Pleasanton North Nursing and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 5 residents (Residents #1) reviewed for assessments: Resident #1's MDS dated [DATE] did not indicate she had a fall since her last MDS assessment. These failures could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 residents (Resident #1 and #2) of 10 residents reviewed for comprehensive person-centered care plans. The facility failed to accurately reflect Resident #1's fall prevention interventions, including low bed, anti-skid socks (socks with rubber on soles to stop slipping), and anti-skid tape on the floor (tape with a gritty type substance to reduce slipping), but did reflect hipsters (which she did not wear) in her comprehensive person-centered care plan. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 (Resident #1) reviewed for care plans. Facility staff failed to follow the fall interventions in Resident #1's care plan that included keeping Resident #1's bed in the lowest position. Resident #1's was observed lying in bed and the bed was not at the lowest position on 11/06/2025. This deficient practice could place residents with the potential for falls at risk for injury to themselves or others.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's right to be treated with respect and dignity for 1 (Resident #14) of 8 residents reviewed, in that: Resident #14 was referred to as a feeder in the assisted dining room. This deficient practice could cause psychosocial harm due to feelings of embarrassment and loss of dignity.

Inspectors wroteBased on Observations, Interviews, and Record review, the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 6 residents (Resident #12 & Resident # 31) reviewed for call light. The facility failed to ensure Resident #12 and # 31's call light was within reach. This failure could place residents at risk of not being able to call for assistance when needed.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 6 residents (Resident #5) reviewed for accuracy of records as evidenced by: The facility failed to ensure Resident #5's MDS assessment accurately recorded the number of days that insulin injections were received during the last 7 days prior to the assessment. This failure could place residents at risk of missing treatments or medications leading to a decline in health or overall well-being. Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 6 residents (Resident #5) reviewed for accuracy of records as evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) program for residents with newly evident or possible severe mental illness for 2 of 4 residents (Resident #4 and Resident #15) reviewed for PASRR services. The facility failed to identify Resident #4 and Resident #15 as having diagnoses of mental illness including Major Depressive Disorder (MDD) on the PASRR Level I screening which would require a PASRR Level II assessment. This deficient practice could place residents at risk of a diminished quality of life related to not receiving or benefiting from specialized PASRR services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards and provide assistive devices to each president to prevent avoidable accidents 1 of 2 residents (Resident #12), reviewed for accidents and hazards: The facility failed to ensure Resident #12 had fall mats in place These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system of record of the disposition of all controlled drugs to enable accurate reconciliation for 1 of 5 residents (Resident #31) reviewed for pharmacy services. The facility failed to ensure Resident #31's medication reconciliation log for the Schedule II medication (substances with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) Norco 5/325 accurately reflected the number of doses administered. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for one of two medication carts (nurse medication cart) and one of one medication rooms observed for drug storage and labeling, as evidenced by:1. The facility failed to ensure the medication room contained no unexpired supplies.2. The facility failed to ensure all insulin pens located inside the nurse medication cart were properly labeled with opened dates. These failures could place residents at risk of receiving inadequate treatments or false results. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #3) reviewed for care plan revision/timing. The facility failed to ensure Resident #3's care plan was revised in a timely manner to reflect falls on (4) occasions. This deficient practice could affect residents' care/services and may cause a delay in treatment and/or decline in health.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 3 Residents (Resident #1) reviewed for Abuse, in that: The facility did not report an allegation of Abuse to the State Survey Agency (HHSC) within 24 hours of Resident #1 falling off the bed. This deficient practice could affect any resident and could contribute to further neglect.

Inspectors wroteBased on, interviews, and record reviews the facility failed to ensure each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; and the health of individuals in the facility would otherwise be endangered for 1 of 3 (Resident #4) reviewed for discharge. Resident #4 was transferred to the hospital for a psychological evaluation on 3/25/2025 and was not allowed to return to the facility. The facility failed to document the bases of Resident #4's discharge. This could affect all residents and could result in residents not having the opportunity to appeal the discharge from the facility.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to a comprehensive person-centered care plan for each resident, consistent with the resident rights and includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 10 ( Resident #3) residents in that: Resident #3's care plan for his pacemaker was not complete with name, serial number and when he last seen the cardiac physician. This failure could affect residents by placing them at risk of not receiving necessary services and care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents received treatment and care based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 (Resident #3) resident in that: Resident #3's care plan for his pacemaker was not his last cardiac physician appointment. This failure could place residents at risk for not receiving appropriate care and treatment and/or a decline in their health.

Inspectors wroteBased on the interview and record review, the facility failed to ensure that 1 of 12 residents (Resident #2) reviewed for medication errors was free of any significant medication errors. The facility failed to administer medication (Glargine, a drug to lower blood sugar) as prescribed for Resident #2. This deficient practice could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and a decline in health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Meat products were stored above other food items in the facility kitchen freezer. These deficient practices could place 34 residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide a safe, functional, and comfortable environment for residents for 1 of 5 residents (Resident #4) reviewed for environment. Resident #4's footrest on the electric bed was in an elevated position and reported to Maintenance on 03/29/2025. Resident #4's bed was not repaired until 04/03/2025. This deficient practice could place residents at risk of being uncomfortable and at risk of injury from equipment that was not functioning properly.

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #4) reviewed for accuracy of medical records. Resident #4 had a physician's order and care plan for hospice services on his medical record after he was discharged from hospice services. This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #4) reviewed for infection control. Resident #4 had an order for enhanced barrier precautions related to a wound and did not have a sign on his door identifying a need for enhanced barrier precautions for Resident #4. This deficient practice could affect residents on enhanced barrier precautions and place them at risk for infection.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 3 of 5 residents (Resident #2, Resident #3, and Resident #4) reviewed for care plans. 1. The facility failed to ensure Resident #2's care plan was revised to reflect a fall sustained on 7/19/24. 2. The facility failed to ensure Resident #3's care plan was revised to reflect falls sustained on 8/17/24 and 8/18/24. 3. The facility failed to ensure Resident #4's care plan was revised to reflect a fall sustained on 8/30/24. These failures could place residents at risk of current needs not being met.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (Resident #3) reviewed for quality of care. The facility failed to ensue that staff conducted (4 of 14 neuro checks done) neurological assessments for 72 hours per facility protocol after an unwitnessed fall with laceration to above right eye on 08/18/2024 for Resident #3. These failures could result with residents not receiving the necessary interventions in a timely manner, by not recognizing a change of condition that could result in a decline in health.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 5 residents (Resident #4) reviewed for clinical records. The facility failed to ensure Resident #4's neurological assessments were accurately documented in the resident's record following a fall on 8/30/24. This failure could place residents at risk for improper care due to inaccurate records.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 residents (Resident #11) reviewed for abuse. The facility failed to ensure CNA A was suspended pending an allegation of abuse or neglect when Resident #11 became combative with care. CNA A did not discontinue care or call for help when Resident #11 became combative. Resident #11 sustained skin tears to his hands, bruising to hands, skin tears to his forearms, and a left-hand fracture. On 6/5/24 at 7:15 p.m. an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation for of 8 residents (Resident #1) reviewed for neglect and abuse, in that; The facility failed to implement its abuse policy and procedures when Resident #11 obtained skin tears, brusising to hands, skin tears to his forearms, and a left-hand fracture after peri-care with CNA A. On 6/5/24 at 7:15 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed prior to exit on 6/7/24, While the IJ was removed on 6/7/24 at 09:15 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not immediate jeopardy and a scope of Isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. [...]

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 safely for 1 of 1 kitchen reviewed for kitchen sanitation. 1. Failed to ensure food was not expired in dry storage. 2. Failed to ensure food was maintained at freezing temperatures in the freezer. 3. Failed to ensure that the icemaker was sufficiently cleaned. 4. Failed to ensure all food storage items were labeled and dated. 5. Failed to ensure dry grains storage bins remained closed when not in use. These deficient practices could place residents at risk for cross-contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 21 residents (Resident #23, Resident #27, and Resident #39) reviewed for care plans. The facility failed to ensure Resident #23's code status was reflected within the care plan. The facility failed to ensure Resident #27's code status was reflected within the care plan. The facility failed to ensure Resident #39's psychotropic used was reflected within the care plan. [...]

Inspectors wroteBased on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 3 of 16 residents (Resident #12, Resident #14, and Resident #20) reviewed for resident rights, in that: 1. The facility failed to ensure Resident #12 had a documented psychiatric diagnosis for a psychotropic drug, Quetiapine, he was receiving daily. 2. The facility failed to ensure Resident #12 had orders for no longer than 14 days for lorazepam PRN (as needed). The orders were written for 90 days or no end date. 3. The facility failed to obtain an updated and signed consent for antipsychotic medication, Quetiapine fumarate that was administered to Resident #12. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused result in serious bodily injury for 1 of 9 Residents (Resident #11) whose records were reviewed for abuse and neglect, in that; The facility failed to report to the state reporting agency (HHSC) in a timely manner possible neglect or abuse of Resident #11 when he sustained injuries after care from CNA A. This deficient practice could affect residents by contributing to further abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASARR) Screening for 1 of 8 residents reviewed for PASRR (Resident #29). The facility failed to ensure Residents #29 had an accurate PASARR Level 1 Screenings indicating diagnoses of mental illness and refer the residents to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 2 of 2 residents (Resident #34 and Resident #11) 1. The facility failed to ensure LVN C followed facility policy while providing wound care to a resident by not dating and initialing the dressing. 2. The facility failed to ensure LVN C completed treatment orders for Resident #11. LVN C documented she completed wound care orders and did not complete them. These deficient practices could place residents at risk for injury, infection, and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 3 residents (Resident #6) reviewed for oxygen therapy in that: Residents #6 oxygen tubing was dated as 4/15/24 and had not been changed weekly as ordered. These deficient practices could place residents who received oxygen therapy at risk for an increase in respiratory complications and or infections.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident, for 1 of 10 residents (Resident #26) reviewed for medication administration, in that: The facility failed to ensure LVN C followed facility policy while administering insulin to a resident in a muscle instead of subcutaneous tissue (uses a short needle to inject a medication into the fatty tissue layer between your skin and muscle. Typically, medication delivered this way is absorbed by your body slowly) as ordered for Resident #26. These deficient practices could affect residents who received medication and place them at risk of an adverse reaction or a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to assure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for 1 of 1 medication cart reviewed for labeling and storage, in that: The facility failed to ensure the medication cart was clean, free of unknown debris, loose pills, a dirty pill cutter, a sticky pill [NAME], and a bottle of medication without label with an expiration date. These deficient practices could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 1 of 2 staff (LVN C) reviewed for infection control, in that: The facility failed to ensure LVN C washed her hands properly prior to wound care on a resident. These deficient practices could place residents at-risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 dishwasher and 1 of 1 vent hood observed for safely functioning equipment. -The chemical dishwasher was not operating at the manufacturer's minimum requirements for rinsing and sanitization. -The vent hood was not inspected and cleaned on the appropriate timeframe. This deficient practice could result in residents not having access to hygienically clean dishes creating a potential for foodborne illness and create a risk of fire exposure in the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to provide a minimum of 80 square feet per resident in 20 of 46 resident rooms as required for (Rooms #1, #2, #3, #4, #5, #6, #7, #8, #11, #13, #15, #16, #17, #18, #19, #20, #21, #22, #23, and #25) reviewed for the 80 square feet per resident requirement. The facility failed to ensure all resident rooms met the minimum size requirements. This deficient practice could affect residents who may reside in these rooms and not allow sufficient room to carry out activities of daily living care, or have the room furnished as they would like and place them at risk for decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 2 of 8 residents (Residents #1 and Resident #5) reviewed for abuse, in that: 1. The facility failed to ensure Resident #1 was free from physical abuse when RN A and NA H restrained the resident using a gait belt wrapped around the resident's abdomen from 10/08/2023 to 3/01/2024 and secured to his wheelchair behind the resident to prevent the resident from standing, used furniture to prevent movement by Resident #1 in his wheelchair and emotional abuse from RN A. 2. The facility failed to ensure Resident's #1 and #5 were free from verbal abuse when RN A used derogatory language and profanity directed at the residents. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 4/18/2024 at 5:27 p.m. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents are free from physical or chemical restraints imposed for purpose of discipline or convenience and that are required to treat the resident's medical symptoms for 1 of 8 (Resident #1) residents reviewed for restraint, in that; The facility failed to ensure that Resident #1 was free from restraint when RN A and NA H tied Resident #1 to a wheelchair with a gait belt wrapped around his abdomen and secured behind the resident out of reach and by using furniture to block his movement while in the wheelchair on multiple occasions from 10/082023-03/01/2024. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 4/18/2023 at 5:27 p.m. The IJ template was provided to the facility on 4/18/2024 at 5:31 p.m. [...]

Inspectors wroteBased on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation for 1 of 8 residents (Resident #1) reviewed for restraint and abuse, in that; The facility failed to develop and implement and abuse policy that clearly defines restraint as abuse and ensure staff had the knowledge of how and where to report allegations of restraint and abuse. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 4/18/2023 at 5:27 p.m. The IJ template was provided to the facility on 4/18/2024 at 5:31 p.m. While the IJ was removed on 4/21/2024 the facility remained out of compliance at a level of potential harm with a scope identified as isolated until interventions were put in place to ensure staff members were in compliance with identifying and reporting abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in the cart for 1 (Licensed Nurse Medication Cart) of 2 medication carts, in that: The facility failed to ensure controlled medications for Resident's #1, #5, #8, and #19 were kept in their original packaging, appropriately labeled and secured with two locks when LVN J pre-dispersed DEA controlled substances which included: 1. One dosage of clonazepam for Resident #1 2. One dosage of Lyrica and one dosage Ativan for Resident #5 3. One dosage of Lyrica for Resident #8 4. Two dosages of liquid morphine for Resident #19. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions.

Inspectors wroteBased on observation, interview and record review the facility failed to immediately inform the resident's physician, and notify, consistent with his or her authority the resident representative when there was a change in condition status for 1 of 8 residents (Resident #1) reviewed for restraint and abuse, in that:. The facility failed to ensure Resident #1's physician and RP were notified when it was discovered on 3/01/2024 Resident #1 had been restrained by facility staff including RN A. This failure could place all residents at risk of a delay in medical treatment and could result in not receiving appropriate care and interventions.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 1 of 4 residents (Resident #3) reviewed for ADL care, in that; The facility failed to ensure Resident #3 was provided incontinent care when he pressed the call light and requested assistance from NA H. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 1 of 1 Nurses' Aides (NA H) were not working in the facility longer than four months without having completed a competency evaluation program. The facility failed to ensure NA H was certified within four months of hire as full-time staff. This deficient practice place residents at risk for receiving care from an individual whose skill level was unproven.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 2 of 4 Residents (Resident #14 and Resident #35) and 1 of 2 staff (LVN A) reviewed for medication administration in that: 1. Resident #14's liquid lorazepam (A medication used to decreased anxiety) narcotic log was inaccurate. The bottle of liquid lorazepam was stored in the medication storage room and did not have a pharmacy label on the bottle. 2. LVN A administered regular insulin to Resident #35 without priming the insulin pen (removing air bubbles from the needle) prior to administering. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 5 residents (Resident #22) reviewed for care plans in that: Resident #22's comprehensive person-centered care plan did not reflect their bowel or bladder incontinence. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 1 of 2 residents (Residents #1) and 1 of 4 staff (LVN A) reviewed for infection control, in that: 1. LVN A used her barehand to turn off the sink faucet after washing her hands prior to wound care for Resident #1 and again after wound care. These deficient practices could place residents who receive wound care at-risk for infections.

Inspectors wroteBased on interview and record review the facility failed to ensure that the facility's Binding Arbitration Agreement provided for the selection of a venue that is convenient to both parties for three of three residents (Residents #1, #14, & #22) reviewed for facility compliance with requirements for binding arbitration agreements. The facility failed to ensure that it's Arbitration Agreement provided for the selection of a neutral arbitrator agreed upon by both parties for Residents #1, #14, and #22. These failures put residents and their representatives at risk of being uninformed about their rights regarding binding arbitration and less able to defend their rights related to disputes, controversy or claims arising out of or related to the services to be performed by the nursing facility.