Parkview Julian Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to implement Urinary Tract infection (UTI-infection in any part of the urinary system [kidneys, ureters, bladder and urethra]) care plan for one of two sampled residents (Resident 1). This failure had the potential to result in repeated UTI infection for Resident 1 and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the IDT (Interdisciplinary Team - group of professionals, along with the resident and the family who collaborate to create and manage a personalized care plan) met to review care plans quarterly for one of two sampled residents (Resident 1). This failure had the potential to result in Resident 1's unresolved concerns and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic (medication used to treat infection) was administered as ordered by the physician for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 developing sepsis (the body's extreme, life-threatening response to an infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fingernails were trimmed for one of three sampled residents (Resident 2) with contractures (shortening of muscles, tendons, skin, or nearby soft tissues that causes joints to become stiff and rigid) on both hands. This failure had the potential to result in Resident 2 developing skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to provide care for midline catheter (a long, flexible, thin tube inserted into a vein in the upper arm used for delivering medications, fluids, or drawing blood samples) as ordered by the physician for one of two sampled residents (Resident 1). This failure had the potential to result in Resident 1 developing complications such as catheter blockage, infection, blood clots, and blood vessel damage.

Inspectors wroteBased on interview and record review, the facility failed to ensure treatments were done as ordered by the physician for one of three sampled residents (Resident 2). This failure had the potential to result in Resident 2 developing further skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its own policy and procedure (P&P) when interventions to manage contractures (shortening of muscles, tendons, skin, or nearby soft tissues that causes joints to become stiff and rigid) was not provided on both hands for one of three sampled residents (Resident 2). This failure had the potential to result in Resident 2 developing worsened contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a GT (Gastric Tube - tube inserted through the stomach to deliver food, liquids, and medication) site was covered with a T-drain dressing (specialized absorbent bandage to protect skin) as ordered by the physician for one of two sampled residents (Resident 2). This failure had the potential to result in Resident 2 developing skin irritation and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) on Resident Isolation - Categories of Transmission-Based Precautions when proper PPEs (personal protective equipment) were not worn and proper resident cohorting (to group individuals who have the same infection together) was not done for one of two sampled residents (Resident 3). These failures had the potential to result in the spread of germs in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were updated for one of three sampled residents (Resident 2). This failure had potential for Resident 2's care providers not to be aware of care needs.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) on Fall Management Program, Refusal of Treatment, and Continence Management Guideline when:1. Certified Nursing Assistant (CNA) 1 did not notify a licensed nurse when one of three sampled residents' (Resident 1) refused to have her soiled brief changed.2. CNA 1 did not check and offer to change Resident 1's soiled brief after a refusal for one hour and 45 minutes.3. CNA 1 did not check and offer to change Resident 1's brief every two hours. These failures had the potential to result in Resident 1 falling from trying to go to the bathroom and sustaining right distal femur (lower part of the right thigh bone) fracture (broken bone) requiring hospitalization and surgery.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Documentation - Nursing, for one of three sampled residents (Resident 1) when Resident 1's Nurse Advance Skilled Evaluation ([NAME]) documentation was inaccurate. This failure had the potential for Resident 1 to receive inappropriate care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of four sampled residents (Resident 1, Resident 30 and Resident 75) had comprehensive activities assessments and activities care plans developed specific to the preferences and interests of Resident 1, Resident 30 and Resident 75. This failure resulted in Resident 1, Resident 30 and Resident 75 not receiving activities specific to their preference or interests. This failure resulted in a decreased quality of life for Resident 1, Resident 30, and Resident 75.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards for food service safety and sanitary kitchen conditions were followed when: 1. Two opened boxes of vegetables in the refrigerator in the dry storage room were not labeled with a received, opened and use by date. This had the potential for residents to be served unpalatable food.2. An opened unlabeled box of butter was stored in one of one refrigerator in the dry storage room. This had the potential for residents to be served unpalatable food.3. Food scoops were stored inside two of four dry good food containers. This failure had the potential to cause foodborne illnesses (illness caused by the ingestion of contaminated food) for residents.4. One of one sampled ice cream scoop was not cleaned prior to being stored with clean utensils. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy and procedure (P&P) titled Miscellaneous Areas when one of three trash bins could not be closed. This failure had the potential to attract flies, vermin, and rodents that carry diseases which could infect the residents and cause an infestation in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary disposal of three used trash bags. This failure had the potential to result in the spread of infection to residents, staff, and visitors. During an observation on 12/15/25 at 8:38 a.m., in room [ROOM NUMBER]'s bathroom, a plastic trash bag containing trash was on the floor next to a trash can inside the resident's bathroom. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2, in Resident 30's bathroom, trash was on the floor. LVN 2 stated, the certified nurse assistant should have placed the bag in the trash can, it should not be there on the floor. During an observation on 12/15/25, at 10 a.m., in Resident 52's room, looking out onto the patio area outside, a clear plastic bag was seen on the ground across the courtyard in the resident's patio area. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan (CP) for one of six sampled residents (Resident 89). This failure had the potential to result in Resident 89 having an unrecognized change in condition and adverse health outcome.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 75) was provided quality health care when: a. Resident 75's laboratory results were not reviewed and reported to the physician in a timely manner. This failure had the potential to result in delayed treatment and worsening of Resident 75's infection. b. Interdisciplinary Team (IDT - a group of health care providers) did not develop an individualized care plan (CP) for Resident 75's contact isolation (CI - infection control process for preventing germs from spreading through direct touch or contaminated surfaces). This failure resulted in staff not being aware of Resident 75's infection and the potential for the infect to spread to staff and other residents in the facility. c. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure annual competencies were completed for one of six sampled employees (Certified Nursing Assistant [CNA] 1) was completed. This failure had the potential for the staff not be aware of their need for improvement in certain areas, which could affect resident care. During a concurrent interview and record on 12/18/25 at 10:48 a.m. with Director of Staff Development (DSD), Certified Nursing Assistant (CNA) 1's personal file (PF), [undated] was reviewed. The PF indicated CNA 1 was hired on 6/5/24. The PF indicated there was no annual competency completed for CNA 1. DSD stated there should have been annual competency done in June of 2025 but there was none completed. During a review of the facility's P&P titled, Care Standards, dated 11/1/17, the P&P indicated, V. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure patio area located between Station B and Station C was maintained in a clean and sanitary manner. This failure had the potential to result in the spread of infection to residents, staff and visitors. During an interview on 12/15/25 at 10 a.m. with Resident 52, in Resident 52's room. Resident 52 stated he would like to have a cover or umbrella on the patio area to sit with family or children who visit on the patio area outside his room. During an observation on 12/15/25, at 10:02 a.m. in Resident 52's room, on to the patio area, a plastic bag was on the ground across the courtyard in the resident's patio area. The plastic trash bag contained a brown substance. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Grievance and Complaints for one of three sampled residents (Resident 1) when the facility did not inform Resident 1of the outcome of the investigation and actions taken to resolve the grievance. This failure had the potential for Resident 1 to feel his grievances were not investigated or resolved.

Inspectors wroteBased on interview and record review, the facility failed to accommodate residents needs when call lights were not answering timely for one of three sampled residents (Resident 1). These failures had the potential for Resident 1 not to receive timely nursing care and maintain the highest practicable physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, when the facility failed to: 1. Report and investigate misappropriation of property to the California Department of Public Health (CDPH - local state agency) and local ombudsman for one of four sampled residents (Resident 1). This failure had the potential for Resident 1 to experience further abuse. 2. Develop and implement a care plan to protect one of four sampled residents (Resident 1), when financial abuse was discovered. This failure resulted in Resident 1 not to be protected from further abuse, and the potential for Resident 1 ' s mental or psychosocial needs to go unmet.

Inspectors wroteBased on interview and record review, the facility failed to follow one of three sampled residents (Resident 1) care plan (personalized plan of care outlining a person's needs and how they will be addressed) to ensure Resident 1 who was high risk for falls (to move downward, typically rapidly and freely without control, from a higher to a lower level), had history of falls, and had Alzheimer's disease (progressive and fatal brain disorder that causes memory loss, cognitive decline [gradual decrease in mental abilities, such as memory, attention, reasoning, and judgment], and behavioral changes), had a floor mat (cushioned floor covering designed to reduce the impact of a fall, minimizing the risk of injury) to the right side of the bed and was wearing nonskid (designed to prevent sliding or skidding) socks when he got out of bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, when the facility failed to: 1. Submit the SOC 341 (California Report of Suspected Dependent/Elder Abuse) to the California Department of Public Health (CDPH - local state agency) and local ombudsman for two of five sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to experience further abuse. 2. Submit the 5-day investigation report to the local ombudsman and the CDPH within 5-days of the incident for one of five sampled residents (Resident 3). This failure had the potential for an incomplete investigation for Resident 3. 3. Notify the attending physician (AP) for one of five sampled residents (Resident 3) allegation of financial abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic (medication used to treat infections) order was given as ordered by the Medical Doctor (MD) for one of five sampled residents (Resident 1). This failure had the potential to result in delayed healing of Resident 1's infection.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) on assessment and management of resident weights for one of three sampled residents (Resident 1) when Resident 1 did not have his weight taken for three months. This failure had the potential to result in inaccurate nutrition assessment due to using outdated weights.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was involved in the comprehensive person-centered care planning process. This failure resulted in violation of resident's rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) transportation was scheduled for doctor's appointment. This failure resulted in Resident 1 missing a necessary doctor's appointment.

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan for one of three sampled residents (Resident 1) when the facility did not monitor Resident 1 after a fire. This failure had the potential for Resident 1 to develop adverse health outcomes from exposure to fire.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Follow their policy and procedure (P&P) titled, Resident Access to PHI (protected health information), when three of four sampled residents (Resident 1, Resident 2, and Resident 3) medical records request (MRR) were not logged. This failure had the potential for MRR not to be reviewed and acted upon timely for Resident 1, Resident 2, and Resident 3. 2. Follow their P&P titled Third Party Disclosures of Protected Health Information, when communication for request were not acted upon timely for three of four sampled residents (Resident 1, Resident 2, and Resident 3). This failure resulted in a violation of Resident 1, Resident 2, and Resident 3's rights for MMR to be acted upon timely for Resident 1, Resident 2, and Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) personal items were inventoried upon admission. This failure had the potential for personal items to be unaccounted for Resident 1 and Resident 2 and the use of dangerous materials in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. Six of 20 sampled residents (Resident 58, Resident 87, Resident 193, Resident 22, Resident 17, Resident 70) had a signed and dated Advance Directive (AD - a legal document that provides instructions for medical care and only go into effect if the individual is unable to make decisions for themselves) 2. Document five of 20 sampled residents (Resident 344, Resident 4, Resident 68, Resident 60, and Resident 45) were informed about their right to complete and Advance Directive or had evidence of declining to complete an Advance Directive. These failures had the potential for responsible parties and/or medical professionals to not honor resident's healthcare wishes and to not provide appropriate treatment in the event of an emergency medical situation.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Smoking, for ten of 11 sampled residents (Resident 42, Resident 17, Resident 24, Resident 42, Resident 43, Resident 62, Resident 78, Resident 89, Resident 243, and Resident 245), who smoked independently on the smoking patio, when a smoking assessment was not completed. This failure resulted in residents not being assessed for safety while smoking and the potential residents to be burned while smoking.

Inspectors wroteBased in interview and record review the facility failed to: 1. Ensure medications were administered according to physicians' order for one of two sampled residents (Resident 82). This failure had the potential for Resident 82's infection to worsen. 2. Ensure three of eight sampled employees (Registered Nurse [RN] 1, Director of Staff Development [DSD], and Director of Nursing [DON]) had current educational training and demonstrated knowledge in cardiopulmonary resuscitation (CPR-life saving intervention during medical emergency). This failure had the potential to staff would not be able to perform life-saving procedures in the event of a heart or respiratory emergency. 3. Provide 57 of 57 Certified Nursing Assistants (CNA) and 27 of 27 Licensed Nurses the required Personnel Educational Program (required employee competencies). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment free of accident hazards for 12 of 22 sampled residents when: 1. One of one sampled resident (Resident 58), at risk for choking, was unsupervised in the dining room. This failure resulted in Resident 58 putting sugar packets into her mouth and chewing on them. 2. 10 of 16 residents that smoke (Resident 17, Resident 24, Resident 42, Resident 43, Resident 48, Resident 62, Resident 78, Resident 89, Resident 243, and Resident 245) were not monitored with smoking materials and supervised during smoking times. This failure had the potential for residents to be burned while smoking. 3. Two of two sampled residents (Resident 17 and Resident 62) had space heaters in their rooms without authorized approval. This failure had the potential for an electrical failure or fire. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Transfer and Discharge, when the facility did not send a notice of transfer to the ombudsman (representatives who assist residents in long-term care facilities with issues related to day-day care, health, safety, and personal preferences) for two of two sampled residents (Resident 42, and Resident 50). This failure had the potential to result in Resident 42, and Resident 50 not having an advocate who could inform them of their admission, transfer, and discharge rights and options.

Inspectors wroteBased on observation, interview, and record review, the facility failed follow their policy and procedure (P&P) titled, Food Preparation when one of one sampled cooks (Cook 1) did not follow the facility's standardized recipe for puree (smooth texture) food preparation to maintain nutritive value. This failure had the potential for residents on a pureed diet to be at risk for nutritive impairment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and maintain food in a sanitary manner when: 1. Food items were expired in one of one dry storage room. 2. One dented can was not stored separately in one of one dry storage room. 3. Food items in one of one dry storage room were unlabeled and undated. 4. Food item in the one of one freezer was unlabeled and undated. 5. Food items in one of two Refrigerator's were unlabeled and undated.

Inspectors wroteFindings: 1. During a concurrent observation and interview on 11/19/24 at 10:47 a.m. with Licensed Vocational Nurse (LVN) 2 inside Resident 70 and Resident 29's bedrooms, the ceiling above Resident 29's bed had water stain larger than a dinner plate with black stains in the center about the size of a silver dollar. LVN 2 examined the water stain on the ceiling and stated, I think there's a leak, it looks like water damage. During a concurrent interview and record review on 11/20/24 at 3:19 p.m. with Maintenance Supervisor (MS), MS stated he had seen the visible signs of water damage. MS reviewed the maintenance binder and stated he could not find documentation where staff had notified him of water damage to Resident 70 and Resident 29's bedroom ceiling. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Informed Consent, for one of two sampled residents (Resident 42) when his informed consent for psychotherapeutic (medication to treat mental disorders) medication was not completed. This failure had the potential for Resident 48 to receive psychotropic medication without knowing the risks and benefits of the medication.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environemnt for three of three residents (Resident 17, Resident 62 and Resident 75) when: 1. One of one sampled resident (Resident 17) clothing was not laundered correctly. This failure resulted in Resident 17's personal clothing being damaged and thrown away. 2. Two of two sampled residents (Resident 62 and Resident 75) rooms had patched unpainted wall areas, broken baseboard and peeling wallpaper. This failure resulted in a personal environment that was not homelike for Resident 62 and Resident 75.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Dialysis Care for two of two sampled residents (Resident 67 and Resident 69) when: 1. One of two sampled residents (Resident 69) did not have an order to monitor dialysis access site. 2. Two of two sampled residents' (Resident 67 and Resident 69) dialysis access sites were not assessed according to access type. These failures had the potential for dialysis access sites to not be assessed for correct care and monitoring.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Pre-admission Screening and Resident Review (PASRR [federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting]), to accurately complete the annual Pre-admission Screening Assessment and Resident Review for two of six sampled residents (Resident 68 and Resident 69). This failure had the potential for Resident 68 and Resident 69 to be placed in an inappropriate setting and not receive required services.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate numbers of staff with certain skill set were available to meet one of two sampled resident (Resident 82) care plan needs. This failure resulted in Resident 82 not receiving needed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Food Preference, when two of six sampled residents (Resident 24 and Resident 43) meal preferences were not honored. This failure had the potential for Resident 24 and Resident 43's nutritional needs to not be met and the potential for unintended weight loss due to the food not meeting their nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations and follow the care plan for one of one sampled resident (Resident 48) to prevent symptoms of dehydration, poor oral (mouth) moisture and skin elasticity (turgor) This failure had the potential to negatively affect the well-being and the hydration status for Resident 48.

Inspectors wroteBased on interview and record review, facility failed to ensure the Director of Staff Development (DSD) had a minimum of two years of experience as a Licensed Nurse to qualify for the DSD position. This failure had the potential to result in DSD ' s inability to provide education to the nursing staff and negatively impact the residents ' health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and Resident 2) physician's orders were followed. This failure had the potential for Resident 1 and Resident 2 to experience adverse health concerns.

Inspectors wroteBased on interview and record review, the facility failed to ensure behaviors were monitored for one of five sampled residents (Resident 1). This failure had the potential for Resident 1 to receive unnecessary psychotropic (medication that affects behavior, mood, thoughts, or perception) medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents care planning meetings were completed timely for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to have unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to administer ordered medications for one of three sampled residents (Resident1). This failure had the potential for adverse outcomes for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided safety to prevent injuries. This failure resulted in Resident 1 sustaining a laceration (cut to skin) to his forehead, which required a hospital medical evaluation and treatment for his injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled resident (Resident 1) attending physician (AP) and resident ' s representative (RR) were notified of alleged abuse. This failure had the potential for Resident 1 ' s AP and RP not to be aware of the alleged abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) received scheduled showers. This failure had the potential to result in unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure suspected abuse was reported timely for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 ' s suspected abuse not to be investigated timely and for the suspected abuse to continue.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure titled, Privacy and Dignity and Catheter-Indwelling, Insertion of , when a urine collection bag [drains urine from the bladder through a tube] was not covered with a dignity bag [bag used to cover urine collection bag], for one of three sampled residents (Resident 3). This failure had the potential to cause Resident 3 embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P), titled Trauma [event that causes long-lasting mental or emotional damage] Informed Care: Screening [assess for risk factors], Training, and Care Integration Program, when: 1. Medical Records (MR) staff and Dietary Aide (DA) 3 did not respond to one of one resident's (Resident 22) request to identify themselves. This failure resulted in Resident 22 weeping and expressing fear when his trauma response was triggered by staff. 2. Social services did not screen newly admitted residents for a history of trauma for five of six sampled residents (Resident 417, Resident 115, Resident 10, Resident 38, and Resident 39). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food handling and a sanitary kitchen environment when: 1. Dietary Aid (DA) 2 failed to perform hand washing after touching a soiled napkin on the floor, before returning to food preparation. 2. Bacon was removed from temperature control beyond facility policy of 30 minutes. 3. Effective contact time for sanitizing during three compartment cleaning method was not performed for water pitchers. These failures had the potential to result in foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) to all of the facility's at-risk population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Infection Prevention and Control Program, when the facility did not: 1. Have a water management program (identify hazardous conditions and control water-related healthcare associated infections) in place. 2. Have a system in place to identify unvaccinated staff. 3. Place one of one sampled resident (Resident 44), suspected to have a contagious infection, in isolation. 4. Promptly discard contaminated (used) intravenous (IV- into a vein) tubing. These failures had the potential for life threatening infections to develop and spread to all other residents, visitors, and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, homelike environment when: 1. Resident 41's remote control for her television did not work. This failure caused Resident 41 to be unable to watch television in her room. 2. Activity room's SMART television was broken. This failure caused residents' participating in activities to be unable to use special program applications they enjoyed. 3. Water was leaking in Resident 76's shared room, Resident 84's shared room, and room [ROOM NUMBER]. This failure had the potential to result in injury from residents or staff slipping on water. 4. Extension cords were wrapped around three of eight sampled residents' (Resident 76, Resident 39, and Resident 44) beds side rail and clutter was on the floor. This failure had the potential to result in resident injury. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit Quarterly Minimum Data Set (MDS- a standardized assessment tool) in a timely manner for four of 13 sampled residents (Resident 83, Resident 68, Resident 22, and Resident 40). This failure resulted in inaccurate assessments and had the potential to contribute to a lack of resident specific care plan interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Medication Storage and Labeling, for monitoring the receipt discontinued controlled medication (prescribed medication with a high risk for abuse/dependence). This failure had the potential for diversion of controlled medications (drugs which may be abused or cause addiction, such as opioids, stimulants, depressants, hallucinogens and steroids).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe administration of medication when: 1. Medications were kept at Resident 117's bedside without a medication self-administration assessment or a physician order for one of 56 sampled residents (Resident 117). 2. Intravenous (IV- into or within a vein) antibiotic (medicine used to treat infection) bag and tubing were unlabeled for one of one sampled resident (Resident 417). These failures had the potential for medications to be administered incorrectly and unsafely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu as planned for therapeutic diets when: 1. The planned menu for a mechanical soft diet order was not followed for one of five sampled residents (Resident 29). 2. A fortified diet was not followed for two of five sampled residents (Resident 91 and Resident 18). 3. A large portion diet order was not followed for one of five sampled residents (Resident 49). 4. A no added salt diet order was not followed for one of five sampled residents (Resident 34). These failures resulted in residents' nutritional needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed follow their policy and procedure titled Catheter-Indwelling, Insertion of, when a urine collection bag (drains urine from the bladder through a tube) was not covered with a dignity bag, for one of two sampled resident (Resident 367). This failure had the potential to cause Resident 367 embarrassment.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure titled Change of Condition Notification [COC], when the physician was not notified of a COC for one of four sampled residents (Resident 85). This failure had the potential to result in further weight loss for Resident 85.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, to report resident to resident abuse to the State Agency (SA) for one of five residents (Resident 20). This failure had the potential for abuse to continue and for Resident 20 and other facility residents to be a risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure the risks, benefits, and alternatives (RBAs) of leaving the facility Against Medical Advice (AMA) were explained by the physician for one of three sampled residents (Resident 56). This failure resulted in Resident 56 not be fully informed of the RBAs of leaving AMA.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Transfer and Discharge, when the facility did not send a notice of transfer to the ombudsman (representatives who assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) for one of five sampled residents (Resident 6). This failure had the potential to result in Resident 6 not having an advocate who could inform them of their admission, transfer, and discharge rights and options.

Inspectors wroteBased on interview and record review, the facility failed to complete and submit comprehensive Annual Minimum Data Set (MDS- standardized assessment tool) assessments in a timely manner for five of thirteen sampled residents (Resident 13, Resident 39, Resident 58, Resident 76, and Resident 60). This failure had the potential to result in inaccurate assessments and to contribute to a lack of resident specific care plan interventions.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS-a standardized assessment tool) for two of 5 sampled residents (Resident 85 and Resident 41). This failure had the potential for negative health outcomes for Resident 41 and Resident 85.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Develop and implement a comprehensive care plan for one of six sampled residents (Resident 113). This failure had the potential to result in unrecognized care concerns, interventions, and outcome goals. 2. Implement a care plan for one of two sampled residents (Resident 57) who required supervision while smoking. This failure had the potential for Resident 57 to sustain burns and/or injury while being unmonitored

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 5 sampled residents (Resident 42) was placed on a bowel and bladder (B&B) training program to maintain or improve her urinary and bowel continence (the ability to control bladder and/or bowel). This failure had the potential to result in Resident 42 becoming permanently incontinent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. An order for a therapeutic (to cure or restore to health) nutritional supplement (used to increase calories and protein intake) was provided for one of four sampled residents (Resident 85). 2. Consumption of the supplement was accurately documented and monitored in one of four sampled residents (Resident 85). These failures had the potential to ineffectively evaluate and delay timely revision of interventions and impede accuracy of nutrition assessments needed to meet residents' nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Behavior-Management, for completing a gradual dose reduction (GDR) for one of three sampled residents (Resident 22). This failure resulted in Resident 22 receiving unnecessary psychotropic medication (medications that affect a person's mental state).