' s refusal of medication on 1/5/2023 and 1/6/2023 and refusal of blood glucose monitoring on 1/5/2023 at 11:30 a.m. and on 1/6/2023 at 6 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had an authorized conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) and had fluctuating capacity to understand and make decisions, a notice of discharge was provided to the CON 1. This deficient practice resulted in Resident 1 being discharged to an assisted living facility ([ALF] housing facility for people with disabilities or for adults who cannot or choose not to live independently) and CON 1 being unaware of Resident 1 ' s discharge status and whereabouts. [...]

Inspectors wroteDuring an interview and record review the facility failed to ensure a resident (Resident 1) who had an appointed conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) was invited to participate in Resident 1 ' s care planning meetings upon admission and quarterly for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 ' s CON not attending the care planning meetings, and unable to participate in Resident 1 ' s care and treatment plans.