Pomona Vista Care Center

Inspectors wroteBased on interview and record review, the facility failed to effectively implement care-planned interventions, for one of four sampled residents (Resident 2), in accordance with the facility's Policy and Procedure (P&P) titled, Comprehensive Care Plans, and after a resident-to-resident altercation between Resident 1 and Resident 2 dated [DATE]. This deficient practice resulted in Resident 2 pushing Resident 1 on [DATE] and Resident 1 falling to the floor and hitting Resident 1's right knee. Additionally, there was a potential for physical decline to Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to prevent a second resident to resident altercation from recurring for two of four sampled residents (Residents 1 and Resident 2) in accordance with the facility's Policy and Procedure (P&P) titled, Accidents and Supervision and as indicated in Resident 2's Care Plan Reports (CPR), dated [DATE]. This deficient practice resulted in Resident 2 pushing Resident 1 and Resident 1 falling to the floor and hitting Resident 1's right knee on [DATE]. The deficient practice had the potential to result in serious injury, pain, and a physical decline to Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure verbal complaints regarding moaning from a roommate was addressed and resolved promptly for one of one sampled resident (Resident 30). This deficient practice led to Resident 30 verbalizing being unable to sleep at night due to constant moaning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 23) was assessed prior to permitting self-administration of albuterol (a medication used to provide fast relief from symptoms such as wheezing, coughing, chest tightness, and shortness of breath) inhaler (handheld device that delivers medication in a measured dose while a person inhales) and did not ensure accurate documentation when Resident 23 self-administered .This deficient practice had the potential for Resident 23 to over-medicate and experience potential unwanted side effects (unintended consequences of medication/treatment).

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation of the most recent Minimum Data Set (MDS - a federally mandated resident assessment tool) for two of two sampled residents (Resident 23 and Resident 1) by failing to: A. Ensure documentation of oxygen (a gas essential for life) therapy (an administration of supplemental oxygen) for Resident 23. B. Ensure documentation of use of anticonvulsant (a drug commonly used to prevent seizures [a sudden and uncontrolled electrical activity in the brain] or stabilize mood disorders) medication for Resident 1. This deficient practice had the potential for Resident 23 and Resident 1 not receiving treatment and/or services related to the oxygen therapy and anticonvulsant medication.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan (CP) that included specific and measurable interventions for two of two sampled residents (Resident 7 and Resident 11) who were at risk for falls. This deficient practice had the potential to result in unmet individualized needs for Residents 7 and 11 and had the potential to affect the residents' physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan (CP, a form where one can summarize a person's health conditions, specific care needs, and current treatments) and develop individualized interventions accordingly after an actual fall incident on 5/14/2026 at 2:50 AM to prevent repeated fall incident on 5/14/2026 at 7:20 PM for one of one sampled resident (Resident 53). This deficient practice had the potential for facility staff to be unaware of new fall prevention interventions for Resident 53.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed for two of two sampled residents (Resident 10 and Resident 61) by failing to:A. Check Resident 10's Hemoglobin A1C (HgbA1C, a blood test that measures the average level of blood sugar levels over the past two to three months) on last Monday of March 2026. B. Check Resident 61's blood pressure (BP - is the amount of force blood uses to get through the arteries. Normal blood pressure reading for most adults is below 120/80 mm Hg) and heart rate (HR or PR refers to the number of times the heart beats per minute. The normal resting heart rate ranges from 60 to 100 beats per minute) prior administration of amlodipine (a medication used to treat high blood pressure and to prevent chest pain). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent falls (unintentionally coming to rest on the ground, floor, or other lower level) for one of three sampled residents (Resident 11), as evidenced by:Resident 11's was not provided assistance when walking from the dining room back to Resident 11's room on 12/4/2025. Resident 11 was not provided assistance when getting up from bed to the bathroom on 1/1/2026. This deficient practice resulted in Resident 11 falling on 12/4/2025 and on 1/1/2026 and had the potential to result in harm and health decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the nurse staffing data for one of three days (5/16/2026). This deficient practice failed to protect the rights of residents and their representatives to access nursing staffing data.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their medication error rate was not 5 percent or greater. Three medication errors were identified out of 29 opportunities and resulted in a medication error rate of 10.34 percent. The facility failed to ensure medications were administered in accordance with physician orders for two of six sampled residents (Resident 3 and Resident 5) by failing to:A. Ensure Resident 3's Omeprazole (medication used to reduce stomach acid and treat stomach irritation or reflux [backward flow of stomach acid into the esophagus [tube that connects the mouth to the stomach]) and Divalproex (medication used to treat seizures [episodes of abnormal brain activity] and mood disorders) medications were administered to swallow whole. B. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one of four sampled residents' (Resident 1's) physician that Resident 1 was scared after being grabbed by Resident 4 in the hallway on 3/2/2026. This failure had the potential for Resident 1 not to receive care and treatment to address Resident 1's physical and psychosocial health after an incident which could negatively affect Resident 1's health and wellbeing.(Cross Reference F609 and F656)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was provided with comfortable and homelike environment by failing to remove two boxes of canned soda, which did not belong to Resident 1, from Resident 1's nightstand. This deficient practice resulted in Resident 1 feeling upset and Resident 1's private privacy space being violated.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for one of four sampled residents (Resident 1) to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement in accordance with the facility's policy and procedure (P&P) titled, Abuse, Neglect, and Exploitation, dated 12/19/2022. This failure resulted in the delay of notification to the Department, the Ombudsman, and to the local law enforcement and had the potential to result in Resident 1 to be subjected to abuse while at the facility.(cross reference F580 and F656)

Inspectors wroteBased on interview and record review, the facility failed to ensure a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) was developed and implemented for one of four sampled residents (Resident 1) to monitor Resident 1's physical and psychosocial well-being after Resident 1 was grabbed on the arm by Resident 4 on 3/2/2026 and Social Services Director (SSD) requested psychology consultation for Resident 1 on 3/3/2026. These deficient practices had the potential to place Resident 1 at risk of not receiving the individualized care services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.(cross reference F580 and F609)

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans (CP) for two of two sampled residents (Resident 42 and Resident 16) when, A. For Resident 42, a CP was not developed that addressed Resident 42's non-compliance to turning and repositioning. B. For Resident 16, a CP was not developed that addressed Resident 16's Post Traumatic Stress Disorder (PTSD, a mental health condition that can developed after experiencing or witnessing a traumatic event) diagnosis. This deficient practice had the potential to result in unmet individualized needs for Residents 42 and 16 and the potential to affect the resident's physical and psychosocial well-being. (Cross Reference F699)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nursing care and services to prevent pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin and/or underlying soft tissue usually present over a bony prominence) for one of four sampled residents (Resident 42) when the facility failed to: a. Develop a care plan to address Resident 42's non-compliance to turning and repositioning. b. Ensure staff would follow the same system for turning and repositioning for Resident 42. c. Ensure proper communication of Resident 42's changes in skin condition. These deficient practices incresed the risk for Resident 42 to develop a deep tissue injury (DTI - Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue on the right malleolus.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 2 sampled residents (Resident 56 and Resident 41), who were fed by enteral feeding tubes (a tube inserted into the digestive system to deliver liquid nutrition when someone cannot eat or drink normally) received appropriate treatment by failure to: a. change the water flush bag for Resident 56 to follow the manufacturer's recommended time of a 24-hour use time. b. clarify a physician's order for oral (PO) medication administration for Resident 56, despite Resident 56 being documented as NPO (nothing by mouth) and receiving medications via gastrostomy-tube (G-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and services for two of two sampled residents (Resident 20 and Resident 41) when, a. Resident 20's oxygen [colorless, odorless gas] was not on continuously as indicated in Resident 20's care plan (CP). b. Resident 41's nebulizer mask and tubing was not changed in accordance with the facility's Policy and Procedure (P&P) titled, Oxygen Administration. These deficient practices had the potential to result in physical declines to Residents 20 and 41.

Inspectors wroteBased on interview and record review, the facility failed to ensure completeness of medical records for two of two sampled residents (Residents 2 and 24). This deficient practice had the potential to lead to inconsistent and/or inaccurate treatments provided to Residents 2 and 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection (the invasion and growth of germs in the body) prevention and control practices designed to provide a safe, sanitary and comfortable environment for 13 of 13 sampled residents (Residents 14, 28, 5, 4, 48, 18, 54, 47, 34, 26, 10, and 30) and the residents (in general) by failing to ensure: a. Personal toiletries and resident care items were labeled with resident names and not stored inside the [NAME] and [NAME] restroom (a restroom that has two doors and is sandwiched between two bedrooms accessible by the residents in both bedrooms) of Residents 14, 28, 5, 4, 48, 18, and of Residents 54, 47, 34, 26, and 10. b. medical supplies, stored in the medication storage room, were not expired. c. staff personal belongings were not stored in the medication storage room. d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident privacy during the provision of personal care for one of two sampled residents (Resident 19). This deficient practice had the potential to cause, or may have caused, psychosocial harm, including embarrassment, loss of dignity, and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide good hygiene to one of one sampled resident (Resident 16). This deficient practice had the potential to cause skin infections to Resident 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent weight loss for one of three sampled residents when Resident 43 did not meet the goal of 75-100 % meal intake. This deficient practice had the potential to result in further weight loss and a physical decline to Resident 43.

Inspectors wroteBased on interview and record review, the facility failed to provide trauma-informed care for one of one sampled resident (Resident 16) by not ensuring that the resident received adequate care and services to address their Post-Traumatic Stress Disorder (PTSD-a mental health condition that can develop after someone has experienced a deeply disturbing or frightening event). This deficient practice resulted in inadequate attention to Resident 16's specific trauma-related needs and the potential to affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurse staffing data in, two of two nursing stations (North Station and South Station), was posted in a prominent place readily accessible to residents and visitors. This deficient practice had the potential for residents and visitors to not be aware of the actual and accurate nursing hours to ensure facility had enough staff to provide care during each shift.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 56) was free from a significant medication error by failing to clarify a physician's order for oral (PO) medication administration, despite Resident 56 being documented as NPO (nothing by mouth) and receiving medications via gastrostomy-tube (G-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This failure resulted in the administration of medication without confirming the appropriate route of administration and placed Resident 56 at risk for adverse medication side effects (unwanted, uncomfortable, or dangerous effects that a resident may have due to a medication).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one locked medicine refrigerator (RM - a refrigerator that is dedicated to storing and keeping the temperature of medicines and biologicals) was maintained under proper temperature controls in accordance with the facility's policy and procedure (P&P) titled, Medication Storage. This deficient practice could potentially lead to degrading and losing the potency (intensity of effect) of the medicines and biologicals which could potentially be harmful and compromise the health, safety, and well-being of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 15 of 22 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 10, 11, 17, 18, 20, 21, 22, 23, and 24) met the minimum 80 square foot (sq. ft.) requirement per resident in multiple resident bedrooms. This failure had the potential to result in adequate useable living space for residents and limited working area for the facility staff to provide the care and services for the residents.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation of an allegation of abuse that occurred between Residents 1 and 2 on 1/18/2025 per the facility's Policy and Procedure (P&P) titled, Abuse, Neglect and Exploitation, by failing to obtain a statement/information from Resident 3 who identified herself as a witness. This failure had the potential to omit possible evidence in the allegation of abuse between Residents 1 and 2.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive Care Plan (CP - document created to identify a patient's needs) in a timely manner to address wandering into resident rooms for one of seven sampled residents (Resident 2). This deficient practice had the potential to leave Resident 2's wandering behavior unaddressed and potentially affecting the safety of Resident 2, other facility residents, and their families.

Inspectors wroteBased on interview and record review, the facility failed to accurately document in the resident's clinical record when close monitoring and one-to-one supervision was implemented for one of seven sampled residents (Resident 2.) This failure had the potential to result in inconsistency of care for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to remain free from physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) for one of two sampled residents (Resident 2) by failing to protect Resident 2 from being hit by Resident 3. On 8/6/2024, Resident 3 hit Resident 2 on Resident 2's chest. This failure had the potential to result in Resident 2 feeling afraid and not safe while under the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (the Department), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours, in accordance with the facility's policy and procedure (P&P), titled Abuse, Neglect and Exploitation, dated 12/19/2022, for one of two sampled residents (Resident 1). This failure resulted in the delay of notification to the Department and other officials and had the potential for Resident 1 to be subjected to potential further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection prevention and control program for a census of 52 residents by failing to ensure Certified Nursing Assistant (CNA) 1 and CNA 2 performed hand hygiene (cleaning hands by either washing them with soap and water, or by using alcohol-based hand rub [ABHR- liquid, gel, or foam which contains alcohol and applied to hands to kill most bacteria and viruses]) in accordance with the hand hygiene in-service (ongoing employee educational and training program) provided to all staff by the Infection Prevention Nurse (IPN- responsible for coordinating infection prevention and control program activities to prevent, detect, and mitigate communicable diseases and infections within the facility) on 5/5/2024. This failure had the potential to spread infection to all residents and staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to monitor and supervise one of three sampled residents (Resident 8) by failing to ensure Resident 8 did not wander (to go about from place to place usually without a plan or definite purpose) into other residents' rooms. This failure had the potential to result in resident-to-resident altercation involving Resident 8 and had the potential to cause injury/harm to Resident 8 and/or other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) was free from physical abuse from Resident 3 who had just hit another resident (Resident 1) by failing to provide a 1:1 (providing one to one continuous nursing or observation care to an individual patient with behavioral problems for a period of time) supervision to Resident 3, in accordance with Resident 3's care plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan), titled The resident has a behavior problem . This deficient practice resulted in Resident 3 hitting Resident 2 after an incident involving Resident 3 who had hit Resident 1 the previous day.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 1, Resident 2) were free from physical abuse from Resident 3 by failing to ensure Resident 3 who was newly admitted to the facility and diagnosed with dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons) was provided and received the appropriate treatment ( specific treatment?) and services to attain or maintain Resident 3 ' s highest practicable physical, mental, and psychosocial well-being. This deficient practice resulted in Resident 1 and Resident 2 being physically abused by Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to readmit Resident 1 back to the facility from the General Acute Care Hospital (GACH) 2 as indicated in the facility's policy and procedure titled, readmission to Facility. This deficient practice violated Resident 1's right to return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to perform neurological checks (neuro checks, an assessment tool that evaluated the brain and nervous system [the body's command center that included the brain, spinal cord, and nerves] functioning) as indicated in the facility's policy and procedure (P&P) titled, Head Injury, for one of two sampled residents (Resident 1), after a change in condition. This deficient practice had the potential to place Resident 1 at risk for any neurological (relating to disorders of the nervous system) issues not being identified.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to revise and implement an individualized care plan for two of two sampled residents (Residents 47 and 19). A. The care plan for Resident 47, who was assessed with range of motion (ROM, full movement potential of a joint) and mobility (ability to move) limitations, was not revised to address the further decline in the ROM of both lower extremities. B. The care plan for Resident 19 was not revised to address Resident 19's need to wear hearing aids. These failures had the potential to cause a decline in the Resident 47 and 19's physical and/or psychosocial well-being related to the delay in the delivery of the necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for two of two sampled residents (Resident 19 and Resident 41) by failing to: a. Ensure Resident 19 was offered her dentures before each meal and facility followed up with Resident 19's dentist timely to obtain the status of dental treatment authorization for a dental procedure. This deficient practice had the potential to cause mouth pain/discomfort, choking, and weight loss for Resident 19. b. Ensure Resident 41's peripheral intravenous (IV, into or within a vein) Heplock (H/L, a medical device catheter placed in a vein to administer medication or fluid into the bloodstream) was changed in accordance with the facility's policy and procedure (P&P), titled Intravenous Therapy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents' (Resident 5) nutritional status and progressive weight loss was accurately and consistently monitored and assessed as needed and acted upon promptly. This failure resulted in significant weight loss to Resident 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was less than 5% for two of five sampled residents (Residents 4 and 10) during the medication administration. The medication error rate was 11.11% due to three medication errors in a total of 27 opportunities observed. A. For Resident 4, Licensed Vocational Nurse 5 (LVN 5) failed to verify Resident 4's Metformin (medication prescribed to lower sugar level in the blood) Extended Release (ER, slowly released into the body over a period of time usually 12 or 24 hours) and famotidine (medication prescribed to lower acid production in the stomach and prevent heartburn [stomach acid irritating the food pipe lining and causing burning chest pain]) were crushable and administered in accordance with the professional standards of practice. B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Residents 4 and 10) were free of significant medication errors. A. Licensed Vocational Nurse 5 (LVN 5) did not verify Resident 4's Metformin (medication prescribed to lower sugar level in the blood) Extended Release (ER, slowly released into the body over a period of time usually 12 or 24 hours) was crushable and administer in accordance with the professional standards of practice. B. Ensure Licensed Vocational Nurse (LVN) verified the medication expiration date prior to the administration of diltiazem (medication to treat high blood pressure and chest pain) to Resident 10 in accordance with the facility's policy and procedures (P&P). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: a. Expired medications were not stored in one of one facility Medication Storage room, in accordance with professional standards of practice and the facility's policy and procedure (P&P) titled, Medication Storage. b. Licensed Vocation Nurse 2 (LVN 2) did not prepare expired medication for one of one resident (Resident 10) during medication pass administration. Resident 10's Diltiazem (medication to treat high blood pressure and chest pain) liquid form medication had an expiration date of 4/6/2024. These failures had the potential to result in resident harm and/or residents not getting the full benefits of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of two red buckets (Red Bucket 1, used to wipe contact surfaces for infection prevention and control) located in the kitchen that contained sanitization fluid had adequate concentration levels. In addition, the facility failed to ensure Almond milk and 2% low-fat milk located in one of two kitchen refrigerator (Refrigerator 2) were labeled correctly as indicated in the Refrigerated Storage Quick Reference Guide. This failure had the potential to result in cross contamination (process by which bacteria can be transferred from one area to another), the spread of infections, and physical declines to residents who ingested the facility's food.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident and/or the responsible party (RP) for three of three sampled residents (Residents 53, 12, and Resident 24) understood the Binding Arbitration Agreement (BAA, contract between the facility and resident/RP requiring disputes to be resolved by a neutral arbitrator [third party decision-maker] instead of a judge or jury in court) signed upon the residents' admission to the facility. This failure had the potential to cause a decline in the residents' psychosocial well-being due to the failure to understand the implications of the signed documents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection prevention and control practices and implement interventions to prevent and control the spread of infections in the facility for five of five sampled residents (Residents 12, 159, 3, 15, & 57) in accordance with the facility's policies and procedures (P&Ps) and national health guidelines by failing to implement the facility's P&P on Enhanced Barrier Precautions (EBP, use of gown and gloves for use during high-contact resident care activities for certain resident population) timely for the following residents: A. Res 12 who had an indwelling urinary catheter (IUC, a flexible plastic tube inserted into and retained in the bladder to provide continuous urinary drainage). B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct an assessment to determine if self-administration of medications was clinically appropriate for one of one sampled resident (Resident 53) as indicated in the facility's policy and procedure (P&P), titled, Resident Self-Administration of Medication. This failure had the potential in harm and to negatively affect Resident 53's physical well-being due to possible drug-to-drug interactions and unforeseen drug adverse effects.

Inspectors wroteBased on interview and record review, the facility failed to follow up with the Department of Health Care Services (DHCS, state-designated authority for Preadmission Screening and Resident Review [PASRR] determinations) for one of two sampled resident (Resident 24) regarding the PASRR process. Resident 24 had a Positive Level I Screening (an initial screening that indicated Resident 24 required a Level II Evaluation, a person-centered evaluation to determine the most appropriate placement and if specialized services were required) on 1/22/24. This failure had the potential to cause a decline in Resident 24's psychosocial well-being due to possible lack of specialized services.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive plan of care for one of one sampled resident (Resident 22). This failure resulted in the resident not receiving individualized care and had the potential to result in Resident 22 not to maintain the highest practical physical and mental well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a preferred activities for one of one sampled resident (Resident 20) as indicated in Resident 20's Minimum Data Set (MDS, an assessment and screening tool) dated 6/14/23, which indicated Resident 20 liked listening to music. This deficient practice had the potential to result in a decline to Resident 20's physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure hearing aids were made available daily for one of one sampled resident (Resident 19). Resident 19 was hard of hearing. This failure resulted in Resident 19 not being able to hear adequately and had the potential to result in a psychosocial decline to Resident 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the care and services for one of one sampled resident (Resident 12) who had an indwelling urinary catheter (IUC, a flexible plastic tube inserted into and retained in the bladder to provide continuous urinary drainage) in accordance with the facility's policy and procedure (P&P) and professional standards of practice. This failure had the potential to increase Resident 12's risk for catheter-associated urinary tract infection (CAUTI, germs enter and infect the urinary tract through the urinary catheter).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 15 of 22 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 10, 11, 17, 18, 20, 21, 22, 23, and 24) met the minimum 80 square feet (sq. ft.) requirement per resident in multiple resident bedrooms. This failure had the potential to result in adequate useable living space for residents and limited working area for the facility staff to provide the care and services for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge (when a resident/patient is moved to another facility or location, and return to the original facility is not expected) for 1 of 3 sampled residents (Resident 1) by failing to ensure: 1. Resident 1, who was at risk for elopement (when an individual who is incapable of protecting himself/herself leaves the health care facility unsupervised and undetected) and required supervision or steadying assistance to walk 50 feet with two turns, was discharged to a secured facility (a facility with provisions to prevent elopement, i.e., exit doors are locked). Resident 1's family filed a missing person report. 2. Sufficient preparation and orientation was provided to Resident 1 prior to discharge on [DATE]. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement an individualized care plan for elopement (leaving a facility without notice) for one of three sampled residents (Resident 1) in accordance with the facility's policies and procedures. This failure had the potential to cause inconsistent care and services provided to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedures titled, Elopement and Wandering Residents, for one of three sampled residents (Resident 1) by failing to: 1. Ensure the interdisciplinary team (IDT, group of staff from different disciplines who work together to share expertise, knowledge, and skills to devise the best plan of care) evaluated the unique factors contributing to Resident 1's high elopement (leaving a facility without notice) risk and developed an elopement risk care plan with person-centered interventions. This failure had the potential to increase Resident 1's risk for elopement which could result in injury or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven sampled employees (Licensed Vocational Nurse 1 [LVN 1]) had a complete background check done prior to providing care to the residents as indicated in the facility's Policy and Procedure (P&P), titled, Pre-Employment Screening. This failure had the potential to result in an unsafe environment for the residents residing at the facility.