Penn Mar Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician's order (PO) for facial X-ray (imaging test) was followed and carried out for one of two sampled residents (Resident 2). This deficient practice had the potential to result in serious health complications for Resident 2 following a physical altercation (incident involving physical contact or the use of force) with Resident 1 on 6/12/26 at 4:18 pm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to one of eight sampled residents (Resident 1) in accordance with Resident 1's Care Plan. This failure resulted in Resident 1 hitting Resident 2 in the face on [DATE] at 3 pm. Resident 2 sustained a laceration (tear or cut in the skin) under Resident 2's left eye, a skin tear (traumatic wound caused by friction when the upper layer of the skin becomes torn from the underlying layers) on the left eyelid, and was transferred to the General Acute Care Hospital 1's (GACH 1's) Emergency Department (ED). [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, seven days a week from 11/1/2025 through 11/19/2025 for six out of 19 days. This deficient practice had the potential to affect the quality of nursing care provided to the residents.

Inspectors wroteBased on interview and record review the facility failed to obtain written informed consent for two of five sampled residents (Residents 6 and 9) by failing to:a. Obtain a written informed consent for the use of Lithium Carbonate (mood stabilizing medication to treat bipolar disorder [mental disorder characterized by periods of depression and of elevated mood]) for Resident 9.b. Ensure Resident 6 had written informed consents for the use of Clozapine (medication used to treat schizophrenia [mental disorder characterized by abnormal social behavior and failure to understand what is real]) and Fluvoxamine Maleate (medication used to treat depression [persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities]) before use. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD- a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them) was not incomplete nor missing the conservator's signature, and readily available in the residents' medical chart for three of five sampled residents (Residents 5, 8 and 21) in accordance with the facility's Policy and Procedure (P&P) titled Advance Directives. These failures had the potential for the facility staff not knowing Residents 5, 8 and 21's specific wishes to follow and provide medical treatment and services against the will of the residents.

Inspectors wroteBased on interview and record review the facility failed to develop and implement an individualized/person- centered care plan (CP) for two of two sampled residents (Residents 9 and 31) in accordance with facility's Policy and Procedure (P&P) titled Care Planning. These deficient practices had the potential for Residents 9 and 31 to not receive necessary treatment and specific care services.

Inspectors wroteBased on interview and record review, the facility failed to conduct competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) for two of five staff (Licensed Vocational Nurse 2 [LVN 2] and Registered Nurse 1 [RN 1]). This deficient practice had the potential for residents not to receive appropriate nursing care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage handling practices by failing to label and discard expired food items stored in two of two facility's refrigerators. Facility failed to ensure: 1. Two (2) Caesar salad containers, one (1) fruit salad container, four (4) ham sandwiches, and three (3) peanut butter and jelly sandwiches from the kitchen refrigerator had use by date.2. Four (4) meat sandwiches observed inside the refrigerator located in the nursing station, had use by date and the date when the sandwiches were made. These deficient practices have the potential to result in pathogen (germ) exposure to residents and place residents at risk for developing foodborne illness (food poisoning) which can lead to hospitalization. [...]

Inspectors wroteBased on interview and record review, the facility failed to:a. Maintain clinical records in accordance with accepted professional standards and practices for one of one sampled resident (Resident 1) by failing to accurately document the monitoring of side effects from antipsychotic medications.b. Ensure medical records were accessible to staff for two of two sampled residents (Residents 26 and 33). These deficient practices had the potential to result in inappropriate care planning, unrecognized service needs, and failure to follow resident's treatment needs.

Inspectors wroteBased on interview and record review, the Quality Assurance Performance Improvement (QA/QAPI - Quality Assurance/Quality Assurance and Performance Improvement, a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee did not fulfill the requirement to have the Medical Director (MD) participate in the QAPI Committee meetings. This failure had the potential to negatively impact resident care coordination and ensure that resident care policies were implemented appropriately.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 9)'s target behavior was monitored for the use of Lithium Carbonate Oral Capsule (medication that treats bipolar disorder (mental disorder with periods of depression and periods of elevated mood) and the indication for use of Benztropine Mesylate Oral Tablet (Cogentin, medication used to treat symptoms of Parkinson's disease, such as tremors and stiffness, as well as involuntary movements caused by certain antipsychotic drugs [antipsychotic medication - drugs that are used to treat symptoms of psychosis]) was accurate for one of five sampled residents (Resident 9) as indicated in the facility's Policy and Procedure (P&P) titled Psychotherapeutic Drug Management. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 6) Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment related to medications was accurately documented to reflect the resident's use of an antidepressant (medication used to treat depression). This failure had the potential to negatively affect Resident 6's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure that medication regimen review (MRR, a comprehensive evaluation of a resident's medications by a pharmacist to ensure the drugs are appropriate, effective, and safe) irregularity identified by the facility's Pharmacy Consultant was acted upon for one of five sampled resident (Resident 31). This deficient practice had the potential for resident harm due to the missed opportunity by the physician and the licensed staff to act upon the reported irregularities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an active, ongoing antibiotic stewardship program (ASP - promote appropriate use of antibiotics while optimizing the treatment of infections, and reduce possible adverse events associated with antibiotic use) with monitoring, tracking, reviewing antibiotic use, and implementing interventions to promote appropriate antibiotic prescribing for the 13 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 8, Resident 9, Resident 21, Resident 26, Resident 31, Resident 33, Resident 36, and Resident 37). This failure has the potential to result in residents receiving unnecessary or inappropriate antibiotics, delayed identification of antimicrobial resistance (bacteria stop responding to medicine), avoidable drug reactions, and compromised resident health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:a. Ensure education was provided about the benefits and risks of the COVID-19 (an illness caused by the coronavirus and affects the lungs and breathing, and can make other parts of the body sick) vaccine, maintain documentation of vaccine education, refusals, or acceptance, and follow their policy for ongoing COVID-19 immunization review for 13 of 13 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 8, Resident 9, Resident 21, Resident 26, Resident 31, Resident 33, Resident 36, and Resident 37). b. Ensure staff documentation contained complete information demonstrating each staff member had been screened, provided with COVID-19 vaccine education, was offered the vaccine and had their current vaccination status recorded. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five out of 11 resident bedrooms accommodated no more than four residents in Rooms 25, 27, 29, 31, and 33. This deficient practice had the potential to result in inadequate space for residents' mobility and staff provision of care to the residents in these rooms.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse (aggressive or violent behavior with the intention to cause physical harm) as indicated in the facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program. This failure resulted in Resident 2 hitting Resident 1 on 3/1/25, 4/12/25, 5/7/25, and on 6/27/25 and resulted in Resident 1 feeling unsafe in the facility. A. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure annual performance evaluations were completed for three of four Certified Nursing Assistants (CNAs) as indicated in the facility's policy and procedure (P&P) titled, Performance Evaluations. This failure had the potential to result in unrecognized skill deficiencies, placing residents at risk for receiving subpar care from staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform neurological (of, relating to, or affecting the functioning of the brain, spine or nerves) assessments for two of three sampled residents (Residents 5 and 6) following an incident with potential head trauma per facility's policy and procedure (P&P) titled, Neurological Assessments. This failure had the potential to result in delayed identification and treatment of neurological changes, placing Resident 5 and Resident 6 at risk for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post daily nurse staffing information in a prominent and accessible location as indicated in the facility's policy and procedure (P&P) titled, Nursing Department - Staffing, Scheduling & Postings. This failure had the potential to result in a lack of transparency regarding nurse staffing levels, affecting residents, families, and regulatory oversight.

Inspectors wroteBased on interview and record review, the facility failed to develop a complete, individualized, and comprehensive plan of care (outlines specific care needs, preferences, and goals for individuals receiving care) for one of four sampled residents (Resident 1). This failure resulted in Resident 1 not receiving individualized care and had the potential to affect Resident 1's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven sampled residents (Residents 1) had a complete neurological (of, relating to, or affecting the functioning of the brain, spine or nerves) assessment check (neurocheck - evaluates brain and nervous system [network of cells, tissues, and organs that controls and coordinates bodily functions) for the 72-hour monitoring period after a resident-to-resident altercation. This failure resulted in incomplete neurological assessments for Resident 1 after a change in condition and had the potential to negatively affect the delivery of necessary care and services in assessing for possible neurological complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was not physically assaulted (someone had been attacked or harmed through physical violence) by another resident (Resident 2) on 3/17/2025. This failure resulted in Resident 1 sustaining bleeding from the nose, discoloration (any change in natural skin tone) on the face and redness on the nose.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three Certified Nursing Assistants (CNA 6) had an active CNA certification when CNA 6 worked for 30 days ([DATE] - [DATE]) with an expired CNA certification. This failure had the potential to put the safety of the residents under the care of CNA 6 at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure all in-services for the year 2024 were maintained, kept and readily accessible in accordance with the facility's policy on record retention for three of three sampled Certified Nursing Assistants (CNAs 3, 4 and 5). This failure had the potential to result in CNAs not receiving necessary training that could affect the resident care and safety.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan (CP) for one of four sampled residents (Resident 1) who was identified as a high risk for elopement (leaving without permission or supervision). Consequently, Resident 1 eloped while attending a court hearing on 12/18/2024. This failure had the potential to result in Resident 1 sustaining a serious injury.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy on wandering and elopement (leaving without permission or supervision) and perform an elopement risk assessment upon admission for one of four sampled residents (Resident 1). This failure resulted in Resident 1 eloping on 12/18/2024 when Resident 1 attended a court hearing with Resident 1's public conservator. This failure had the potential to result in Resident 1 sustaining a serious injury during elopement.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medical Doctor's (MD) notification of a change of condition (COC) was documented in the resident's medical record for one of four sampled residents (Resident 1) when Resident 1 eloped (leaving without permission or supervision) from a court hearing on 12/18/2024. This failure had the potential to negatively impact the delivery of services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement its Policy and Procedure (P&P) on Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) for three of three sampled residents (Residents 2, 20 and 41) by failing to: a. Ensure the Advance Directive Acknowledge (ADA) Form was completed on admission for Resident 41. b. Ensure the ADA Form was completed on admission for Resident 2. c. Ensure the ADA form was completed on admission for Resident 20. These failures had the potential for the facility staff to provide medical treatment and services against the will of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) quarterly assessment was completed within federal time frames per Center of Medicare and Medicaid Services (CMS) requirement to participate for three of three sampled residents (Residents 1, 7 and 14). These failures had the potential risk to affect Residents 1, 7 and 14's care by not providing CMS specific resident information and assessment on a quarterly basis.

Inspectors wroteBased on interview and record review, the facility failed to ensure the initial face-to-face visit (in person meeting between a patient and a physician) was made by a physician (a person qualified to practice medicine) for two of two sampled residents (Residents 41 and 247). These failures had the potential for Residents 41 and 247 not to receive necessary care or receive delayed treatment and services to meet the residents' needs.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day for three of seven days a week (4/7/2024, 5/5/2024 and 6/9/2024). This failure had the potential to affect the quality of care, quality of life, health, and safety of all the residents who resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review of Certified Nursing Assistant (CNA) at least once every 12 months for two of three CNAs (CNA 2 and CNA 3). These failures had the potential for nurse aides not having competent skills when taking care of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe food storage and handling practices in one of one facility kitchen, by failing to: a. Label one sealed frozen roast beef with received date in Freezer 1. b. Discard one opened bag of expired frozen raspberry and one unopened and expired bag of frozen raspberry in the dairy freezer. c. Discard two bags of expired toasted bread (thick-cut white bread) and three bags of expired hamburger buns in the dry storage area. These failures had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) to the residents.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of one sampled resident (Resident 33) for the diagnosis of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were implemented to address the resident's limited range of motion (ROM, distance and direction a joint or body part could move around a fixed joint) and leg edema (also known as fluid retention, swelling caused by fluid buildup in the body's tissues) for one of one sampled resident (Resident 41). This failure had the potential to cause further decline in Resident 41's range of motion, mobility, and physical functioning.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled staffs [Certified Nurse Assistant 3 (CNA 3)] had an active Basic Life Support/Cardiopulmonary Resuscitation (BLS/CPR, a training course that teaches individuals how to respond to breathing and cardiac emergencies in adults. The CPR certification is intended for healthcare professionals) certificate before assigned CNA 3 to care for residents in the facility. This failure had the potential to place the residents at risk for not having their needs meet safely and in a manner that promotes the residents' rights, physical, mental, and psychosocial well-being by competent staff.

Inspectors wroteBased on interview and record review, the facility failed to act upon the pharmacist's medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication.) recommendation for one of five sampled residents (Resident 24). This deficient practice had the potential for Resident 24 receiving unnecessary mediations and not maintaining the resident's highest practicable level of physical, mental, and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician's psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) order for Ativan (a psychotropic drug to treat anxiety disorders), had a specific indicated behavior for its use for one of five sampled residents (Resident 1). This deficient practice had the potential for Resident 1 receiving unnecessary mediations, experiencing side effects of medications, not maintaining the resident's highest practicable level of physical, mental, and psychosocial well-being, and preventing or minimizing adverse consequences related to medication therapy to the extent possible.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five out of 11 resident bedrooms accommodated no more than four residents in Rooms 25, 27, 29, 31, and 33. This deficient practice had the potential to result in inadequate space for residents' mobility and staff provision of care to the residents in these rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Residents 1, 2, 3) were provided with their own deodorant for personal use. This deficient practice had the potential to increase the risk of spreading infection among Residents 1, 2, 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for four of seven sampled residents (Residents 2, 3, 6 and 7) as indicated in the facility's policy and procedure on Abuse Prevention and Prohibition Program, when: a. Resident 1 kicked and hit Resident 2 on the face and arms on 8/12/2024 at 11:15 pm and a few minutes later (undetermined time) hit Resident 2 again. Resident 2 sustained abrasion (scraping of skin) of the bridge of the nose, right side of jawline and right side of the neck and discoloration of Resident 2's right knuckle. b. Resident 1 stabbed Resident 3 with a broken plastic plate on 8/13/2024 at 7:20 am. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement appropriate plans of actions under its Quality Assurance and Performance Improvement (QAPI) program after identifying 31 resident-to- resident altercations from January to July 2024. This deficient practice had the potential to result in negative outcomes for the residents' quality of care.

Inspectors wroteBased on interview and record review, the facility failed to monitor the resident while receiving Clozaril (medication used to treat mental and or mood disorders) for auditory and visual hallucinations (hearing or seeing things that do not exist in reality) as ordered by the physician, for one of nine sampled residents (Resident 5). This deficient practice had the potential for Resident 5 to inflict harm to others.

Inspectors wroteBased on interview and record review, the facility failed to protect residents' rights to be free from emotional abuse (non-physical behaviors that were meant to control, isolate, or frighten) and physical abuse (any intentional act causing injury or trauma to another person) for three of seven sampled residents (Residents 3, 4 and 7) when: a. Resident 3 punched Resident 4 in the face on 5/29/2024 in the patio. Resident 4 punched Resident 3 in the mouth on 5/29/2024 in the patio. This deficient practice resulted in Resident 3 and Resident 4 being subjected to emotional and physical abuse. Resident 4 became upset and punched Resident 3 on the mouth. Resident 3 sustained superficial cut (cuts that do not involve fat or muscle tissue and not bleeding heavily) measured approximately 0.5 centimeter (cm-unit of measurement) to right lower lip with slight bleeding. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Medical Doctor (MD) of a physical altercation on 5/24/2024 for two of nine sampled residents (Residents 5 and 6). Resident 6 punch Resident 5 in the left eye and forehead. This failure had the potential to result in serious injury to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were supervised and monitored in accordance with Medical Doctor's (MD) order for one of nine sampled residents (Resident 6) by failing to: 1. Monitor Resident 6's behavior on 5/10/2024, 5/13/2024, and 5/27/2024 when Resident 6 was receiving Depakote (medication used to stabilize mood) for behavior problems of auditory hallucinations (hearing noises or voices that do not exist in reality). 2. Provide one-to-one monitoring (continuous observation to protect a resident from harm) for Resident 6 for on 6/3/2024. These failures had the potential to result in serious injury to Resident 6 and/or others.

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedure (P&P) on Abuse Reporting and report an alleged physical abuse for one of nine sampled residents (Resident 5) to the California Department of Public Health (CDPH). Resident 9 hit Resident 5 on the left side of Resident 5's face on 5/21/2024. This failure had the potential for Resident 5 to be exposed to further abuse from Resident 9.

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 two of 12 sampled residents (Residents 1 and 3) by failing to: a. Protect Resident 1 from being slapped by Resident 2. On 4/21/2024, Resident 2 slapped Resident 1 on the back of Resident 1's head. This failure resulted in Resident 1 feeling afraid and not feel safe while under the care of the facility. b. Protect Resident 3 from being kicked by Resident 4. On 5/1/2024, Resident 4 kicked Resident 3 on Resident 3's left elbow. This failure resulted in Resident 3 to not feel safe while under the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow a Medical Doctor's (MD) order dated 3/27/2024 at 9:59 PM for neurological checks (neuro-checks, assessing the resident's mental status by evaluating sensory [things a person sees, hears, smells, tastes, or touches] and motor functions) every four hours for 24 hours, then every shift for two days for one of four sampled residents (Resident 3) when Resident 3 sustained a hit to the head from a physical altercation with Resident 1. This failure had the potential for Resident 3 to develop complications from an injury to the head.

Inspectors wroteBased on interview and record review, the facility failed to identify and reduce the risk of elopement (when a person wanders away, walks away, runs away, escapes, or otherwise leaves the facility unsupervised, unnoticed, and or prior to the scheduled discharge date ) in the resident's environment for one of four sampled residents (Resident 4) by failing to ensure locked Gates 1 and 2 were opened one at a time. The Director of Staff Development (DSD) unlocked and opened locked Gate 1 to the patio while entering the facility. While, at the same time, Staff Member (SM) 5 unlocked and opened locked Gate 2 facing the facility's parking lot. Consequently, Resident 4 pushed away the employees (DSD and SM 5) and ran away from the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise residents' care plans to be individualized to address residents' specific behaviors for three of eight sampled residents (Resident 2, 4, 7). 1. For Resident 2, the facility failed to revise Resident 2's care plan after having three incidents of alleged inappropriate sexual behavior on 2/14/2024 when Resident 1 reported to staff that Resident 2 pulled down his pants and asked Resident 1 for oral sex, on 2/28/2024 when Resident 2 reported to staff having multiple instances of oral sex with Resident 3, and on 3/17/2024 when Resident 4 stated Resident 2 came into Resident 4's room at night, pulled down his blanket, and asked Resident 4 for oral sex. 2. For Resident 4, the facility failed to revise Resident 4's care plan after Resident 4 hit Resident 2 on the face on 3/18/2024 at 8:45 AM. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and monitoring for three of eight sampled residents (Resident 1, 2, and 4) as indicated in the facility's policies and procedures (P&P) titled, Hallway Monitor and Rounds/Headcount. 1. Resident 1 reported to the Recreational Activities Assistant (RAA) that Resident 2 pulled down Resident 2's pants and asked Resident 1 to perform oral sex on Resident 2 in Resident 2's room. 2. Resident 4 reported to staff that Resident 2 came into Resident 4's room in the middle of the night, pulled down Resident 4's blanket, tried to grab Resident 4's genitals, and asked Resident 4 for oral sex. As a result of these failures, Resident 2 experienced feelings of mental and emotional distress and felt unsafe until Resident 1 was moved to another room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an alleged sexual abuse incident between Resident 1 and Resident 2 immediately, but no later than two hours to the California Department of Public Health (CDPH), local law enforcement, and Ombudsman (resident advocate who investigated and resolved complaints, usually through recommendations or mediation) as indicated in the facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program. This deficient practice violated the Federal mandated reporting timeframe and had the potential to subject Resident 1 to possible further sexual abuse and psychological (mental and/or emotional) harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pureed food was not mixed together for one of one resident (Resident 4) on pureed diet in a total of 12 sampled residents. This deficient practice had the potential for Resident 4 to not be provided with palatable, attractive, and appetizing food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure: 1. Opened food items in the dry storage area and refrigerator had a written or labeled use-by-date. 2. Expired food items were removed from the dry storage area and refrigerator. 3. An insecticide spray was not inside the kitchen in an open shelf. 4. A high concentration of chemical sanitizing solution was not used for the dishwasher. These deficient practices had the potential to result in foodborne illnesses and chemical food contaminants.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a properly functioning call light system for 11 of 11 rooms (room [ROOM NUMBER], 24, 25, 26, 27, 28 ,29, 30, 31, 32, and 33). This deficient practice had the potential to negatively affect the residents' well-being when the residents are unable to call staff for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the choice to shower was respected for one of 12 sampled residents (Resident 147). This deficient practice had the potential to violate Resident 147's right to make choices about her life in the facility including interests and preferences that were important to her and could have a negative effect on Resident 147's well-being.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as scheduled and as ordered by the physician for two of 12 sampled residents (Resident 18 and 148). 1. For Resident 18, Licensed Psychiatric Technician 1 (LPT 1) failed to administer Risperdal (Risperidone, a medication used to treat symptoms of schizophrenia [a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions]) 2 milligrams (mg, unit of measurement) as scheduled during the 9 a.m. medication administration. 2. For Resident 148, LPT 1 failed to administer Metformin (a medication used to control high blood sugar levels) 850 mg with food as ordered by the physician. These deficient practices had the potential to cause uncontrolled behavioral symptoms for Resident 18 and unwanted side effects for Resident 148.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide range of motion exercises (ROM) for one of two sampled residents (Resident 19). Resident 19 was not receiving ROM exercises for contractures (fixed tightening of muscle, tendons, ligaments, or skin) of right and left hands since 11/6/23. This deficient practice placed Resident 19 at risk for further development of contractures of both hands.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up and act upon a recommendation by the Registered Dietician (RD) to consider a speech therapist (ST, an individual who provides professional services in the areas of communication and swallowing) consultation for one of one resident on pureed diet in a total sample of 12 residents (Resident 4). This deficient practice had the potential to result in further weight loss for Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post accurate nurse staffing information on 12/5/23 and 12/6/23, that included resident census and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift every day. This deficient practice of posting inaccurate nurse staffing information had the potential to mislead the residents and visitors and could result in inappropriate nursing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medication was available and in stock in the facility for one of 12 sampled resident (Resident 18). Resident 18's routine medication, Risperdal (medicine that helps with symptoms of some mental health conditions) 2 mg disintegrating oral tablet, was not available during the 9 a.m. medication administration and was not in stock in the facility. This had the potential to result in an increase of behavior symptoms for Resident 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was free from unnecessary drug for one of two sampled residents (Resident 27). Resident 27 was given Macrobid (antibiotic, medication used to fight infections caused by bacteria) for seven days without an adequate indication for its use. The McGeer Criteria (used to conduct infection surveillance for tracking appropriateness of antibiotic prescribing in nursing homes) was not met before the use of antibiotic drug for Resident 27. This deficient practice placed Resident 27 at risk for antibiotic drug resistance (happens when bacteria change and resist the effects of an antibiotic; resistant bacteria may continue to grow and multiply).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication administration error rate was not greater than 5%. The facility had 2 medication administration errors out of 28 medication opportunities for error observed, to yield a medication administration error rate of 7.14%. The medication errors were as follows: 1. For Resident 18, Licensed Psychiatric Technician 1 (LPT 1) failed to administer Risperdal (Risperidone, a medication used to treat symptoms of schizophrenia [a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions]) 2 milligrams (mg, unit of measurement) as scheduled during the 9 a.m. medication administration. 2. For Resident 148, LPT 1 failed to administer Metformin (a medication used to control high blood sugar levels) 850 mg with food as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for residents, staff, and the public by failing to ensure: 1. Staff immediately wipe clean Resident 5's saliva on the floor due to excessive drooling (saliva flowing out of the mouth uncontrollably) to prevent risk of slip and fall of resident, staff, and the public. 2. Staff monitor Resident 5's excessive drooling and dripping of saliva on the floor to prevent incident of slip and fall in the facility. As a result, on 12/7/23 at 9:32 a.m., Health Facilities Evaluator Nurse (HFEN) 1 slipped and fell on the floor in the hallway. HFEN 1 complained of pain and difficulty walking on the left foot and sustained skin redness and discoloration on both knees and skin redness on the left foot.

Inspectors wroteBased on interview and record review, the facility failed to inform and provide written information to the resident and the resident representative regarding the right to formulate an Advance Directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated) for one of 12 sampled residents (Resident 15). This deficient practice had the potential for Resident 15 or Resident 15's representative to not be informed of their rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five out of 11 resident bedrooms accommodated no more than four residents in each room. Rooms 25, 27, 29, 31, and 33 had more than four residents as indicated in the facility's Client Accommodation Analysis (form indicating square footage measurement and number of residents for each room in the facility), signed and dated by the Administrator (Admin) on 12/6/23. This deficient practice had the potential to result in inadequate space for residents' mobility and staff provision of care to the residents in these rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision while in the hallways for three of 44 residents residing in the facility. (Residents 1, 2 and 3). These deficient practices had the potential to result in resident-to-resident altercation and injury to Residents 1, 2 and 3 due to lack of supervision.

Inspectors wroteBased on observation and interview the facility failed to provide sufficient nursing staff to ensure residents' safety and attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for three of three sampled residents (Residents 1, 2 and 3). These failures had the potential to result in an adverse outcome to resident's care or services including potential for physical or psychosocial harm.