Palos Verdes Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from verbal abuse. The facility failed to:1. Separate Resident 1 and Resident 2 immediately when Licensed Vocational Nurse (LVN) 1 was notified by Certified Nursing Assistant (CNA) 1 about the alleged verbal abuse and altercation between Resident 1 and Resident 2 on 3/28/2026 at 5:30 a.m.2. Follow the facility's policy and procedures (P&P) titled, Resident to Resident Altercation, which indicated the staff will separate the residents if two residents are involved in an altercation and identify what happened. These failures had the potential to put Resident 1 at risk for further verbal abuse, unnecessary anxiety and fear from Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse in a timely manner for one of two sampled residents (Resident 1). The facility failed to:1. Report allegation of verbal abuse in a timely manner. Resident 1 reported the verbal abuse to Certified Nursing Assistant (CNA) 1 on 3/28/2026 at 5:00 a.m. CNA 1 reported it to Licensed Vocational Nurse (LVN)1 on 3/28/2026 at around 5:30 a.m. LVN 1 then reported the the allegation to Registered Nurse Supervisor (RNS)1 on 3/28/2026 at 7:15 a.m. SOC 341 ( Report of Suspected Dependent Adult -Elder Abuse- California form used by mandatory reporters to officially report suspected abuse, neglect, or financial exploitation of elders 65 years and above) indicated it was faxed on 3/28/2026 at 2:20 p.m.to California Department of Public Health (CDPH).2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2) did not experience loss of dignity during an incontinent brief change after a bowel movement. This failure resulted in Resident 1 feeling humiliated and fearful that CNA 1 could have access to his personal information, and Resident 2 feeling anger, upset and violated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient dietetic (concerning diet and nutrition) oversight for 46 out of 46 sampled residents. The Dietary Supervisor was not working full-time, and the Registered Dietitian was functioning only on a consulting basis. This lack of oversight was evidenced by lapses in food service delivery, including kitchen staff not following the scheduled menu for pureed diets , inaccuracies in therapeutic diets, inadequate maintenance of essential kitchen equipment such as the ice machine and dishwashing machine, and deficiencies in food safety and sanitation practices. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the trash receptacle outside the kitchen was covered, not overflowing, and properly disposed of. This failure had the potential to attract pests and rodents, pose health risks, and result in infection control violations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to1. Ensure that the water temperature reached the required 160 degrees Fahrenheit ( F- unit of temperature) for proper sanitation when washing residents' laundry in two of three facility washing machines. This failure had the potential to cause cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products), exposing residents' laundry to bacteria, viruses, and other harmful microorganisms due to inadequate sanitization.2. Review and update facility's policies and procedure for Infection Prevention and Control Program (IPCP- structured, evidence-based plan used in the facility to stop the spread of germs and protect residents and staff) annually. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four of 44 sampled residents (Resident 2, Resident 32, Resident 16 and Resident 41) received meals according to the scheduled dietary menu and prescribed diet textures. The facility failed to:1. Ensure Resident 2 and 32 were provided with a pureed fortified meal as scheduled on the facility's dietary menu.2. Ensure Resident 16 and Resident 41 receive the correct texture and consistency of coconut cake during tray line on 2/10/2026 according to their prescribed diet. These failures had the potential to put Resident 2, Resident 32, Resident 16 at risk for not meeting their nutritional needs and Resident 41 at risk for aspiration (accidental breathing of food, fluids, or stomach contents into the airway and lungs instead of the esophagus).

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in a safe and sanitary manner for 44 out of 46 sampled residents in the facility. The facility failed to:1. Ensure reach in refrigerator had an internal thermometer that was in working condition. 2. Ensure dish washing machine was maintained and operated at the proper recommended temperature of 120 degrees Fahrenheit (F- unit of measurement).3. Ensure the ice machine was clean and sanitary.4. Ensure [NAME] (CK) 2 washed her hands after touching the lid of a step on trash can before stirring the soup in the stove.5. Ensure an open brown bag of flour and an open bag of pasta were stored in a sanitary manner in the dry storage area. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure:1. Two of five residents (Resident 4 and Resident 6) were provided education regarding the risks and benefits of refusing influenza (flu - a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) and pneumococcal (pneumonia - an infection/inflammation in the lungs) vaccines (medications used to prevent diseases).2. One of five residents (Resident 19) was not given the influenza and pneumococcal vaccine. This failure had the potential to result in residents from making informed decisions regarding refusal of influenza and pneumococcal vaccine, increasing the risk for vaccine-preventable illness, complications, hospitalization, and transmission of infection within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility's dishwashing machine was maintained in a safe and operational condition. The facility failed to:1. Ensure the dishwashing machine's temperature was running at the recommended temperature of 120 degrees Fahrenheit ( F- unit of measurement). This failure had the potential to increase the risk of cross- contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and food-borne illnesses (any illness resulting from eating contaminated/spoiled foods) among the residents.

Inspectors wroteBased on interview and record review, the facility failed to honor one of four sampled residents' (Resident 38) right to self determination by not accommodating Resident 38's request to have a shower. This failure had the potential to negatively impact Resident 38's quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure missing personal items belonging to one of one sampled resident (Resident 47), including colored pencils and pens used for activities and a personal bottle of hot sauce, were located or replaced. This failure had the potential to result in Resident 47 experiencing frustration or depressed mood due to the facility not returning or replacing the missing items.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 5) was free of chemical restraints (use of medication to control a patient's behavior or restrict the patient's movement and not required to treat the medical symptom). The facility failed to:1. Ensure Resident 5 was provided with non-pharmacological interventions (intervention that does not primarily use medicine) before administering as needed (prn) psychotropic medication (any drugs that affects the brain activities associated with mental processes and behavior) of Ativan (Lorazepam- medicine used to treat anxiety)2. Ensure psychotropic medication used as a prn for Resident 5 did not exceed 14 days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the recommended ankle brachial index (ABI- painless test that measures blood pressure in your ankles and arms) with arterial doppler (non-invasive, painless ultrasound test that uses sound waves to evaluate blood flow) for one of 15 sampled residents (Resident 6) was completed as ordered on 1/28/2026 for a right second toe diabetic ulcer (open sore, commonly on the bottom of the foot, affecting resident with diabetes). This failure resulted in Resident 6 experiencing emotional distress due to uncertainty about whether his toe might require amputation( surgical or traumatic removal of a limb or extremity (arm, leg, finger, toe).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 4), who had limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and limited mobility, received appropriate treatment and services to increase ROM, prevent further decline, and maintain or improve mobility. This failure had the potential to place Resident 4 at increased risk for further ROM decline and the development of contractures (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff).

Inspectors wroteBased on interview and record review, the facility failed to ensure two Certified Nursing Assistants (CNAs) had completed required annual competency evaluations. This failure had the potential to result in residents receiving inadequate care and services due to staff not demonstrating current competency.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance (QAA a group of people developing and monitoring quality compliance) Committee, failed to ensure effective oversight of facility operations and failed to ensure implementation of the 2025 Plan of Correction (POC) addressing deficient practices identified during the previous 2025 recertification survey. This failure resulted in repeat deficiencies in food storage, food preparation, and sanitation, as well as failure to ensure required annual in-service training for Certified Nursing Assistants (CNAs) was completed.

Inspectors wroteBased on interview and record review the facility failed to ensure:a. Education was provided about the benefits and risks of the COVID-19 (an illness caused by the coronavirus and affects the lungs and breathing and can make other parts of the body sick) vaccine for one of five residents (Resident 4) and/or the resident's representative.b. One of five staff (Dietary Aide 1) had documentation containing information demonstrating the staff member had been screened, provided with COVID-19 vaccine education, was offered the vaccine and had their current vaccination status recorded. This failure had the potential to result in residents and staff remaining unprotected against COVID-19, increased risk of serious illness, delayed identification of vaccine status, and missed opportunities to prevent the spread of infection within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure adequate room size and space to support the comfort and well being of one of 46 sampled residents (Resident 34). This failure had the potential to negatively impact Resident 34's quality of life by limiting his ability to move freely and safely within his living space.2. Ensure 18 of 24 residents' rooms (room [ROOM NUMBER], 102, 103, 104, 106, 107, 108, 109, 110, 116, 118, 215, 217, 219, 221, 223, 229, 231) met the requirements of 80 square feet for each resident. This failure had the potential to result in inadequate provision of safe nursing care and a lack of privacy for residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure two Certified Nursing Assistants (CNAs) completed the required 12 hours of annual in service training. This failure had the potential to result in a lack of, or delay in, necessary care and interventions for residents due to staff not maintaining required knowledge and skills.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) social security checks were not co-mingled (the mixing or combining of funds or assets from different sources into a single account or pool) into the facility's payroll account when Resident 1's social security checks were directly deposited into the facility's payroll account for six months (7/2021-12/2021). This deficient practice resulted in $27,568.37 of Resident 1's social security checks being deposited into the facility's payroll account and used for employee paychecks. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure funds for one of four sampled residents (Resident 1) were reconciled and returned to Resident 1 within three days of his discharge from the facility (4/28/2024) This deficient practice resulted in multiple social security checks belonging to Resident 1, totaling $27,568.37, being deposited into the facility's payroll account between 7/2021 and 12/2021, without evidence that the funds were deposited to Resident 1's trust account while he was a resident at the facility, or that within 30 days of his discharge from the facility a check was issued to him. This deficient practice had the potential for other resident's funds to be unaccounted for and unreimbursed.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan for three of four sampled residents (Resident 17, 35 and 14). The facility failed to: 1. Develop care plan for Resident 17's intentional weight loss. 2. Develop care plan for Resident 35 who was receiving Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) services. 3. Develop and implement care plan for Resident 14 who had a diagnosis of post-traumatic stress disorder (PTSD-a mental health condition that is caused by an extremely stressful or terrifying event). These deficient practices had the potential to negatively affect the delivery of necessary care and services to Resident's 17,35 and 14.

Inspectors wroteBased on observation and interview the facility failed to: 1. Ensure a tray of multiple individually poured orange juices and cranberry juices in the refrigerator were dated. 2. Ensure trays with multiple individually open containers of fruit in the refrigerator were dated. 3. Ensure a container of cooked ham that had an open date of 4/30/25 and use by 5/10/25 was removed from the refrigerator. 4. Ensure a container of cooked chicken with mushrooms in the refrigerator had a use by date. 5. Ensure that multiple containers filled with cold breakfasts cereals had use by dates. 6. Ensure a bag of cooked fish in the freezer had a use by date. 7. Ensure a bag of cooked roast beef in the freezer had a use by date. These failures had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 42) call light was within reach. This deficient practice had the potential for Resident 42 not to receive necessary assistance when needed, and experienced loss of self-esteem.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one sampled resident (Resident 23) had a recommended Level II Preadmission Screening and Resident Review evaluation ([PASARR]-a mental health evaluation done to determine if an individual can benefit from specialized mental health services). This failure placed Resident 23 at risk for inappropriate placement, not receiving necessary care, and services.

Inspectors wroteBased on interview and record review the facility failed to ensure annual performance evaluations were completed for Certified Nursing Assistants (CNA), CNA 1, CNA 2 and CNA 4. This deficient practice had the potential for the facility not to be able to assess areas of weakness identified in performance reviews and skills necessary to provide nursing services to assure resident safety.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure the medication error rate of less than five (5) percent, due to improper medication administration for one of six sampled residents (Resident 31). This failure resulted in seven medication errors out of 26 opportunities and a medication administration error rate of 26.92 percent (%) due to Licensed Vocational Nurse (LVN) 2 failed to administer Resident 31's medication leaving residual medication in the medication cups.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of six sampled residents (Resident 31) received the correct dose of hydroxychloroquine (treat rheumatoid arthritis[a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility] ), vitamin C, memantine (medication used to treat dementia [a progressive state of decline in mental abilities]), metformin ( medication for diabetes mellitus [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing]), multivitamin-mineral, prednisone ( for rheumatoid arthritis) and senna (medication for constipation) as ordered by the physician. This failure had the potential for Resident 31 to have pain, vitamin C deficiencies, high blood sugar, changes in behavior and constipation.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (effort to improve how antibiotics are prescribed and used to ensure they are used effectively, reduce overuse, and prevent antibiotic resistance) for one sampled resident (Resident 23). Resident 23 was prescribed an antibiotic drug without meeting the McGreer criteria, after being screened for right eye swelling and tears. This failure had the potential to result in Resident 23 developing antibiotic resistance (not effectively treating infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview and record review the facility failed to ensure Certified Nursing Assistant (CNA ) had completed required dementia and abuse trainings upon hire and annually for four out of four CNA. 1. CNA 1's hire date on 12/18/2023, CNA 1only had four out of the five required hours of dementia training. 2. CNA 2's hire date on 5/28/2024, CNA 2 only had two out of the five required hours of dementia training. 3. CNA 3's hire date on 4/24/2025, CNA 3 had no dementia or abuse training. 4. CNA 4's hire date on 4/29/2013, CNA 4 only had three out of the five required hours of dementia training and had no abuse training. These failures had the potential to put the safety of the residents at risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 18 of 24 residents' rooms (room [ROOM NUMBER], 102, 103, 104, 106,I07,108,109,110,215,217,219,221,223,229,231,116,118) met the requirements of 80 square feet for each resident. There were 18 rooms with two beds per room and one room with four beds. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident, who was transported to a shower room, did not get hit by a shower room door and sustain an injury to a left great toe for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nurse Assistant (CNA 1) requested assistance to hold the door to Shower room [ROOM NUMBER] while he was pulling Resident 1 on a shower chair into the Shower room [ROOM NUMBER]. 2. Ensure CNA 1 and Licensed Vocational Nurse (LVN 1) reported Shower room [ROOM NUMBER]'s door malfunctioning by documenting about it in the Maintenance Logbook. 3. Ensure CNA 1 and LVN 1 reported to the Maintenance Supervisor (MS) that the door to Shower room [ROOM NUMBER] was not staying wide open to transport the residents safely through the Shower room [ROOM NUMBER]. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident, who was transported from the medical appointment in a facility van did not fall backwards in a wheelchair and sustained injury for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Driver 1 secured Resident 1 in the van using a four-point straps (secures a wheelchair with four straps attached to the wheelchair at four separate securement points and attached to the vehicle at four separate anchor points) when the resident was in a wheelchair while being transported back to the facility after a medical appointment in the facility's van. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure facility staff including Certified Nursing Assistant (CNA 1 had training and competency evaluation on transporting resident using facility van. This failure resulted in, Resident 1's wheelchair tilted back and hit her head on the van lift when Driver 1 made a left turn towards the facility that was slightly uphill slope. Resident 1 sustained a right occipital (the back of the head) scalp laceration (a cut or tear in the skin or underlying tissue) and hematoma (a pool of mostly clotted blood that forms in an organ, tissue or body space), neck sprain (a soft tissue injury that occurs when a ligament [attach bone to bone] in a joint {two or more bones are connected} is stretched too far or torn) and a right shoulder sprain. Resident 1 was discharged from GACH on 10/1/2024 at 6:56 p.m., to Resident 1's home. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide wound treatment to an existing wound for one of three sampled residents (Resident 1), per Resident 1's physician's orders and care plan. This deficient practice resulted in Resident 1's right medial leg wound not be treated or assessed, maggots present in Resident 1's wound and Resident 1's transfer to a General Acute Care Hospital (GACH) for evaluation and treatment. This deficient practice had the potential for worsening of the infection to Resident 1's wound resulting in physical as well as psychological harm related to the presence of maggots in Resident 1's right medial leg wound.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control practices to prevent the spread and transmission of multidrug resistant organism (MDROs- microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) in the facility for 11 out of 11 sampled residents by failing to: 1. Ensure personal protective equipment (PPE-equipment used to prevent or minimize exposure to hazards) was accessible and readily available to staff while providing direct care to residents at high risk of acquiring MDRO. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was posted and updated daily. This deficient practice resulted in the inability of residents and visitors to access the facility's staffing information to ensure safe staffing ratios were implemented.

Inspectors wroteBased on interview and record review, the facility failed to ensure all Certified Nursing Assistants (CNA), were provided the required dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities) care training necessary to ensure the continuing competence of the facility's nursing staff's knowledge and skills. This deficient practice had the potential to result in a delay and interruption of the provision of necessary care and interventions necessary when providing care to dementia residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations form two of three sampled residents (Resident 42 and Resident 16) by failing to: 1. Ensure Resident 42's call light was in functioning condition and able to use. 2. Ensure Resident 16's call light was within reach. This deficient practice resulted in Resident 42 unable to call for assistance when Resident 42 need pain medication and had the potential for Resident 42 and 16 not to receive necessary assistance when needed, and experienced loss of self-esteem.

Inspectors wroteBased on interview and record review the facility failed to ensure three of 14 sampled residents (Resident 21, 4, and t 18) had a Gradual Dose Reduction (GDR, an attempt to decrease or discontinue psychotropic (medication that treats mental illness) on psychotropic medications (any drug that affects behavior, mood, thoughts, or perception) no more than three months after starting unless clinically contraindicated. This deficient practice had the potential to result in Resident 21, Resident 4 and Resident 18 receiving unnecessary use of psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of infectious agents that could cause food borne illness (food poisoning: any illness resulting from the food spoilage or contaminating food) for 39 out of 45 total residents in the facility by failing to: 1. Ensure foods were dated, labeled, and discarded before the use by date (expiration dates). This deficient practice had the potential to affect residents and result in pathogen (germ) exposure and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting (throwing up), diarrhea (loose stool) and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review the facility's Quality Assessment and Assurance (QAA committees established for the purpose of improving the safety and quality of health services) and Quality Assurance Performance Improvement (QAPI- approach to maintaining and improving safety and quality in nursing homes ) committee failed to implement corrective action to the systemic problems identified: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (define) for five of five sampled residents (Resident 11, 19, 25, 247 and 346) prescribed an antibiotic (medication to treat infection) without meeting the McGeer Criteria (a set of clinical definitions used for surveillance in long-term care facilities. These criteria define the resident symptoms and other clinical criteria that are used to meet infection surveillance definitions). This deficient practice had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interviews and record review, the facility failed to report an injury of an unknown source to the California Department of Public Health (CDPH) no later than two hours for one of one sampled resident (Resident 1) who had swelling and bruising to the right facial cheek area. This deficient pratice had the potential to result in unidentified abuse in the facility and the failure to protect residents from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 42) humidifier and oxygen tubing were labelled with date change. This deficient practice had the potential to place Resident 42 at risk of inhaling contaminated mist through the humidifier and can lead to possible respiratory infections.

Inspectors wroteBased on interview and record review the facility failed to provide a larger sized wheelchair for 1 of 24 residents sampled (Resident 4) to promote mobility and maintain independence. This deficient practice had the potential to result in Resident 4 having an increased decline in physical function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure open date label on morphine sulfate solution (medication for moderate to severe pain) one of one sampled residents (Resident 22). This deficient practice had the potential to placed Resident 22 at risk to received expired medication and result in altered effectiveness of the medication and worsening of the resident's symptoms.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 18 of 24 residents' rooms (room [ROOM NUMBER], 102, 103, 104, 106, 107,108,109,110,215,217,219,221,223,229, 231,116, 118) met the requirements of 80 square feet for each resident. There were 18 rooms with two beds per room and one room with four beds. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.

Inspectors wroteBased on interview and record review on 9/25/2023 the facility failed to physically assist one of one sampled resident (Resident 1) during a transfer from wheelchair to bed resulting in Resident 1 falling and sustaining injuries. This deficient practice of not providing physical assistance to Resident 1 during a transfer resulted in Resident 1 falling and a subsequent transfer to a General Acute Care Hospital (GACH) for treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident, who had a history of wandering (a person that roams around and becomes lost or confused about their location) and aggressive behavior (hitting and yelling at others), had 1:1 monitoring (staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act) for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was monitored for wandering behavior to prevent Resident 1 from physical harm to self and others. 2. Ensure staff followed Resident 1's Care Plan (CP), titled Resident with wandering episodes to constantly monitor the resident's whereabouts and maintain a safe and hazard free environment. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate orientation, specific competencies and skill sets were assessed for registry staff (independent contractors that take care of patients) and Certified Nurse Assistants (CNA) necessary to care for wandering residents by failing to: 1. Ensure staff were competent and received in-services before providing care to wandering residents (an impaired resident can move about inside the facility without an appreciation of personal safety needs and possibly enter harm's way) in the facility. 2. Ensure the corrective action stated in the facility's Plan of Correction ([POC- is a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by state field staff were followed and carried out). [...]