Rancho Seco Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent was obtained prior to the administration of psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) for three of 26 sampled residents (Resident 2, Resident 20, and Resident 30). This failure increased the potential for residents or their responsible parties (RP, legal representative) to not be informed of the risks and benefits of the medications and possible treatment alternatives.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of quality were followed for four residents out of a census of 92, when:1. Licensed Nurse (LN) 6 did not sign and date Resident 98's medicated patch;2. LN 5 did not wear appropriate personal protective equipment (PPE, equipment such as gloves, masks, or safety glasses worn to minimize exposure to hazards) while handling Resident 23's hazardous medication (medications that can cause serious effects including cancer, organ toxicity, fertility problems, genetic damage, and birth defects if not handled appropriately);3. LN 5 did not crush Resident 81's medications for administration; and 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had 8 percent (%; a unit of measurement) error rate when two medication errors out of 25 opportunities were observed during a medication (med) pass for one of five residents (Resident 72). This failure resulted in medications not given in accordance with the prescriber's order and the potential to affect the residents' clinical conditions leading to health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1. Unauthorized nursing staff did not have access to medications once their employment with the facility ended;2. Safe medication labeling practices in accordance with accepted professional standards when opened inhalers and biologicals were not properly labeled with sufficient information to clearly identify the specific residents for which they were prescribed in medication (med) carts A and D; and3. Unwanted or refused doses of medication were not stored in the med cart. These failures decreased the facility's potential to prevent diversion or misuse of medications, medication errors and preventable infections from cross-contamination of resident medications from accidental misadministration of similar or same drugs for a census of 92 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect and keep secure when not in use, confidential resident health records for a census of 92 residents, when Licensed Nurse (LN) 5 left medication boxes with confidential resident information unattended during medication (med) pass. This failure had the potential to expose and disclose the residents' personal and confidential health information to unauthorized individuals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated resident assessment tool) was accurate for two of 26 sampled residents (Resident 29 and Resident 30), when:1. Resident 29's discharge assessment was not completed as required; and2. Resident 30's nutritional status assessment for two quarterly reviews did not indicate enteral feeding (a medical method of delivering liquid nutrients directly into the stomach or small intestine using a feeding tube). These failures increased the facility's potential for incorrect submission and reporting of residents' assessments.

Inspectors wroteBased on interview and record review, the facility failed to confirm one of 26 sampled residents (Resident 96's) code status in an emergency, when Licensed Nurse (LN) 3 did not follow Resident 96's physician's order to do not attempt resuscitation (DNR). This failure resulted in delivering unwanted life-sustaining treatment that was inconsistent with Resident 96's wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures for one of 26 sampled residents (Resident 81), when Licensed Nurse (LN) 5 did not change gloves or perform hand hygiene between oral (by mouth) and eye medication administration for Resident 81. This failure decreased the facility's potential to prevent cross contamination and infections among vulnerable residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from abuse, when Resident 2 swung a stuffed animal at Resident 1, grabbed her right arm, kicked her right leg, and threatened her. This failure decreased the facility's potential to protect Resident 1 from physical and verbal abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5 percent (%) for one of 23 sampled residents (Resident 10), when three medications out of 34 opportunities were not given in accordance with the physician's orders and professional standards of practice. This failure resulted in a medication error rate of 8.82%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled and safely stored for a census of 95 residents, when:1. Expired and discontinued medications were stored in medication cart (med cart) C;2. Two bottles of wound treatment solutions and one tube of wound ointment were found stored in the treatment cart at station 2, opened and undated; and3. Three packets of antibiotic ointment (a thick, greasy cream applied to the skin to prevent bacterial infections in minor cuts, scrapes, and burns) were found expired and stored in the treatment cart at station 2. These failures decreased the facility's potential to safely store medications for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a manner to conserve its nutritive value for a census of 95 residents, when the recipe was not followed for cooking carrot, pea, and fish. This failure had the potential for residents to experience decreased food intake and less nutrients in the served food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and serve food in a sanitary manner for a census of 95 residents, when:The refrigerator and freezer temperature were not monitored on multiple dates of two months;An expired cinnamon stick bottle was available for use; andThe [NAME] did not serve food in sanitary manner during tray line. These failures had the potential to result in foodborne illnesses among vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented for a census of 95 residents, when:1. Licensed Nurse (LN) 1 did not disinfect the blood pressure (BP) monitor in between resident use;2. Five sterile wound dressings (a medical covering completely free of germs and contaminants, designed to protect open wounds from bacteria) were opened and stored in the treatment cart at station 2; and3. A housekeeper (HK) did not wear the required personal protective equipment (PPE, any gear to protect your body from germs, hazardous chemicals in a medical setting like gloves, gowns, and masks) while deep cleaning the room of a resident on Enhanced Barrier Precaution (EBP, infection control method). These failures had the potential to spread infection among residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs and preferences for one of 23 sampled residents (Resident 94), when Resident 94 was not evaluated upon her request to use a motorized wheelchair at the facility. This failure decreased the facility's potential to maintain Resident 94's independent functioning, dignity, well-being and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of 23 sampled residents (Resident 13), when the care plan did not address Resident 13's hospice (comfort-focused support for people with terminal illness) care and interventions. This failure decreased the facility's potential to address Resident 13's individualized care and specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for one of 23 sampled residents (Resident 48), when staff did not implement an appropriate communication system for Resident 48. This failure increased Resident 48's potential to experience delays in receiving necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to review the pharmacist's recommendations for psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) for two of 23 sampled residents (Resident 19 and Resident 52), when:1. Resident 19's medication regimen review (MRR) for trazodone (a medication to treat depression) was not followed; and2. Resident 52's MRR for lorazepam (a medication to treat anxiety) was not followed. This failure increased the residents' potential to receive unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 23 sampled residents (Resident 53) was free from unnecessary medications, when Resident 53's lorazepam (an anti-anxiety medication) was prescribed without a stop date. This failure increased Resident 53's potential to receive an unnecessary medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents (Resident 1, Resident 2, and Resident 3) were free from abuse when:1a. Resident 1 and Resident 3 were observed slapping each on the arms on 11/9/25; and 1b. Resident 1 and Resident 2 were observed slapping each other on the arms on 11/11/25. This failure resulted in Resident 1 and Resident 2 sustaining abrasions on their arms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable environment, when multiple residents complained of cold temperature and the residents' rooms temperatures were below the requirement. In addition, the facility failed to act in a timely manner when the boiler (a central component of heating system that provides warmth to the building) was not functioning for a census of 98. These failures resulted in residents' discomfort, difficulties with sleeping and had the potential to negatively impact the residents' quality of life.

Inspectors wroteBased on observations, interviews, and a review of records, the facility failed to ensure one of four sampled residents (Resident 1) was free from physical abuse when Resident 2 slapped Resident 1 on the right cheek and punched him in the stomach. This failure resulted in physical contact that posed a risk of injury and demonstrated the facility's inability to protect Resident 1 from abuse by another resident. Resident 1 was admitted to the facility in Winter of 2024 with diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), inguinal hernia (when part of the intestine or soft tissue pushes through a weak spot in the abdominal muscles in the groin area) and depression. A review of Resident 1's Order Summary Report (OSR) indicated, Resident Capable of Understanding Rights, Responsibilities, And Informed Consent. [...]

Inspectors wroteBased on interview, record review and policy review, the facility failed to provide supervision and monitoring for one of three sampled residents (Resident 1) when Resident 1, after two attempts, eloped from the facility. This failure had the potential to result in serious injury or death for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that promoted dignity and respect for one of four sampled residents (Resident 1) when Resident 1 was observed spitting in hallways and was reported to open his bowels on the facility patio. This failure had the potential to minimize Resident 1's self esteem and to negatively impact the psychosocial well-being for other residents in the facility.

Inspectors wroteBased on interview, and record review the facility failed to protect one of 4 sampled residents (Resident 1) from physical abuse when Resident 2 pushed Resident 1 in the face. This failure resulted in Resident 1 sustaining a bloody nose.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1 and Resident 2) in a census of 95 were free from abuse when Resident 2 hit Resident 1 with a wooden and metal reacher. This failure increased the potential for physical injury and psychosocial distress.

Inspectors wroteBased on interview, and record review, the facility failed to protect one of four sampled residents from abuse (Resident 1), when another resident (Resident 2) hit Resident 1 on the arm repeatedly. This failure caused fear and had the potential to cause physical injury to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was promoted for two of five sampled residents (Resident 2 and Resident 3), when the residents room smelled with a very strong urine odor. This failure led Resident 2 to feel a sense of an undignified existence and Resident 3 felt uncomfortable and lacking in dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 4 sampled residents (Resident 2) was free from abuse when Resident 1 ran over Resident 2 ' s foot with his wheelchair two times. This failure had the potential to cause injury, fear, and distress to Resident 2.

Inspectors wroteBased on observation, interview and record review the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and the kitchen environment in accordance with professional standards for food service safety when: 1. One bag of grits was found open and left unsealed, and was without open and use-by dates, 2. Kitchen environment was not maintained (e.g. walk-in refrigerator floor sealant was worn off with areas of missing metal and texture coating, kitchen walls and ceiling had areas of missing texture and paint, and showed signs of water damage), 3. Fruit and vegetable sink lacked an air gap (a backflow prevention device that prevents contaminated water from re-entering the sink), 4. Five metal bowls and nine steam table pans were stacked and stored wet, 5. Small wares were not discarded when damaged (e.g. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of 24 sampled residents (Resident 70) was assisted with nail care as part of her Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when Resident 70 had long fingernails and toenails. This failure had the potential for Resident 70 to sustain skin injury and/or to acquire an infection, and not achieve her highest practicable well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one out of 24 sampled residents (Resident 30) was provided with an ongoing activity program that meet psychosocial needs (a combination of mental health, emotional, spiritual, or behavioral needs that are important to a person) when Resident 30 was not provided with any activity that met her psychosocial needs from 2/17/25 to 3/3/25 and from 3/6/25 to 3/24/25. These failures had the potential for Resident 30 to not achieve her highest mental, emotional, spiritual, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the completed and/or discontinued controlled medications (substances that have the potential for abuse and addiction and are therefore regulated by law) were remove from the medication cart and destroyed by two licensed facility staff nurses for two of 24 sampled residents, Resident 8 and Resident 59 when, controlled medications not being used were found in two medication carts. These failures had the potential for diversion (obtain or use of prescription medicines such as controlled medications illegally), medication errors, and/or misuse of controlled medications in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare pureed foods (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding ) by methods that conserve nutritive value, flavor, and appearance for ten out of 91 residents (Resident 25, Resident 26, Resident 28, Resident 30, Resident 48, Resident 49, Resident 54, Resident 64, Resident 81, and Resident 347) when the recipes were not followed, and water was used to thin the pureed foods. Failure to ensure the flavor and nutritional value of food may result in decreased intake, weight loss and decreased nutritional value further compromising the medical status of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 91 when: 1. Two facility staff did not wear required personal protective equipment (PPE) when they performed resident care for Resident 73 who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use); 2. A facility staff, Licensed Nurse (LN) 9 did not disinfect a blood pressure cuff after using it on three residents, Resident 47, Resident 68 and Resident 80; and, 3. Excess treatment supplies remaining from Resident 85's wound care treatment were placed back into the treatment cart. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plans for dysphagia (difficulty of swallowing) were developed for two out of 24 sampled residents, Resident 49 and Resident 79. This failure increased Resident 44 and Resident 79's risk of not receiving proper nursing care interventions for dysphagia and had the potential to cause choking and aspiration (inhale into the lungs).

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 24 sampled residents (Resident 346) received treatment and care in accordance with professional standards of practice, facility's policy and procedures (P&P), and physician's order when Resident 346's right ankle wound care order was not consistently done. This failure possibly resulted in Resident 346 experiencing right ankle pain, increased bleeding on the right ankle, increased confusion, increased heart rate (beat), and elevated temperature and ultimately getting Resident 346 transferred to an acute hospital and was diagnosed with right ankle infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 24 sampled residents (Resident 364) received treatment and care in accordance with professional standards of practice, and facility's policy, procedure (P&P), and physician's orders when Resident 346's suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen) care and treatment was not done consistently. This failure had the potential to result in suprapubic catheter site infection, clogging of the catheter, and possible development of suprapubic catheter complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change the peripherally inserted central catheter (PICC) line (a thin flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart to deliver medications) dressing for one of 24 sampled residents (Resident 3). This failure had the potential to result in a serious infection and/or further health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a physician's order for oxygen therapy for one of 24 sampled residents (Resident 49). This failure had the potential to result in hypoxia (a state where tissues in the body, including the brain, don't receive enough oxygen) and/or shortness of breath.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's diet orders regarding fluid consistency for two of 24 sampled residents, Resident 49 and Resident 79. This failure placed Resident 49 and Resident 79 at risk for choking, aspiration (inhale into the lungs) and the possible development of pneumonia (a lung infection making it difficult to breathe).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food in accordance with the physician's prescribed diet for one out of 24 sampled residents (Resident 30) when Resident 30's prescribed fortified diet (a diet designed to increase the calorie level of foods commonly consumed by resident) was not followed. This failure had the potential for Resident 30 to continuously lose weight, to negatively affect Resident 30's medical condition, and for Resident 30 to not achieve his highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system was accessible for two out of 24 sampled residents (Resident 85 and Resident 39) when the call light buttons were observed not within reach. This failure had the potential to result in residents' needs not being met and prevent the residents' communication for assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored locked for a census of 93 residents, when two medication carts were left unlocked and unattended. This failure had the potential for medication misuse and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for one of three sampled residents (Resident 1), when: 1. Licensed Nurse 2 (LN 2) did not maintain hand hygiene before donning gloves; and 2. LN 2, LN 3, and the Wound Doctor (WD) did not use required Personal Protective Equipment (PPE, a gown) while providing wound care assessment for Resident 1 ' s right foot; and This failure had the potential to spread infection among residents.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one of three sampled residents (Resident 1) when Resident 2 punched Resident 1 on the head. This failure resulted in Resident 2 punching Resident 1 and sustaining a fall with an abrasion to the elbow.

Inspectors wroteBased on interview and record review, the facility failed to protect nine out of 97 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8 and Resident 9) from sexual abuse and the potential to affect all residents in the facility when the facility knowingly employed Certified Nursing Assistant 1 (CNA 1) with a history of a criminal misdemeanor (an offense punishable under criminal law). This failure led to nine residents ' (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8 and Resident 9) being sexually assaulted (sexual contact upon a person without their consent or on a person who is incapable of providing consent. Includes rape, unwanted sexual touching, oral sex and exposure) by CNA 1, with the potential to affect all residents in the facility who received care. On 2/21/25 at 7:25 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents ' right to be free from sexual abuse by a staff member for nine of ten sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9) when Certified Nursing Assistant 1 (CNA 1) sexually assaulted (sexual contact upon a person without their consent or on a person who is incapable of providing consent. Includes rape, unwanted sexual touching, oral sex and exposure) Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9. This failure caused the residents fear, anxiety, inability to sleep, to feel ashamed, embarrassed and at risk for long term psychosocial trauma such as social isolation, emotional instability, post-traumatic stress disorder and suicidal risk. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate staff to resident allegations of sexual abuse (sexual contact upon a person without their consent or on a person who is incapable of providing consent. Includes rape, unwanted sexual touching, oral sex and exposure) for nine of ten residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8 and Resident 9) by Certified Nursing Assistant (CNA 1) when additional victims were identified (Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, and Resident 10) after the facility ' s initial investigation. This failure resulted in the facility not identifying all victims of abuse in a timely manner which delayed counseling, monitoring and increased the risk for unmet emotional trauma.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Administrator (ADM) managed the facility effectively to meet the need of all residents when a Certified Nursing Assistant (CNA)1, was hired after the ADM and Director of Staff Development (DSD) had knowledge of CNA1 ' s history of abuse. This failure put all resident at risk of abuse and resulted in sexual abuse of nine residents.

Inspectors wroteBased on interview and record review, the facility failed to report immediately to the Department three allegations of sexual abuse for three of ten sampled residents (Resident 1, Resident 2, and Resident 5), when the Department received the facility ' s reports of alleged sexual abuse after two hours of occurrence. This failure decreased the facility ' s potential to protect vulnerable residents and provide a safe environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of 3 sampled residents (Resident 1) from physical and verbal abuse when he was hit on the left leg by Resident 2 during an argument in the shared bathroom. Additionally, Resident 2 used profanity towards Resident 1. This failure resulted in Resident 1 sustaining an abrasion on the left shin and he was afraid of leaving the room for fear of coming into contact with Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2), who had a known history of constipation, received treatment for bowel management as ordered by the physician and, failed to notify the physician when the resident had no bowel movement for 6 days. This failure resulted in Resident 2 experiencing abdominal pain, discomfort, was upset, frustrated and visibly shaken from inability to open his bowels.

Inspectors wroteBased on observation and interview, the facility failed to promote and maintain dignity and respect for one of three sampled residents (Resident 1) when the resident waited for 38 minutes to be assisted with feeding. This failure had the risk potential to minimize Resident 1's self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident-centered activities were implemented for one of six sampled residents (Resident 1) when one on one (1:1) visits were not done and documented for Resident 1. This failure decreased the facility's potential in supporting and enhancing the physical, mental, and psychosocial well-being for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident 1) accurately reflected Resident 1's wound when his MDS Section M Skin Conditions was not accurately documented. This failure had the potential to result in Resident 1 not receiving interventions to improve skin condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for one of three sampled residents (Resident 1) when referral to a podiatrist (a doctor who treats the foot, ankle, and related structures of the leg) was not ordered and carried out upon admission. This failure resulted in the delay in receiving necessary care and services for Resident 1.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1) the facility failed to protect the resident's right to be free from physical abuse by another resident when Resident 2 slapped Resident 1. This failure resulted in Resident 1 developing left eye swelling and experiencing pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the Resident's rights to be free from abuse for 1 of 3 sampled residents (Resident 1) when Resident 1's daughter witnessed Resident 2 throwing urine and feces at Resident 1. This failure resulted in Resident 1 abused by Resident 2 with the potential for Resident 1 to develop infection and emotional distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's right to be free from abuse for one resident (Resident 2) of three sampled residents when staff witnessed Resident 1 hit Resident 2. This failure decreased the facility's potential to ensure Resident 2's right to be free from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment was consistent with professional standards of practice, for an existing pressure ulcer (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure or pressure in combination with shear and/or friction) for one of four sampled residents (Resident 1), when Resident 1 did not receive wound care as ordered and the facility did not notify the physician when Resident 1 repeatedly refused wound care. This failure resulted in an infection of Resident 1's pressure ulcers and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to privacy for one of four sampled residents (Resident 1) by allowing an individual to enter their room without permission. This failure had the potential to negatively impact the resident's emotional well-being and sense of security.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's right to privacy for one of four sampled residents (Resident 1) by allowing an individual to enter their room without permission. This deficiency had the potential to negatively impact the resident's emotional well-being and sense of security.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a comfortable environment for three of six sampled residents (Resident 4, Resident 5, and Resident 6) when the heating system in their rooms were not working. This failure caused the residents to be cold and uncomfortable.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was free from accident hazards for a census of 91 when: 1. Bedframe without a mattress was stored in the hallway; 2. Plastic trim edging was not attached to the beds footboard; 3. Portable space heater was used in a resident room; 4. Windowsills were missing and broken; and 5. Ceiling was damanged. There failures increased the risk for injury to residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' respect and quality of care were maintained for one of three sampled residents (Resident 2) when Resident 2 was not able to reach the call light. This failure had the potential to increase Resident 2's fear of not being able to call for help when needing assistance.

Inspectors wroteBased on interview and record review, the facility failed to implement measures to safely transfer one of three sampled residents (Resident 1) when staff did not follow facility Policy and Procedures (P&P) for safe resident handling/transfers and the Physical Therapy (PT) recommendations for the use of a sit to stand lift (a device designed to assist patients who have some mobility but need help to rise from a sitting position) with (2) staff assistance. This failure resulted in a fracture (break) of the bone in the lower leg and increased pain for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan for one of three sampled residents (Resident 1) who was admitted to the facility with a sacral (bony region of the lower spine) pressure ulcer stage 3 (full thickness loss of skin extending to the tissues). This failure had the risk potential for the pressure ulcer to deteriorate due to lack of appropriate interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality when physician ' s laboratory orders were not done in a timely manner for one of 3 sampled residents (Resident 1) when Resident 1 displayed increased signs of confusion. This failure had the risk potential to delay diagnoses of her increased confusion and delay disease management.

Inspectors wroteBased on observation, interview and record review, the facility failed to secure medications were stored locked for a census of 96, when a medication cart and treatment cart in station A were open in the hallway unattended. These failures had the potential for medications misuse and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with adequate supervision when Resident 1 fell out of his bed during care. This failure resulted in Resident 1 sustaining a laceration of the plantar surface (sole of foot) of 2nd toe that required 5 sutures, a laceration of base of 3rd toe that required 3 sutures and a fracture of the right great toe.