Park Avenue Healthcare & Wellness Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the environment remained free of accident hazards and/or residents received adequate supervision for two of three sampled residents (Residents 1 and Resident 3) when:For Resident 1, the facility failed to implement and/or reevaluate interventions the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) recommended, following Resident 1's falls on 4/15/2026, 4/29/2026, 5/25/2026, and 6/1/2026. For Resident 3, the IDT failed to recommend interventions to prevent further falls following Resident 3's falls on 4/28/2026, 6/1/2026, 6/5/2026, and 6/7/2026. The facility also failed to implement and/or reevaluate interventions the IDT recommended, following Resident 3's falls on 3/12/2026, 3/23/2026, and 4/30/2026.a. [...]

Inspectors wroteCross Reference F 563Based on interview and record review the facility failed to ensure the Responsible Party (RP-an individual chosen by the resident to act on behalf of the resident to support the resident in decision-making) did not make undelegated decisions for one of three sampled residents (Resident 2) when facility staff did not ask Resident 2 if Family Members (FM) 1 and 2 could receive a medical update for Resident 2. This failure resulted in Resident 2 experiencing feelings of sadness and had the potential for psychosocial (the emotional and social requirements that individuals have to feel safe, supported, and capable of functioning well in their environment) distress and feelings of decreased self-worth.

Inspectors wroteCross Reference F551Based on interview and record review the facility failed to provide immediate access by family members (FMs) for one of three sampled residents (Resident 2) when Resident 2's FM 1 and FM 2 were denied further visitation access to Resident 2. This failure resulted in Resident 2 not receiving visits from FM 1 and FM 2, made Resident 2 feel sad, violated Resident 2's right, and had the potential to result in Resident 2 experiencing psychosocial (the emotional and social requirements that individuals have to feel safe, supported, and capable of functioning well in their environment) distress and feelings of decreased self-worth.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan for one of two sampled residents (Resident 1) regarding the implementation of a pacemaker monitoring system as indicated on the facility's policy. This deficient practices had the potential for Resident 1 to receive improper care and monitoring of the resident's heart rhythms.

Inspectors wroteBased on record review and interview, the facility failed toInform and obtain orders from Resident 1's physician regarding the use and implementation of a pacemaker monitoring Device (PMD, bedside or mobile app devices that securely transmit data from an implanted cardiac device to a healthcare team). Place Resident 1's cardiac pacemaker (CP, small battery-operated device that helps the heartbeat in a regular rhythm) information readily accessible in the resident's paper or electronic chart as indicated in facility policy titled Pacemaker - Management, and lesson plan titled Pacemaker Management. Program type: Education for Licensed Nurses. These failure had the potential to place Resident 1 at risk for delay of care and monitor of the PMD.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate clinical records by failing to document required meal intake percentages for one of three sampled residents (Resident 1). This failure resulted in incomplete/inaccurate nutritional records and had the potential to negatively affect Resident 1's health and well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe and clean environment for one of three sampled residents (Resident 2) when:a. The wall in Resident 2's room was observed with brown spots.b. The recliner chair in Resident 2's room was observed with brown smears on the seat of the recliner. These failures resulted in Resident 2 living in an unclean environment and had the potential to result in psychosocial decline to Resident 2.

Inspectors wroteBased on interview and record review the facility failed to obtain medication admission orders for one of three sampled residents (Resident 1) when the medical doctor (MD)1 did not respond to Registered Nurse (RN) 1's request for medication admission orders. This failure resulted in Resident 1's medications not being obtained timely and had the potential to result in adverse medical outcomes for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure the recommended therapeutic diet (a diet ordered by a physician or a delegated registered or licensed dietitian as part of treatment for a disease or clinical condition) was ordered for one of three sampled residents (Resident 1) when Registered Nurse (RN) 1 did not order a diabetic diet (an eating plan that helps control blood sugar levels) for Resident 1. This failure had the potential to result in Resident 1 experiencing adverse health effects such as hyperglycemia (high blood sugar levels).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate treatment and catheter care services for two of three sampled residents (Resident 147 and Resident 2). For Resident 147 and Resident 2, who had indwelling catheters (a medical device that drains urine from your bladder into a bag outside your body), there was no assessment or monitoring of the catheters for any change in condition. This deficient practice could potentially result in Resident 147 to develop a urinary tract infection (UTI - an infection in the bladder/urinary tract) and Resident 2 to develop a recurrence of a UTI leading to more serious complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure milk was not left at room temperature for more than 2 hours for three of three sampled residents (Resident 20, Resident 72 and Resident 98). This deficient practice had the potential to result in foodborne illness.a. During a review of Resident 20 admission Record (AR), the AR indicated the facility admitted Resident 20 on 11/21/2020, with diagnoses that included generalized muscle weakness, hypothyroidism (when the thyroids does not make and release enough hormone into the bloodstream which slows down metabolism which make you gain weight or feel tired all the time). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain and implement its infection control program by failing to ensure:a. personal toiletries were labeled and not stored inside the shared restroom for three of three sampled residents (Resident 38, Resident 107 and Resident 195), b. the lint trap for one of four sampled dryers (Dryer 4) was clean and did not have an excessive lint buildup. These deficient practices had the potential to spread the transmission of disease, infection, and the potential for a fire hazard, which placed residents including Resident 38, Resident 107 and Resident 195 and the healthcare staff at risk.

Inspectors wroteBased on observation and interview, the facility failed to maintain electrical equipment in a safe operating condition when one of one 3-door reach in refrigerator (Refrigerator 1 - a type of commercial refrigerator used in food service that is designed for easy access and storage of items within arm's reach) had water dripping from the condenser fan (a component of the refrigeration system that helps maintain the cooling system) onto the containers below. This failure had the potential to result in food contamination and foodborne illnesses (illness caused by food contaminated with bacteria) for the residents consuming the food at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to offer milk for one of one resident (Resident 113).in accordance with the resident's preference This deficient practice had the potential to result in Resident 113 to feel ignored and to possibly stop verbalizing necessary needs. During a review of Resident 113's admission Record (AR), the AR indicated the facility admitted Resident 113 on 9/27/2010, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember, it is severe enough to affect a person's daily functioning), contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints to the right and left hand). [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review Level II [2] (PASARR-a federal assessment requirement to help ensure individuals, who have a mental disorders or intellectual disabilities, are placed in facilities that provide appropriate care) screening for one of two sampled residents (Resident 6) when the facility did not reply to recommendations by the California Department of Health Care Services (DHCS-a state agency that oversees the provision of services such as health care and mental health). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions and monitor and record pain characteristics every shift for one of one sampled resident (Resident 51) and failed to ensure a comprehensive person - centered care plan was developed and implemented for one of three sampled residents (Resident 2), who received an anticoagulant (blood thinner - e.g., warfarin, heparin, or low-molecular weight heparin) and was at risk for bleeding. This deficient practice had the potential to result in unmet individualized needs for Resident 2 and Resident 51 and had the potential to affect the resident's physical well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure appropriate care and services were provided for two of two sampled residents (Resident 2 and 83) by failing to:A. Ensure Resident 2, who was on anticoagulant (medication that thins the blood) therapy, was monitored for bleeding in the month of June 2025. B. Follow up on an infectious disease consult (a consultation with a specialist [a doctor who has special knowledge and skill relating to a particular area of study] in infectious diseases to help diagnose, manage, or prevent infections) for Resident 83's recurrent urinary tract infections (an infection in any part of the urinary system: kidneys, bladder, or urethra [tube through which the urine leaves the body]) as per the physician's order, dated 7/10/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up with optometry (a healthcare profession that focuses on the examination, diagnosis, and treatment of eye and vision disorders) to replace a missing pair of glasses for one of one resident (Resident 13) in a timely manner. This deficient practice had the potential to result in worsened eyesight to Resident 13 and resulted in Resident 13 feeling frustrated and ignored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 38 and Resident 24), were provided an environment free of accident hazards by failing to ensure:A. Resident 38's bed was in a low position when Resident 38 was at high risk for falls (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of and overwhelming external force) and had a history of falls. B. Resident 24 did not keep cigarettes and a lighter in Resident 24's possession. This deficient practice had the potential to result in recurrent falls for Resident 38. Additionally, the deficient practice had the potential for Resident 24 to cause a fire and placed the residents and healthcare staff in danger.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 115), who was receiving enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine), received appropriate care and services by failing to respond timely to the continuous alarm (beeping) from Resident 115's gastrostomy tube (GT - a type of feeding tube) pump. This deficient practice could lead to GT complications and potentially harm Resident 115.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 115), received proper respiratory (relating to breathing) care by failing to ensure Resident 115's tracheostomy (trach - a surgically created hole [stoma] in your windpipe [trachea] that provides an alternative airway for breathing) mask (T-mask) was properly in place. This deficient practice resulted in Resident 115 not receiving the physician ordered oxygen (02 - a colorless, odorless, tasteless gas essential for living) therapy, could potentially cause Resident 115's respiratory status (the movement of air in and out of the lungs) to be compromised, and could lead to respiratory distress / failure.

Inspectors wroteBased on interview and record review, the facility failed to ensure performance evaluations (PEs) were conducted every 12 months for one out of four certified nursing assistants. This deficient practice had the potential to compromise resident safety and well-being. During a record review of CNA 7's personnel file, no PE was due as of 7/25/25 due to a recent date of hire for CNA 7. During a concurrent interview and record review on 7/25/25 at 7:45 a.m. with the Director of Development (DSD), the DSD provided the two most recent PEs for CNA 4, CNA 5 and CNA 6. CNA 4 and CNA 6 received timely PEs or were not yet due for their annual PE as of 7/25/25. CNA 5 was due for a PE on or before 5/26/24 and 5/26/25. The DSD provided 2 PEs for CNA 5, one dated 6/2/25 and the second PE dated 4/10/23. CNA 5's PE dated 6/2/25 indicated the evaluation was signed only by the evaluator and not by CNA 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pharmacist's recommendations, dated 5/31/2025 and 6/30/2025 on the Medication Regimen Review (MRR), related to Tylenol (a pain reliever and fever reducer) was acted upon for one of two sampled residents (Resident 5). This deficient practice placed the resident at risk of not receiving the correct dosage of Tylenol from May 31, 2025 to July 25, 2025. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] with diagnoses that included non-pressure chronic ulcer of right ankle with unspecified severity, unspecified edema (swelling caused by an accumulation of fluid in the body's tissues) and cellulitis (a skin infection that causes swelling and redness) of right lower limb. [...]

Inspectors wroteBased on interview and record review, the facility failed to document Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services provided for one of one resident (Resident 193) as per the facility's policy and procedure (P&P) titled, Documentation, dated 1/1/2012. This deficient practice led to inaccuracies in Resident 193's medical record and had the potential to lead to inconsistent RNA treatments provided to Resident 193.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 43 sampled residents (Resident 6) had a call light (a device used to call for assistance) within reach. This failure had the potential to result in Resident 6 being unable to call for assistance and delayed care to Resident 6.

Inspectors wroteBased on interview and record review, the facility failed to notify Resident 3's doctor of Resident 3's refusals to allow the nurse to perform accu checks (sampling a drop of blood from the finger to determine the blood glucose [sugar] level) on 5/5, 5/8, 5/11, and 5/12/2025. These failures had the potential to result in Resident 3 to not receive treatment to address Resident 3's risks for hypoglycemia (a condition where the level of glucose in the blood drops below a healthy range) or hyperglycemia (having too much glucose in the blood) which could negatively affect Resident 3's health and wellbeing. (Cross Reference F656)

Inspectors wroteBased on interview and record review, the facility failed to implement the comprehensive person-centered care plan for one of three sampled residents (Residents 3) when the facility staff failed to notify Resident 3's doctor of Resident 3's refusals of accu checks (sampling a drop of blood from the finger to determine the blood glucose [sugar] level) as indicated in Resident 3's untitled care plan, initiated on 1/3/2024. This failure had the potential to result in Resident 3 to not receive treatment to address Resident 3's risks for hypoglycemia (a condition where the level of glucose in the blood drops below a healthy range) or hyperglycemia (having too much glucose in the blood) which could negatively affect Resident 3's health and wellbeing. (Cross Reference F580)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 10 sampled residents (Resident 5) had a written physician's order to go out on pass (temporary permission of a resident to leave the facility within a specified time) before Resident 5 left the facility to go on an overnight pass on 5/23/2025. This failure had the potential for Resident 5 and other residents to be allowed out of the facility without being properly assessed for safety awareness, decision-making capacity, physical disabilities, and the ability to call for medical assistance if required and when indicated. Resident 5 left the faciity on 5/23/2025 and came back on 5/24/2025 with abrasions and bruises on both arms and legs, and bleeding in the back of the head. (Cross reference F842)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was provided wound care treatment as ordered by Resident 1's physician. This failure had the potential for Resident 1's wound to become infected and/or for Resident 1's wound to not heal.

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical record for one of 10 sampled residents (Resident 5) was complete and accurate when there was no written physician's order to go out on pass (temporary permission of a resident to leave the facility within a specified time) before Resident 5 left the facility to go on an overnight pass on 5/23/2025. This failure had the potential for Resident 5's whereabouts to not be known to facility staff and for Resident 5 to be allowed out of the facility without being properly assessed for safety awareness, decision-making capacity, physical disabilities, and the ability to call for medical assistance if required and when indicated. Resident 5 left the faciity on 5/23/2025 and came back on 5/24/2025 with abrasions and bruises on both arms and legs, and bleeding in the back of the head.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 9 did not physically assault (occurs when a person uses physical violence and causes injury to another person's body) two of six sampled residents (Resident 7 and Resident 8). On 3/31/2025, Resident 9 hit Resident 7 multiple times on Resident 7's face with Resident 9's closed fist and pulled Resident 8's necklace and held Resident 8's neck. As a result, on 3/31/2025 Resident 7 sustained a facial (face) contusion (bruising or skin discoloration), a closed head injury (head injury that does not break through the skull and occurs when the head gets hit hard), swelling and discoloration to Resident 7's left cheek, discoloration to the left and right eyelids, and bleeding from inside Resident 7's mouth. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four of four sampled residents (Resident 1, 4, 5, and 6) call lights (call bell- a device used by a resident to signal his or her need for assistance from staff) were answered promptly. This failure had the potential for Resident 1, 4, 5, and 6 needs not being met. Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to ensure three of four sampled residents (Resident 1, Resident 7, and Resident 8) received adequate supervision by failing to, a. Ensure Resident 1 ' s call light (a device used by a resident to signal his or her need for assistance from staff) was answered promptly by facility staff. b. Ensure Resident 9 did not physically assault (occurs when a person uses physical violence and causes injury to another person's body) Resident 8 right after Resident 9 physically assaulted Resident 7. These failures resulted in Resident 1 falling to the floor on 4/1/2025, and had the potential for Resident 1 to sustain injuries. Additionally, the failures resulted in Resident 9 holding Resident 7 in chokehold [position] around Resident 8's neck and resulted in redness to Resident 8's neck.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an individualized person-centered care plan (CP), for one of six sampled residents (Resident 7), that addressed a possible head injury to Resident 7 due to being struck in the head multiple times by Resident 9 during a resident-to-resident altercation (fight between two residents). This failure had the potential to result in unmet individualized needs for Resident 7 and the potential to affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses (LN) developed and implemented a care plan (CP) for one of three sampled residents (Resident 2) with interventions to help prevent a fall after Resident 2 was determined to be a high-fall risk based off Resident 2 ' s Fall Risk Assessment (FRA) dated 1/11/2025, based on the facility ' s policy and procedure (P&P) titled, Fall Management Program, and Comprehensive, Person-Centered Care Planning. As a result of this failure, on 3/8/2025 at 4:15 pm, Resident 2 fell out of bed and was found on the floor by Certified Nurse Assistant (CNA) 2. Resident 2 sustained a left elbow skin tear (a wound that happens when the layers of skin separate or peel back). Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of three sampled residents (Resident 2) as indicated in the facility ' s policy and procedure (P&P) titled, Fall Management Program, by failing to: 1. Ensure licensed nurses (LN) developed and implemented a care plan (CP) for Resident 2 with interventions to help prevent a fall after Resident 2 was determined to be a high-fall risk based off Resident 2 ' s Fall Risk Assessment (FRA) dated 1/11/2025. 2. Ensure LNs made Resident 2 part of the fall management program on 1/11/2025 when Resident 2 was assessed to be at high-risk for falls. As a result of this failure, on 3/8/2025 at 4:15 pm, Resident 2 fell out of bed and was found on the floor by Certified Nurse Assistant (CNA) 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation on the Fall Risk Assessment (FRA) for one of three sampled residents (Resident 2), according to the facility ' s policy and procedure (P&P) titled, Completion and Correction, by failing to: Ensure Registered Nurse (RN) 2 accurately assessed and documented Resident 2 ' s FRA on 3/8/2025, after Resident 2 sustained a fall. As a result of this failure, after Resident 2 fell on 3/8/2025, Resident 2 ' s revised FRA was completed, and indicated Resident 2 was not at high-risk for falls. This failure had the potential for Resident 2 to not receive the care and services needed to prevent another fall from happening and could lead to Resident 2 not being monitored appropriately.

Inspectors wroteBased on interview and record review, the facility failed to promptly respond to call lights (a device used by a resident to signal his or her need for assistance from staff) for three of five sampled residents (Residents 7, 11, and 12) according to the facility ' s Policy and Procedure (P&P) titled, Communication - Call System, revised January 1, 2012. This failure had the potential to result in residents care needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 7 and 9) received food that were palatable and attractive according to the facility ' s Policy and Procedure (P&P) titled, Dietary Department - General, revised June 1, 2014. This failure had the potential for Residents 7 and 9 to be at risk of unplanned weight loss, a consequence of poor food intake.

Inspectors wroteBased on interview and record review, the facility failed to serve the meal indicated on the facility ' s lunch menu, on 3/9/2025, to one of three sampled residents (Resident 9) according to the facility ' s Policy and Procedure (P&P) titled, Menu, undated. This failure had the potential for Resident 9 to not receive adequate nutrition while in the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the Notice of Proposed Transfer and Discharge (NPTD- informs the resident and the resident's representative of the transfer or discharge and the reasons for the move) for a facility-initiated discharge for one of 10 sampled residents (Resident 4) was sent to the Ombudsman (OMB- an advocate for residents of nursing homes, board and care centers, and assisted living facilities) before the resident was discharged from the facility on 12/23/24. This failure had the potential for Resident 4 to not be protected from being inappropriately discharged from the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical record for 2 of 10 sampled residents (Resident 1 and Resident 3) was complete and accurate when: 1. Licensed Vocational Nurse (LVN) 1 did not accurately document Resident 1's condition in the Change in Condition Evaluation (CIC), dated [DATE] and timed at 7:30 am. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent and control the spread of Influenza (flu, highly contagious, sometimes deadly respiratory infection [the invasion and growth of germs in the lungs and the airway, caused by the influenza virus) for 7 of 15 sampled residents (Residents 1, 2, 3, 4, 5, 6 and 7) during the current flu season (from 10/1/2024 to 3/31/2025) in according to the facility's policy and procedure (P&P) titled, Influenza Prevention and Control, by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation on the Consent/Declination Influenza Immunization (CDII) forms in seven of 15 sampled residents (Residents 1, 2, 4, 9, 10, 11, and 12), according to the facility's policy and procedure (P&P) titled, Completion and Correction, by failing to: 1. Ensure Infection Preventionist (IP, a healthcare profession who specializes in preventing the spread of infections in healthcare settings) 1 did not willfully falsify Residents 1, 2, 4, 9, 10, 11, and 12's flu vaccine declinations when IP 1 indicated the residents' responsible parties (RPs) did not want Residents 1, 2, 4, 9, 10, 11, and 12 to have the flu vaccine. IP 1 did not speak to Residents 1, 2, 4, 9, 10, 11, and 12's RPs. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policies and procedures (P&P) titled, Hand Hygiene (procedures that included the use of alcohol-based hand rubs (containing 60%-95% alcohol) and hand washing with soap and water), and Enhanced Barrier Precautions (EBP- set of infection control measures that use personal protective equipment [PPE- equipment worn to minimize exposure to hazards] to reduce the spread of multidrug-resistant organisms [MDRO- organism that is resistant to most antibiotics] by wearing a gown and gloves) by failing to: 1. Ensure two of four certified nurse assistants (CNAs 2 and 4) wore appropriate PPE when entering Residents 13 and 14's rooms, who required patient care and were on EBP. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and/or diseases in the healthcare setting) were followed in accordance with the facility's policies and procedures (P&P) titled, Hand Hygiene (procedures that included the use of alcohol-based hand rubs (containing 60%-95% alcohol) and hand washing with soap and water), and Management of COVID-19 (infections airborne disease caused by SARS-CoV-2 virus) by failing to: 1. Ensure six of 12 sampled staff (Certified Nurse Assistant [CNA] 2, CNA, 3, CNA 4, CNA 5, and CNA 6, and Treatment/Licensed Vocational Nurse [LVN] 6 wore appropriate PPE when entering residents' room and when providing care for residents on TBP (Transmission Based Precautions) for COVID-19. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan (CP) was developed and implemented that included appropriate interventions to address individualized needs for one of three sampled residents (Resident 2) in accordance with the facility's policies and procedures (P&P) when the facility determined Resident 2 was at risk for elopement. This failure had the potential to result in unmet individualized needs for Resident 2 and the potential to affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services to prevent potential accidents for one of three sampled residents (Resident 6) by failing to ensure: Resident 6, who had a history of seizures (a sudden, uncontrolled burst of electrical activity in the brain), had bilateral padded side rails in bed. This deficient practice had the potential to affect Resident 6's safety and increase the risk for injury in an event of a seizure episode.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 48 and Resident 109) had their call lights within reach. This failure had the potential to result in Residents 48 and 109 not to receive care and services timely.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 57 and Resident 161) had a resident-centered care plan developed and implemented that addressed: a. Resident 57's risk for falls. b. Resident 161's actual fall that occurred on 7/8/2024. These failures had the potential to result in unmet individualized needs for Residents 57 and Resident 161 and the potential to affect the resident's physical well-being. Additionally, there was a potential for Residents 57 and 161to not receive the necessary care and services to achieve their optimal level of functioning.

Inspectors wroteBased on interview and record review, the facility failed to revise comprehensive Care Plans (CP) for two of two sampled residents (Resident 176 and Resident 36). a. Resident 176's CP was not updated following significant weight loss and to include snacks were increased to three times a day (TID) in Resident 176's nutritional regimen. b. Resident 36's CP was not revised following a fall incident that occurred in the restroom on 6/18/2024. These failures had the potential to result in in unmet individualized needs for Residents 176 and 36 and the potential to affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their own policy and procedure (P&P) to ensure safe medication administration for residents with a Gastrostomy tube (G-tube, a tube that placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) for one of two residents (Resident 510). On 7/9/2024, Licensed Vocational Nurse 3 (LVN 3) administered medications through Resident 510's G-tube, LVN 3 failed to stop and reassess Resident 510, notify the supervisor (in general), or contact the physician (MD) when Resident 510's g-tube became clogged for over 30 minutes. This failure increased the risk of pain or discomfort to Resident 510 and had the potential to cause the displacement of Resident 510's G-tube and/or aspiration (inhaling food, stomach acid, medication, or saliva into the lungs).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication administration and accurate accountability of all controlled medications (medications with a high potential for abuse) as indicated in the facility's policy and procedures (P&P) by failing to: 1. Ensure one of two sampled resident's (Resident 510) medications for potassium chloride (a medicine used to prevent or treat low potassium levels in the body, side effects include stomach bloating, severe vomiting, severe stomach pain, stomach irritation, or chest pain), administered through a Gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications), was administered with sufficient fluid in accordance with the manufacturer's specification. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 84) remained free of unnecessary psychotropic medication (drug prescribed to affect the mind, emotions, or behavior) use when Resident 84 received quetiapine (Brand Name [Seroquel], antipsychotic, a type of psychotropic medication indicated for psychosis [a collection of symptoms that affect the mind, where there has been some loss of contact with reality]) and trazodone (an antidepressant) for inadequate indications. The facility failed to develop and implement person centered non-pharmacological behavioral interventions ([NPI] any intervention intended to improve the health or the well-being of individuals that do not involve the use of medication) in Resident 84's plan of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow safe and proper storage practices in one of one kitchen (Kitchen 1) in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to: a. Ensure food items in Kitchen 1 were labeled/dated. b. Ensure dishware/kitchenware were stored under sanitary conditions. c. Ensure food was stored in a sanitary manner to prevent growth of microorganisms that could cause food-borne illnesses (illness caused by food contaminated with infectious organisms) for one of three sample residents (Resident 36) when Resident 36's yogurt and opened nutritional shake were left out at room temperature for more than two hours inside Resident 36's room. [...]

Inspectors wroteb-c. During a review of Resident 164's MDS, dated [DATE], the MDS indicated Resident 164 had severe cognitive (processes of thinking and reasoning) impairment. The MDS indicated Resident 164 required set up and cleaning assistance with eating and substantial/maximal assistance with personal hygiene. During a review of Resident 164's AR, the AR indicated Resident 164 was readmitted to the facility on [DATE] with diagnoses that included acute (sudden) respiratory failure (inadequate lung gas exchange), acute pulmonary edema (buildup of fluid in the lungs), and unspecified dementia (lose ability to think, remember, learn, make decisions, and solve problems). During a review of Resident 164's H&P, dated 4/5/2024, the H&P indicated Resident 176 did not have the capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and provide influenza ([flu] a common, sometimes deadly infection of the nose, throat and lungs) and pneumococcal (a serious bacterial lung infection) vaccinations (a simple, safe and effective way of protecting you against harmful diseases, before you come into contact with them), and ensure education was provided to three of five sampled residents (Resident 14, Resident 196 and Resident 200) and or representatives regarding the risk and benefits and the potential side effects of the vaccinations and whether the resident received the influenza and pneumococcal vaccines, could not receive the vaccines due to medical contraindications, or refused the vaccines, as indicated in the facility's policy and procedures (P&P), titled Influenza Prevention and Control and Pneumococcal Vaccination - Pneumovac or Pneumococcal [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy, for one of one sampled resident (Resident 60), was maintained. During initial tour of the facility, on 7/8/2024, Resident 60's privacy curtain remained partially opened and Resident 60's genitals and lower part of the body was exposed while Resident 60 received care. This deficiency resulted in violating Resident 60's right to privacy and dignity and had the potential to result in a decline in psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to accurately code significant weight loss on the Minimum Data Set (MDS, an assessment and screening tool), for one of one resident (Resident 176). This failure resulted in an inaccurate assessment of Resident 176's status and had the potential to result in in unmet individualized needs and affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 36) received treatment and care in accordance with professional standards of practice, physician order, and policy for Medication Administration. The facility failed to ensure Resident 36 who had known and documented allergy with iodine (a chemical element found in small amounts in sea water, used in medicine, photography, and a dye [substance for changing something's color]), was not administered iodine to treat Resident 36's laceration on forehead. This deficient practice had the potential to place Resident 36 at risk for an allergic reaction (are inappropriate responses of the immune system to a normally harmless substance) and could potentially triggered anaphylactic reaction (a severe, life-threatening allergic reaction that needed to be treated right away.).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a nasal cannula (NC, a device-lightweight flexible plastic tubing used to deliver supplemental oxygen, tubing ending is placed in the nostrils and is fitted over the patient's ears) was labeled with a date and a cautionary sign was posted on the resident's door to indicate oxygen was in use and no smoking in the room, for one of three sampled residents (Resident 61) receiving oxygen therapy. This deficient practice placed Resident 61 at an increased risk of acquiring an infection and the potential for a decline in physical well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of three sampled residents (Resident 206) with meals that accommodated the resident's food preferences by failing to ensure Resident 206 received coffee with his meal. This deficient practice made Resident 206 feel angry and upset.

Inspectors wroteBased on interview and record review, the facility failed to offer and provide the COVID-19 (a mild to severe respiratory illness that spread from person to person) immunization (a process by which a person becomes protected against a disease [a disorder of structure or function in a human, animal, or plant]) and ensure education was provided to two of five sampled residents (Resident 196 and 200) and or their representatives regarding the risk and benefits and the potential side effects of the vaccination and whether the residents received the COVID-19 vaccines, could not receive the vaccines due to medical contraindications, or refused the vaccines. This deficient practice had the potential for Resident 196 and 200 to not be provided the opportunity to decline or be currently immunized to lower risk of acquiring, transmitting, or experiencing complications from COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and implement its Infection Control Program to prevent the transmission of disease and infection when: a. Certified Nursing Assistant (CNA) 1 failed to report to facility that CNA 1 had a skin rash on CNA 1's arm that stated on 6/1/2024, in accordance with the facility's Policy and Procedure (P&P) titled, Employee Illness, revised January 2019. b. CNA 2's supervisors, (the Treatment Nurse [TN], and the Director of Nursing, DON) failed to prevent CNA 2 from caring for residents (in general) at the facility when CNA 2 informed facility on 6/7/2024 that CNA 2 had a rash. c. CNA 1 and CNA 2 provided care to 29 of 216 residents at the facility while CNA 1 and CNA 2 had scabies (infestation of the skin caused by the human itch mite). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eleven sampled resident (Resident 4) was free from physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) by failing to protect Resident 4 from physical abuse and remove Resident 4 immediately when Resident 5 physically assaulted (the illegal act of causing physical harm or unwanted physical contact to another person, physical attack) Resident 4. This deficient practice resulted in pain, an abrasion (a cut or a scrape on the skin) that required treatment, and a transfer to the GACH (General Acute Care Hospital) 1's ED (Emergency Department) to further evaluate Resident 4. Additionally, the failure resulted in Resident 4 feeling unsafe and scared in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 3 sampled residents (Resident 1, Resident 2, and Resident 3) were provided drinks according to their preferences when: 1. Resident 1 did not have any drinks on Resident 1's lunch tray on 5/13/2024. 2. Resident 2 did not have juice on Resident 2's lunch tray on 5/13/2024. 3. Resident 3 did not have juice and coffee on Resident 3's lunch tray on 5/13/2024. These failures had the potential for Resident 1, Resident 2, and Resident 3 to not receive proper hydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) did not use a disposable plate for lunch on 5/13/2024. This failure had the potential to violate Resident 2's right to a dignified dining.

Inspectors wroteBased on interview and record review, the facility failed to honor 2 of 3 sampled residents' food preferences (Resident 1 and Resident 2) when: 1. Resident 1 did not get three over easy eggs for breakfast on 4/26/2024 according to Resident 1's preferences. 2. Resident 2 did not get any meat for breakfast on 5/13/2024 according to Resident 2's preferences. These failures resulted in Resident 1's and Resident 2's food choices to not be honored and had the potential for Resident 1's and Resident 2's nutritional needs to not be met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received foods according to the therapeutic diet (diet ordered by a physician as part of treatment for a disease) prescribed by Resident 1's physician. This failure had the potential for Resident 1's health to be negatively impacted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that promoted dignity and respect during a meal for one of three sampled residents (Resident 7) by failing to ensure the CNA made sure the resident was at eye-to-eye level to assist the resident. This deficient practice had the potential to negatively impact Resident 7's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one of four sampled residents (Residents 1) on 4/33/2024, when Resident 2 physically assaulted (assault, the illegal act of causing physical harm or unwanted physical contact to another person) Residents 1. This failure resulted in Residents 1 to sustain minor injury around Resident 1's right eye as the result of physical abuse by Resident 2 while under the care of the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for one of three sampled residents (Resident 7) by not addressing Resident 7's preference (the right or chance to choose) during meals. This deficient practice had the potential to result in inconsistent implementation of care and denied Resident 7's right for having a preference.

Inspectors wroteBased on interview and record review, the facility failed to ensure medically related social services were provided for one of three sampled residents (Resident 2) by failing to: 1. Ensure the Social Services Assistant (SSA) timely (prompt/without delay) arranged transportation for Resident 2's scheduled appointment to see Resident 2's pain management physician, Medical Doctor 2 (MD 2, physician who specialized in decreasing pain), on 1/29/2024 at 10 am, as ordered by Resident 2's Primary Physician (PP). 2. Ensure SSA or facility staff notified Resident 2's Responsible Party (RP) 1 of the missed transportation arrangement and delay in transporting Resident 2 to his scheduled appointment with MD 2. These deficient practices resulted in Resident 2's appointment being rescheduled at a later time and RP 1 personally transporting Resident 2 to Resident 2's new appointment time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 1 and 6) were free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by failing to: 1. Protect Resident 1 and Resident 6 from physical abuse when Resident 2 physically assaulted (the illegal act of causing physical harm or unwanted physical contact to another person) Resident 1 and Resident 6 on 2/3/2024 at 6:45 a.m. 2. Ensure Licensed Vocational Nurse (LVN) 2 notified the Director of Nursing (DON) of Resident 2's aggressive behavior on 2/2/2024 in accordance with the facility's policy and procedure (P&P) titled, Resident-To-Resident Altercations. As a result, on 2/3/2024 at 6:45 a.m., Resident 2 hit Resident 1 and 6 while under the care of the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the spread of infection during a Coronavirus-19 (COVID-19 an illness caused by a virus that can spread from person to person) outbreak (the occurrence of disease cases more than normal expectancy) in the facility, in accordance with the facility's Policy and Procedure (P&P) on Hand Hygiene, facility's Mitigation Plan, Department of Public Health (DPH) recommendation and the local guidelines for preventing and managing COVID-19 in Skilled Nursing Facilities by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to report one of 15 sampled resident ' s (Resident 2) allegation of abuse to the California Department of Public Health (CDPH), the Ombudsman (an official appointed to investigate individuals ' complaints against facility administration), and Law Enforcement within two (2) hours. This deficient practice placed Resident 2 and all facility residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one of five sampled residents (Resident 3) on 10/17/2023 when Resident 4 pushed Resident 3 to the floor, got on top of Resident 3, and punched Resident 3. This failure resulted in Resident 3 being subjected to physical abuse by Resident 4 while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (Department), Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours, in accordance with the facility ' s policy and procedures (P&P) titled, Abuse -Reporting & Investigations for one of five sampled Residents (Resident 1). This failure had the potential for Resident 1 to be at risk of further abuse by Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed provide a safe and functional environment for residents, staff, and the public, regarding unapproved remodeling projects and was non-compliant with the State building codes. This deficient practice of an unsafe and improper functional environment has the potential to have negative effects to the safety, welfare and health of the residents, staff, and the public.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 10) received cancer (a disease in which abnormal cells divide uncontrollably and destroy body tissue) treatments including radiation (treatment of using beams of intense energy to kill cancer cells) treatment planning and oncology (study, treatment, and prevention of tumors) follow-up appointments as ordered by Resident 10's Medical Doctor (MD) 3/Radiation Oncologist 1 [a medical practitioner qualified to diagnose and treat tumors (a solid mass of tissue that forms when abnormal cells group together)] and failed to follow the facility's policy and procedure (P&P) titled, Referrals to Outside Services, by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate nutritional and hydration care and services to two of two sampled residents (Resident 2 & 3) by failing to: 1. Assess, provide, and implement nutritional interventions for Resident 2 ' s weight loss. 2. Monitor Residents 2 & 3 ' s weight weekly. These failures resulted in unplanned weight loss for Residents 2 and 3.

Inspectors wroteBased on interviews and record review, the facility failed to address and obtain the necessary services for the dementia care needs of one of 12 sampled residents (Resident 2) by failing to: a. Follow up the planned consult with Medical Doctor 1 (MD 1, a psychiatrist). b. Ensure Resident 2's target behaviors and side effects related to the use of psychoactive medications (drugs that affect brain activity associated with mental processes and behavior) were closely monitored and documented accurately in Resident 2's medical records. c. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the consultant pharmacist (CP) reported an irregularity of failing to define a specific target behavior (e.g., striking out at staff, resisting care, etc.) for the use of chlorpromazine (a medication used to treat mental illness) in one of three sampled residents (Resident 2) during the Medication Regimen Reviews (MRR - monthly reports completed by the consultant pharmacist highlighting potential issues with a resident's medication therapy) completed between 4/26/23 and 9/8/23. 2. Ensure the CP reported an irregularity of licensed staff failing to monitor for target behaviors tied to the use of chlorpromazine, Zyprexa, Depakote, and Xanax in one of three sampled residents (Resident 2) during the MRRs completed between 4/26/23 and 9/8/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of unnecessary medications by failing to: 1. Ensure licensed staff monitored psychotropic (any medications that affect brain activity associated with mental processes and behavior) medications (Zyprexa, Xanax, Depakote, and chlorpromazine [psychotropic medications used to treat mental illnesses]) for effectiveness by documenting episodes of target behaviors (e.g., striking out at staff, resisting care, etc.) in one of three sampled residents (Resident 2) between 4/26/23 and 9/8/23. 2. Ensure licensed staff documented potential adverse effects (unwanted or dangerous side effects of medications) of sedation (the administration of a drug to induce a state of calm or sleep) due to the use of chlorpromazine in one of three sampled residents (Resident 2) between 4/26/23 and 9/8/23. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure transportation services for radiation [treatment of using beams of intense energy to kill cancer (a disease in which abnormal cells divide uncontrollably and destroy body tissue) cells] treatment planning and oncology (study, treatment, and prevention of tumors) follow-up appointments for one of two sampled residents (Resident 10), as ordered by Resident 10 ' s (MD) 3/Radiation Oncologist 1 [a medical practitioner qualified to diagnose and treat tumors (a solid mass of tissue that forms when abnormal cells group together)] and failed to follow the facility ' s policy and procedure (P&P) titled, Referrals to Outside Services, by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from chemical restraints (any drug used for discipline or staff convenience and not required to treat medical symptoms) by failing to: 1. Document a clinical rationale for the continued use of chlorpromazine (a medication used to treat mental illness) for Resident 2 between 4/26/23 and 9/8/23. 2. Ensure chlorpromazine used to treat dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) was tied to a specific target behavior (e.g., striking out at staff, resisting care, etc.) for Resident 2 between 4/26/23 and 9/8/23. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure each Minimum Data Set (MDS, a standardized resident assessment and care-planning tool) assessment was conducted accurately by the appropriate health professional during the entire observation period (2 weeks or 7 days) for one of 12 sampled residents (Resident 2). This failure had the potential to lead to incorrect treatments and services provided to Resident 2 due to inaccurate MDS assessments. Please cross reference with F756, F757, and F744.

Inspectors wroteBased on record review and interview, the facility failed to document one of two sampled residents (Resident 2) skin condition in the care plan as indicated in the facility ' s policy and procedures. This failure had the potential to result in an oversight of Resident 2 ' s skin condition.

Inspectors wroteBased on interviews and record review, the facility staff failed to update the falls care plan for one of 12 sampled residents (Resident 2) after the fall incidents on 8/9/2023 and 8/19/2023 to address Resident 2's use of psychoactive medications (drugs that affect brain activity associated with mental processes and behavior), which placed Resident 2 at a higher risk for falls. This failure had the potential to cause more injuries due to recurrent falls. Please cross reference with F756, F757, and F744

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 13) was provided a communication tool or resources to effectively communicate the resident's needs. Resident 13 who spoke a Chinese dialect, was not provided a communication tool. This deficient practice had the potential to result in the resident ' s care needs not effectively conveyed to the staff which could lead to a decline in the resident ' s quality of life.

Inspectors wroteBased observation, interview, and record review, the facility failed to provide tracheostomy (incision made in the windpipe to relieve an obstruction to breathing) care by a licensed nurse or Respiratory Therapist (RT), when Certified Nursing Assistant staff reattached the tracheostomy tubing (tubing that connects the tracheostomy to oxygen) to the tracheostomy cannula (used for general ventilation) for one of 14 sampled residents (Resident 10). This failure had the potential for Resident 10 to experience worsening respiratory distress or respiratory failure due to unqualified staff caring for Resident 10 ' s tracheostomy.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services that assure accurate acquiring of pain medication such as Morphine Sulfate (MS, a controlled pain killer), baclofen (a medication to treat muscle spasms [painful contractions and tightening of your muscles]) and tizanidine (medication treats muscle spasms) to meet the needs for one of three sampled residents (Resident 4). This deficient practice in Resident 4 had pain without pain relief medications and had the potential for exacerbate (worsen symptoms) medical conditions which could lead to physical decline, psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices during a Coronavirus (COVID 19, a mild to severe respiratory illness that spread from person to person) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) in accordance with the Department of Public Health's (DPH) guidelines and the facility's Policy and Procedure (P&P) by failing to: a. Annually conduct an N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit testing (the use of a protocol to evaluate the fit of a respirator on an individual) for two of two Licensed Vocational Nurses (LVN 1 and LVN 2). b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to put measures in place to ensure safety and supervise residents who were diagnosed with dementia (a decline in mental ability severe enough to interfere with daily life) from wandering out, placing residents who reside in the locked unit (locked, secured, or alarmed units) at risk from elopement (occurs when a resident leaves the premises or a safe area without authorization) by failing to: 1. Ensure Resident 138 who was diagnosed with dementia and assessed as a high risk for elopement by the facility, did not walk out of the facility's locked unit unsupervised. 2. Implement Resident 138's plan of care who had a history of walking out of the facility, by placing a monitoring device (continuously keeps track) on the resident to monitor the resident's whereabouts. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 5 sampled residents (Resident 8, 259, and 106) with an indwelling urinary catheter (a flexible tube inserted into the bladder to provide continuous urinary drainage to a collection bag) received appropriate treatments and services by: 1. For Resident 8, the facility failed to assess and document evidence for the presence of sediment (cells, debris and other solid matter) in the urine. 2. For Resident 106, the facility failed to secure the urinary catheter device to prevent accidental pulling or dislodgement that can cause pain. 3. For Resident 259, the facility failed to obtain a physician's order for the urinary catheter; failure to measure the urinary output in volume. Accurate urine output measurement essential in evaluating both fluid status and renal perfusion (flow of the urine). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 4 sampled residents (Resident 137 and 559) receiving enteral tube feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) received appropriate care and services. 1. For Resident 137, the facility failed to ensure the resident received the total dose of feeding formula ordered by the physician. 2. For Resident 559, the facility failed to ensure the feeding formula and tubing were changed every 24-48 hours in accordance with the physician's order and facility's policy and procedures. These deficient practices had the potential to result in complications of the enteral feeding such as infection and inadequate nutrition.

Inspectors wroteBased on observation and interview the facility failed to provide adequate staff to provide necessary care and services for 5 of 37 sampled residents (Residents 64, 139, 46, 11, and 16). 1. Residents 64 and 139 stated the facility did not have enough staff to provide assistance when needed. 2. During a group meeting Residents 46, 111, and 16, stated the facility did not have sufficient staff to assist with activities of daily living (ADL's) when requested.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all controlled medications (generally a drug or chemical whose manufacture, possession, or use is regulated by a government, such as illicitly used drugs or prescription medications that are designated by law) were properly accounted for when several dates had no signature to verify staff had counted the controlled drugs with another staff. This deficient practice had the potential to cause a discrepancy in medication management in the facility and account for residents' medications accurately.

Inspectors wroteBased on interview, and record review, the facility failed to provide documented evidence the monthly medication review (MMR) for three of 37 residents (Resident 29, 106, and 148) was reviewed by a licensed pharmacist at least once a month This deficient practice had potential to cause adverse consequences related to the medications that could affect the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to have a medication error rate of less than five percent during medication administration. Twelve medication errors were observed out of twenty-five opportunities which resulted in a medication error rate of 48%. 1. For 4 of 4 sampled residents (Residents 82, 153, 139 and 10), medications were administered late. 2. For 1 of 4 sampled residents (Resident 10) no apical pulse (is the vibration of blood as the heart pumps can be found in the left center of the chest, just below the nipple), or respiratory rate were taken. These deficient practices had the potential to result in harm to the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure sanitary conditions were maintained in the kitchen. This deficient practice had the potential for unsanitary food practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices by failing to: 1. Ensure staff (Certified Nursing Assistant 6 [CNA 6]) donned (put on) personal protective equipment (PPE, protective clothing, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from the spread of infection or illness), gown before entering Resident 359's room located in the yellow zone (area where residents under investigation are allocated). 2. Ensure two of five sampled residents (Resident 144 and 361) urinary catheter's (a flexible tube inserted into the body for removal of urine) bags did not touch the floor. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to monitor the use of antibiotic (a medication used to treat bacterial infections), for residents on the Antibiotic Stewardship Program (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic). This deficient practice had the potential to cause unnecessary or inappropriate antibiotic use for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate bed linen for one of two sampled residents (Resident 359) as indicated on the facility policy. Resident 359's mattress did not have a fitted sheet and the Resident was laying on a bare mattress. This deficient practice resulted with Resident 359 feeling uncomfortable and had the potential to negatively impact the resident's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to inform one of 37 sampled Residents (Resident 40) total health status and medical condition in a language Resident can fully understand. This failure violated Resident 40's right to be informed and had the potential for the resident not to make choices regarding her medical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen was not self- administered for one of two sampled residents (Resident 16). Resident 16 had an inhaler (also known as a puffer, pump or allergy spray, which is a medical device used for delivering medicines into the lungs through the work of a person's breathing) and oxygen concentrator at bedside. This deficient practice had the potential for Resident 16 to administer the oxygen inaccurately, unauthorized access to the oxygen and complications due to inadequate or excessive oxygen intake.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote care that maintains the resident's dignity for one of 37 sampled residents (Resident 75). During a dining observation, Certified Nurse Assistant 4 (CNA 4) was observed standing while feeding Resident 75. This deficient practice had the potential to violate Resident 75's right to be treated with respect and dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 1 sampled residents (Resident 11) needs are met by making sure resident's call light is within reach. Resident 11's call light was observed on the floor behind the resident's bed and out of Resident 11's reach. This deficient practice had the potential for Resident 11 to not be able to call staff for help or assistance when needed.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse and mistreatment to the authorized agencies by no less than 2 hours, in accordance to state law for one of one sampled resident (Resident 40) who alleged Certified Nurse Assistant 6 (CNA 6) did not change her and left a scratch on her. This deficient practices violated the Resident 6's right and had the potential to place the resident's safety at risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess one of 2 sampled residents (Resident 16) to determine the resident's capacity for safe use of oxygen. Staff did not aware that Resident 16 administered the oxygen on her own. This deficient practice resulted in Resident 16 not receiving enough oxygen and placed the resident at risk for respiratory distress.

Inspectors wroteBased on interview and record review, the facility staff failed to accurately document the Pre-admission Screening And Resident Review (PASARR- federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one of 37 sampled residents (Resident 19). This failure had the potential for Resident 19 not to be screened or receive services related to mental illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish care areas into the comprehensive care plan for 4 of 37 sampled residents (Residents 106, 148, 259, and 103) 1. For Resident 106, there was no care plan for the use of Ambien (medication for sleep). This deficient practice placed Resident 106 at risk for staff not to provide specific care to the resident while using Ambien. 2. For Resident 148, there was no care plan for Eliquis (medication to prevent blood clot formation). This deficient practice placed Resident 148 at risk for staff not to provide specific care to the resident while using Eliquis. 3. For Resident 259, a newly admitted resident, the facility failed to ensure a care plan was initiated in a timely manner, regarding the use of urinary catheter (a tube placed in the body to drain and collect urine from the bladder). [...]

Inspectors wroteBased on interview and record review the facility failed to provide assistance with activities of daily living (ADL's) for one of 37 sampled residents (Resident 139). This failure had the potential for Resident 139 not to receive necessary care and services needed.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to follow physician's orders for three of 37 sampled residents (Residents 10, 57, and 85). 1. For Resident 10, the facility staff failed to follow physician's order to check the residents's respiratory rate (number of breaths in a minute) and apical pulse (point of maximal impulse and is located at the apex [the base] of the heart) as ordered. 2. For Resident 57, the facility staff failed to follow physician's order to pad the resident's bed side rails. 3. For Resident 85, the facility staff failed to follow physician's orders to pad the resident's bed side rails. These failures had the potential to result in harm or injury to Residents 10, 57 and 85.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment consistent with professional standards of practice and in accordance with the facility's policy and procedure by failing to ensure the low air loss mattress (LAL, special type of mattress used for both the prevention and treatment of pressure ulcer) was set according to resident's weight for one of four sampled residents ( Resident 559). This deficient practice had the potential to result in delayed healing of Resident 559's existing pressure ulcer (injury to the skin and/or underlying tissue resulting from prolonged pressure) and risk of developing new pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform nutritional evaluation one of 5 sampled residents (Resident 259). For Resident 259, the facility failed to assess Resident 259's height and weight and possible nutritional problems related to the diseases and conditions. The facility also failed to perform an initial dietary evaluation that included food preferences upon the resident's admission to the facility These deficient practices had the potential of not meeting Resident 259's nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 16 and 70) received appropriate respiratory care services. 1. For Resident 16, the facility failed to document the resident's respiratory status that included assessment and treatment prior to discontinuing albuterol (medication used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and other lung and airway diseases). 2. For Resident 70, the facility failed to ensure the oxygen tubbing was labeled. These deficient practices had the potential to result in an ineffective respiratory treatment, respiratory distress and decline in resident's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 37 sampled residents (Resident 85) was assessed for bed rails (are adjustable metal or rigid plastic bars that attach to the bed) entrapment (is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail). This deficient practice resulted in Resident 85 getting her left leg caught in the bed rails and had the potential for injury and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for the use of indwelling urinary catheter (tube inserted into the bladder to drain urine), for 1 of 5 sampled residents (Resident 259) with indwelling urinary catheters. This deficient practice had the potential for injury for Resident 259 and had the potential for unnecessary use of the catheter.

Inspectors wroteBased on interview, and record review the facility failed to adequately monitor signs and symptoms of bleeding for one of 37 sampled residents (Resident 148) who was taking Eliquis (medication that reduces or prevent blood from clotting) This deficient practice had the potential for Resident 1 to not receive adequate monitoring while taking Eliquis.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer psychotropic medications (any medication capable of affecting the mind, emotions, and behavior), without documented indication, attempt for Gradual Dose Reduction (GDR, is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued), and as ordered by the physician for three of 37 sampled residents (Residents 29, 106, and 67). 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Medication Storage policy and procedure by failing to: 1. Ensure Resident 111's reusable medication (eye drop) was properly labeled. 2. Ensure staff's belongings were not stored inside the medication cart. 3. Ensure to monitor the room temperatures were medications were stored. 4. Ensure Resident 67 did not have a medicine cup with six pills unlabeled and unattended on her bedside table. These deficient practices had the potential to alter the use, effectiveness, and potency of medications.

Inspectors wroteBased on interview and record review the facility staff failed to accurately document medical records for two of 37 sampled residents (Resident 10 and 139). This deficient practice had the potential for an inaccurate record or lack of care being provided for the residents.