Panorama Gardens Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for one of seven sampled residents (Resident 2). This deficient practice had the potential to delay the provision of services and residents' needs not being met. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of seven sampled residents (Resident 1) failing to create a care plan with specific interventions addressing Resident 1's use of a mechanical lift (a medical tool or machine used to safely move people who cannot stand or walk on their own). This deficient practice had the potential to result in unsafe transfers, placing the resident at risk for injury. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the needed resident-centered (an approach that puts the individual's needs, preferences and well-being at the heart of their care plan) care and services for three of four sampled residents (Resident 1, 3, and 4) by failing to: 1. Implement the facility's significant change in condition policy by not having documented evidence that a change in resident's condition was completed when a skin discoloration was identified on 5/23/2026 for Resident 1. This deficient practice had the potential to place Resident 1 at risk of not receiving appropriate care due to inaccurate and incomplete resident medical care information. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) for one of four sampled residents (Resident 1), who was identified to have a skin discoloration on 5/23/2026. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 4) received care and services in accordance with professional standards of practice by failing to administer Resident 1's Entresto oral tablet (medication used to reduce the strain on a weakened heart by relaxing blood vessels and helping the body remove excess fluid) as prescribed by the physician. This deficient practice resulted in the administration of Entresto oral tablet which could have resulted in adverse reactions (undesired harmful effect resulting from a medication or other intervention) such as hypotension (low blood pressure) and dizziness.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) received care and services in accordance with professional standards of practice by failing to complete a pain risk assessment following the identification of a new onset of pain on 5/26/2026. This deficient practice had the potential to place Resident 1 at risk for unmanaged pain, resulting in increased discomfort and suffering. During a review of Resident 1's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 1 on 9/25/2021 and readmitted on [DATE] with diagnoses including diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and vascular dementia (a progressive state of decline in mental abilities). [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1), by failing to ensure Registered Nurse Supervisor (RNS) documented an assessment conducted during a Change of Condition (COC- any noticeable or significant alteration in a person's physical health, mental status, or functional ability) on 5/26/2026. This deficient practice had the potential to create confusion regarding Resident 1's condition, care and services, and could have placed the resident at risk of receiving inappropriate or incomplete care due to inaccurate medical records documentation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that promoted and maintained residents' rights for two of four sampled residents (Resident 1 and Resident 4) by: Failing to ensure Certified Nursing Assistant 1 (CNA 1) acknowledged and communicated with Resident 1 and informed Resident 1 before lowering Resident 1's head of the bed. Failing to ensure Housekeeping Staff (HK) knocked on Resident 4's door prior to entering Resident 4's room. These deficient practices had the potential to compromise Resident 1 and Resident 4's dignity, privacy, autonomy (resident's right to make their own choices), self-esteem and sense of self-worth. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the proper use of a low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI- injuries that break down the skin and underlying tissue when an area of skin is placed under pressure]) by placing multiple layers of linen on top of the LALM for one of four sampled residents (Resident 1). [...]

Inspectors wroteBased on interview and record review the facility failed to implement its policy regarding nursing staff competency by failing to ensure that Certified Nursing Assistants (CNA) received comprehensive clinical competency skills review prior to the CNA's annual performance evaluation for one of three sampled CNAs (CNA 3). This deficient practice had the potential to result in unrecognized competency deficits and place residents at risk of not receiving necessary care and services in accordance with professional standards and their identified needs. During a concurrent interview and record review on 5/29/2026 at 12:18 p.m., with the Director of Staff Development (DSD), the DSD reviewed CNA 3's personnel file and CNA 3's C.N.A. Comprehensive Clinical Competency Review- Skills Checklist form and stated that CNA 3's clinical competency review was conducted on 1/22/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report an allegation of staff to resident sexual abuse (non-consensual sexual contact of any type with a resident) immediately but no later than two hours to the State Agency (California Department of Public Health [CDPH]), local law enforcement (LLE) agency, or the Ombudsman (an advocate who supports residents by resolving issues related to their health, safety and well-being), for one of eight sampled residents (Resident 2). This deficient practice resulted in the delay for an onsite inspection by the CDPH to ensure the safety of Resident 2 and had the potential to result in unidentified abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 69 and Resident 13), who were investigated under the pressure ulcer (PU - damage to an area of the skin caused by prolonged pressure or friction, often over bony areas like the tailbone, heels or elbows) care area, received care consistent with professional standards of practice by failing to: 1. Prevent the worsening of a Stage Two (2) (an open, shallow wound that has damaged the epidermis [top layer of the skin] and the dermis [middle layer of the skin], with the fluid-filled blister appearing as a ruptured or intact blister containing fluid) fluid-filled blister (a painful skin condition where fluid fills a space between layers of skin) on Resident 69's left heel, initially identified on 8/22/2025. The facility failed to: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to maintain range of motion (ROM- full movement potential of a joint) and mobility (ability to move) for two of four sampled residents (Resident 13 and Resident 69) reviewed under the Position/Mobility care area by failing to: 1. Provide Resident 13 with ROM exercises to both arms and legs following the identification of ROM limitations on the initial Joint Mobility Evaluation (JME- brief assessment of a resident's ROM in each joint of both arms and legs), dated 3/18/2025. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report a change of condition to the physician and/or the resident representative for three of 28 sampled residents (Resident 10, 63, and 13) by failing to: a. Notify the physician when Resident 10's blood sugar was greater than 200 milligrams per deciliter (mg/dL, a unit of measure for blood sugars, normal reference range 80 - 130 mg/dL) as indicated in the physician's order. This deficient practice placed Resident 10 at risk of becoming hyperglycemic (high blood sugar levels) which could lead to increased thirst, headaches, blurred vision and diabetes-related ketoacidosis (DKA- a lack of insulin and a high amount of ketones causes the blood to become acidic). b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) for four of 28 sampled residents (Resident 13, 38, 86, and 154) by failing to: 1. Develop interventions for Resident 13 to prevent further range of motion ([ROM] full movement potential of a joint) limitations upon admission on [DATE], develop interventions upon identification of severe ROM limitation (0-25 percent [%] range intact) in the left hand on 6/2/2025, and include the provision of the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) program in Resident 13's care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to update a resident`s care plan to include pain interventions for one of two sampled residents (Resident 69) reviewed under the pressure ulcer care area after Resident 69 developed Stage Two (2) (an open, shallow wound that has damaged the epidermis [top layer of the skin] and the dermis [middle layer of the skin], with the fluid-filled blister appearing as a ruptured or intact blister containing fluid) fluid-filled blister (a painful skin condition where fluid fills a space between layers of skin) on the left heel. This deficient practice had the potential to result in inadequate management of Resident 69's pain resulting in decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to: a. Implement the listed care plan intervention to raise the head of one of the sampled resident's (Resident 5) bed, while in bed, during 2 random observations. This deficient practice had the potential to result in Resident 5 having shortness of breath (difficulty breathing) and complications of congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently sometimes resulting in leg swelling).b. Follow the physician's order to notify the physician when the accucheck (blood sugar result) result was greater than (>) 200 milligrams per deciliter (mg/dL, a unit of measure for blood sugars) for one of three residents reviewed under the care area of insulin. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 28 sampled residents (Resident 63) investigated for frequency of visits, was evaluated by a physician at the required intervals by failing to:1. Ensure Resident 63 was seen by the physician at least once every 60 days between the dates of 11/15/2024 and 3/01/2025. 2. Ensure Resident 63 was seen by the physician within the first 30 days after readmission, and then at 30-day intervals up until 90 days after readmission from a general acute care hospital (or simply hospital) on 4/25/2025. This had the potential for Resident 63's physician to miss addressing the beginning of Resident 63's elevated blood sugars.

Inspectors wroteBased on interview and record review, the facility failed to establish and implement policies with clear guidance in treating a resident with elevated blood sugar levels in the months of 7/2025 and 8/2025 for one (Resident 63) of 28 sample residents. Additionally, although attempts were made to contact Resident 63's primary care physician since 8/07/2025, the licensed nurses did not speak to the doctor by phone until 8/25/2025 after the survey team inquired regarding Resident 63's elevated blood sugars for the month of 8/2025. This had the potential for Resident 63 to suffer from complications related to hyperglycemia.

Inspectors wroteBased on interviews and record review, the facility failed to ensure there was evidence to support the initiation of a psychotropic (drug that affects brain activities associated with mental processes and behavior, which includes but not limited to medications used to treat anxiety [a feeling of fear, dread, and uneasiness that is more intense and persistent than normal and can interfere with daily life]) for one of five sampled residents reviewed under the unnecessary medication, chemical restraints/psychotropic medications care area (Resident 12). This failure had the potential of unnecessary chemical restraint.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who required assistance with nail trimming was provided care and services to maintain good personal hygiene for one of four sampled residents (Resident 11). This deficient practice had the potential to result in a negative impact on the resident`s self- esteem due to an unkempt appearance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for two of seven residents (Resident 9 and 40) investigated under the Accidents care area by failing to:1. Ensure bedside rails were not used for a resident (Resident 9) that does not require such use to prevent risk of limb entrapment which could lead to injury.2. Ensure Resident 40's bedside rails were fully covered by padding per the physician's orders. These deficient practices had the potential to place Residents 9 and 40 at an increased risk of injury and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide trauma-informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) to one of two residents (Resident 12) investigated under the Behavioral-Emotional care area when the resident's triggers (a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening) for his diagnosed Post-Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) were not adequately assessed and the resident's care plan (a document that outlines a patient's healthcare needs, goals, and the interventions and treatments planned to achieve those goals, serving as a roadmap for their care and facilitating [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident for risk of entrapment (when a resident is trapped in the spaces in between or around the bed rails [adjustable metal or rigid plastic bars that attach to the bed that are available in a variety of types, shapes, and sizes], mattress, or bed frame), obtain an informed consent and a physician order for the use of bedside rails for one of two of residents (Resident 9). This deficient practice had the potential to place the resident at risk of accidents such as a body part being caught between the rails which could lead to injury. Cross reference with F689.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two sampled residents (Resident 52) observed received their medication on time when Resident 52 received Zenpep (a prescription medication used to treat exocrine [releasing substances through a duct to the outside of the body or into an organ] pancreatic insufficiency (EPI), a condition in which the pancreas does not produce enough enzymes to properly digest food. When taken with a meal or snack, it helps break down food and helps the body to properly absorb nutrients from food, which can relieve symptoms such as fatty stools, gas, and bloating) more than 2 hours after the scheduled time as prescribed to be taken with meals. This failure had the potential to worsen resident's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document in the medical record for one of 28 sampled resident (Resident 69) for the provision for Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) services on 8/26/2025. This failure resulted in inaccurate medical records for the provision of Resident 69's RNA services for sit-to-stand transfers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that three out of 35 resident rooms with three beds met the square footage requirement of 80 square feet (sq ft- unit of measure) per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) was involved in determining whether the self-administrations was clinically appropriate for one of four sampled residents (Resident 1) who was not assessed for self-administration for the use of Imodium (used to control and relieve diarrhea) oral tablets and probiotic (a pill containing live good bacteria that can help promote a healthy balance of bacteria in the body) oral tablets that were stored at the resident's bedside. This deficient practice had the potential to result in Resident 1 unsafely administering medications and unsafely access medications stored at bedside. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of four sampled residents (Resident 1) addressing Resident 1's self-administration of Imodium (used to control and relieve diarrhea) oral tablets and probiotic (a pill containing live good bacteria that can help promote a healthy balance of bacteria in the body) oral tablets that were stored at the resident's bedside. This deficient practice had the potential to negatively affect the delivery of care and services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect by not confirming if Resident 1 wanted to have a shower completed on 1/29/2025. This deficient practice had the potential to affect Resident 1's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to follow its own policy and procedure (P&P) titled Change of Condition Reporting dated March 2024, by not reporting to the physician that the nursing staff did not obtain urine for a urinalysis (UA- test that checks your urine for signs of health issues like infections, kidney problems, and liver disease) ordered on 9/21/2024 for one of three sampled residents (Resident 1). This deficient had the potential for Resident 1 not being provided treatment based on the results of the UA, which could lead to a worsening infection, decreased quality of life and possibly death.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's responsible party (RP) 1 was informed about dental treatment recommendations for one of two sampled residents (Resident 85). This deficient practice violated the resident's and RP 1's right to make an informed decision regarding dental treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device was within reach for one of two sampled residents (Resident 87). This deficient practice resulted in Resident 87 being unable to call a health care worker for help as needed.

Inspectors wroteBased on interview and record review, the facility failed to review and update the care plan after a change of condition (an improvement or worsening of a patient's condition which was not anticipated) for one of three sampled residents (Resident 71 ). This deficient practice had the potential to result in Resident 71 receiving inadequate care and supervision at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided communication devices in the language that the residents were able to understand for two of two sampled residents (Resident 105 and Resident 107). These deficient practices prevented the residents from being able to communicate with the staff and had a potential to delay receiving appropriate care and treatment the residents needed.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess one of three sampled residents (Resident 144) with an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) upon admission and readmission to the facility. This deficient practice had the potential to lead to the inadequate care of Resident 144.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Social Services department completed their admission assessment for two of two sampled residents (Resident 29 and Resident 301). This deficient practice had the potential for delay in the delivery of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift was posted daily on 8/23/2024. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by the staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to administer medications within one (1) hour of the due scheduled time (either one hour before or one hour after) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in ineffective management of Resident 1 ' s neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet) and anxiety (intense, excessive, and persistent worry and fear about everyday situations).

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of six sampled residents (Resident 1) was kept free from significant medication error (the administration of medication, or omission of a medication that endangers the health and safety of a resident), when on 5/30/2024, Student Nurse 1 (STU 1) administered medications to Resident 1 that were intended for a different resident (Resident 2). This deficient practice resulted in Resident 1 receiving three (3) medications that were intended for Resident 2 and placed Resident 1 at increased risk of severe health complications including hallucinations (false perception; the experience of seeing, hearing, feeling, or smelling something that does not exist), mood changes (such as agitation [feeling of irritability or restlessness]), and could possibly lead to hospitalization or death. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident ' s responsible party (RP) of a room change for one of three sampled residents (Resident 2). This deficient practice violated the resident ' s and resident ' s RP ' s right to be informed in advance of a room change.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 having long, untrimmed toenails that had the potential to result in a negative impact on the resident`s self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for two of three sampled residents (Resident 1 and Resident 2). This deficient practice resulted in Resident 1 and Resident 2 having long, untrimmed toenails with sharp edges that had the potential to result in a negative impact on the resident`s self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident ' s rights to a dignified existence and self-determination was met for one of four sampled residents (Resident 1) when the Certified Nursing Assistant 1 (CNA 1) checked the inside of Resident 1 ' s incontinence (loss of bladder control) briefs while the resident was asleep. This deficient practice resulted in Resident 1 ' s rights being violated when the resident was not provided the opportunity to make the decision as to whether or not have her incontinence briefs checked.

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 ensure those wishes are carried out should the person be unable to communicate them to a doctor) were documented and communicated to staff responsible for care, for six of 10 sampled residents (Resident 132, 43, 94, 77, 45, and 44). This deficient practice had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences.

Inspectors wroteBased on observation, interview, and record review, the facility: 1. Failed to consistently monitor laboratory values tied to the use of Retacrit (a medication used to increase the number of red blood cells) between 6/24/2021 and 7/19/2021 in one of five sampled residents (Residents 121). This deficient practice increased the risk that Resident 121 did not receive Retacrit per the physician's orders which could have led to health complications possibly resulting in hospitalization or death. 2. Failed to ensure Resident 8 was monitored for the side effects of Norco (Acetaminophen and Hydrocodone -an opioid combination medicine used to relieve moderate to severe pain) 10-325 mg (milligrams-unit of measurement), for one of one resident (Resident 8) investigated under the care area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe handling of medications and maintain a safe and secure storage of all medications for six of six residents (Residents 23, 57, 43, 61, 34, and 20), by: 1. Failing to ensure unopened insulin (hormone made by the pancreas that helps blood glucose to enter cells in the muscle, fat, and liver, where it is used for energy) medications for Residents 23, 57, and 43 were stored in the refrigerator, and when placed in room temperature have observed a storage period of 28 days per facility's policy. 2. Failing to ensure expired medications were removed immediately from the Medication Cart Nursing Station 2 for Residents 61, 34, and 20. These deficient practices placed the residents at risk of receiving expired and ineffective medications.

Inspectors wroteBased on interview and record review, the facility failed to draw a complete blood count (CBC, a laboratory blood test) every Wednesday per the physician's orders between 7/2/2021 and 7/19/2021 for one of five sampled residents (Resident 121). This deficient practice had the potential to negatively affect Resident 121's safety and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control policy and procedure by failing to: 1. Ensure that Licensed Vocational Nurse 6 (LVN 6) performed hand hygiene immediately upon leaving Resident 56's room and before using the computer in the medication cart and failing to perform hand hygiene again after using the computer and reentering Resident 56's room to proceed with setting up the tube feeding for one of one sampled resident (Resident 56). 2. Ensure staff were screened completely for signs and symptoms of Coronavirus-19 (COVID-19, an illness caused by a virus that can spread from person to person) prior to the start of their shift for two of 186 staff members as evidenced by three incomplete entries in the employee screening log on 7/26/2021, 7/27/2021, and 7/28/2021. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the baseline care plan for one of one sampled resident (Resident 124) who had a baseline care plan that identified resident-specific interventions in regards to resident's bowel and bladder incontinence care. This deficient practice had the potential for Resident 124's wound to her coccyx (tail bone) area to worsen when facility staff was unable to provide a thorough perineal care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper pressure ulcer preventative measures were in place by not following the manufacturer's instructions for an alternating pressure mattress (alternating pressure therapy uses pressure redistribution to stimulate blood flow, blood nourishes the skin in which air cells on the mattress slowly inflate and deflate under the patient at a predetermined or adjustable cycle time. This allows time for blood flow to reach the skin healing and skin breakdown or bedsores) for one (Resident 78) of three residents investigated for pressure ulcers. This deficient practice placed the resident at risk for discomfort, development of pressure injuries, and delayed wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a pad alarm (sensor that alerted caregivers when a resident was getting up from bed or chair) was placed on the wheelchair per physician order, for one of one sampled residents (Resident 127). This deficient practice placed Resident 127 at risk for falls and serious injuries that included possible fractures (break in the bones) and bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for suprapubic catheter (device that is inserted into the bladder to drain urine through a small cut made in the lower abdomen) care for one of one sampled resident (Resident 77) by failing to: 1. Ensure cloudy urine full of sediments (gritty particles in urine) and leakage in the urinary drainage bag was treated appropriately. 2. Secure the catheter (flexible tube inserted into the bladder to drain urine) tubing to Resident 77's thigh for stabilization as ordered by physician. These deficient practices had the potential to result in a urinary tract infection (UTI - an infection in any part of the urinary system) for Resident 77.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse 8 (LVN 8) did not administer one dose of Retacrit (a medication used to treat blood problems) on 7/12/2021 per the physician's hold (do not administer) orders for one of five sampled residents (Resident 121). By administering Retacrit (a medication used to increase the number of red blood cells), when the hemoglobin (Hgb, a red blood cell protein responsible for transporting oxygen in the blood) indicated it was to be held, had the potential to place a resident at risk for cardiovascular problems (heart problems, such as stroke or heart attack).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two steel bins of beef and pork, stored in the freezer were cooled down appropriately following storage in the freezer. This had the potential for foodborne illnesses (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) to occur when being rewarmed to be served to residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate and complete documentation for Resident 56's pre and post dialysis (process of removing waste products and excess fluid from the body) assessment for one of one resident. This deficient practice had the potential for unidentified communication to other healthcare members before and after dialysis treatment.