Rio Hondo Subacute & Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to implement timely and appropriate scabies outbreak control measures for facility staff after receiving two of two confirmed resident cases of scabies diagnoses that started on 6/5/2026 for 24 of 24 facility staff on 6/05/2026. The facility failed to: 1. Ensure Infection Preventionist Nurse (IPN) 1 create a close contact facility staff list for Resident 1 was diagnosed and confirmed with scabies on 6/5/2026. 2. Ensure IPN 1 inform and assess exposed facility staff from Resident 1 on 6/5/2026 and maintain ongoing and accurate surveillance for staff to identify new or unresolved cases of Scabies. IPN 1 did not start the staff surveillance line list until 7/06/2026. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident's physician order for skin scraping and specimen collection, completed by Physician Assistant (PA) 1, was communicated to the laboratory on 6/25/2026, for one of three sampled residents (Resident 2), who was suspected of scabies and required confirmation of diagnosis, in accordance with the facility's policy and procedure (P&P) titled Lab and Diagnostic Test Result. This deficient practice had the potential to result in delayed or inaccurate diagnosis, inappropriate or unnecessary treatment, and increased risk of transmitting scabies to other residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the timely availability, ordering, and administration of a prescribed medication (Pregabalin 50 mg, three times daily) for one of three sampled residents (Resident 1). The facility failed to obtain required physician signatures, follow pharmacy procedures, coordinate with appropriate prescribers, communicate medication availability issues among licensed nursing staff to administer Pregabalin as ordered. The facility's failures caused staff to fail to administer 20 scheduled doses of the controlled medication Pregabalin to Resident 1, leaving the resident with uncontrolled neuropathic pain for more than seven days and negatively affecting their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents receive adequate supervision and assistance to prevent avoidable accidents when the facility receptionist (unlicensed staff) assisted one of two sampled residents (Resident 6) during a fall on 6/25/2026 at 8:30 PM. Receptionist (REC), an unlicensed staff, assisted Resident 6, who required partial/moderate assistance, off the floor and onto the couch without waiting for a licensed nurse to assess and transfer the resident, in accordance with the facility's policy and procedure (P&P) for Fall Management and the REC's job description. This failure had the potential to result in further injury or avoidable accidents following the fall. On 6/27/2026, Resident 6 complained of severe pain and swelling to the right foot. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with professional standards of practice for one of three sampled residents (Resident 1). Licensed Vocational Nurse (LVN) 2 documented in Resident 1's Medication Administration Record (MAR) that Pregabalin (a controlled medication [a medication carries the risk of abuse, misuse, and physical or psychological dependence] used to treat nerve pain) 50 mg was administered to the resident on 6/9/2026 at 5 PM and 6/10/2026 at 5 PM. However, the medication was not available in the facility at those times or delivered by the pharmacy and was not administered to the resident. On 6/10/2026 at 5:50 PM, the medication was delivered by the pharmacy, approximately 24 hours after LVN 2 documented giving the medication to Resident 1. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure one of three sampled residents (Resident 1), who was totally dependent with care of daily living, abnormal posture with a left knee contracture (a permanent tightening or shortening of muscles, tendons, or skin that causes a joint to become stiff and locks it into a bent position), non-verbal, and had an altered mental status, was free from fall and injury in accordance Resident 1's care plan (CP), titled Resident utilizes LALM for Wound/Skin Management, dated 1/31/2026, and the facility procedure, titled Repositioning, revised 2013 and Fall Management, dated 5/26/2021 by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the continuity of care for one of 2 sampled residents (Resident 1) during their admission to the facility transitioning from a general acute care hospital (GACH) by failing to reconcile Resident 1's admission orders as evidenced to include vancomycin (an antibiotic or medication used to treat infection). This failure led to a break in course of therapy for Resident 1 and a delay of more than 24 hours to administer vancomycin (an antibiotic to treat Clostridioides difficile, also known as C. diff or C. difficile, which is a highly contagious bacterium that infects the large intestine, causing severe inflammation and watery diarrhea) that had a potential to worsen resident's infection and health condition. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one of one sampled resident (Resident 1) who was nonverbal (unable to talk) and unable to report pain was accurately assessed and provided pain management in accordance with the facility's policy and procedure titled Pain Management and resident's care plan by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to order from the pharmacy and administer an antibiotic (medication to treat infection) as ordered by the physician for one (1) of one resident (Resident 1) in a timely manner. As a result of this failure Resident 1 had delayed and missed four (4) doses of vancomycin (an antibiotic that treats certain infections) oral suspension for more than 24 hours that could lead to worsened infection and a decline in resident's health condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement safety protocols, provide adequate supervision, and ensure effective monitoring to prevent the elopement of Resident 1. On 4/23/2026, at approximately 2:31 AM, Resident 1 exited the facility without staff knowledge and supervision. The resident remained missing until approximately 5:30-6 AM (approximately 3.5 hours later), at which time Resident 1 was located at a nearby bus stop, and was taken to the local general acute hospital (GACH). Additionally, the facility failed to complete a Leave of Absence without Notice assessment at the time of R1's admission to the facility, as required by facility policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances verbalized by one of three sample residents (Resident 1) and keep resident appropriately appraised of progress towards resolution. In addition, the facility failed to issue a written grievance decision to the resident, in accordance with the facility's policy on Grievance/Concern. A complaint received on 4/17/2026 indicated Resident 1 had previously reported to the facility regarding resident's missing belongings from his car that included a speaker, stereo, some clothing, wires, and a few miscellaneous items. This deficient practice increased the risk for negative psychosocial impact on Resident 1's quality of life.

Inspectors wroteBased on interview and record reviews, the facility failed to obtain and maintain a complete informed consent for the use of psychotropic medications (medication that affects mood and behavior) for three of three sampled Residents (Resident 1, Resident 2, 13, 16 and Resident 106) prior to administration in accordance with the facility's policies titled Psychotropic Medication Use - Quality of Care and Psychotropic Medication Use, which require obtaining and verifying informed consent prior to the administration of psychotropic medications. The facility failed to ensure: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff demonstrated that the needs of two out of three sampled residents (Residents 76 and 92) were accommodated when: 1. Resident 76's call light pad (a pressure sensitive device that residents use to call for help to the room) was observed not within reach of Resident 76's who is a quadriplegic (paralysis of all four limbs and the torso). 2. Resident 92's call system (a device used by the resident's to call for help by pressing a button) was accessible to the resident at all times by failing to provide a call light pad (a specialized, easy-to-press button designed for resident's with limited hand strength or dexterity) when the resident was unable to use a call light button and the call light was observed to be placed out of reach. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure four of five sampled residents (Resident 13, 14, 21, and 124) Advance Directives Acknowledgement Form (ADA-written statement of resident's medical treatment wishes) was offered or obtained and readily accessible in the resident's medical records. These deficient practices had the potential for residents' medical treatment wishes not be honored during emergencies or when incapacitated (the clinical state in which a patient is unable to participate in a meaningful way in medical decisions) and unable to participate in medical decision-making.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were securely stored, contained inside locked containers properly and disposed appropriately in according with facility's policies and procedures titled Medication Labeling and Storage The facility failed to: 1. Licensed Vocational Nurse (LVN) 6 left one of three sampled residents (Resident 96) medications such as Nitroglycerine (medication used to treat angina or chest pain, Midodrine (medication used to help increase blood pressure) and Depakote (medication used to prevent seizures) were left on top of the medication cart in the hallway unattended. 2. Ensure two of two Medication Carts (MC #1 and #2) were observed with had no pills and capsule on top of the waste container lid attached to the carts. [...]

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 in accordance with the facility's policies and procedures, titled storage of Food and Supplies, Procedures for Refrigerated Storage, and to follow Food Code Cooling Cooked Time/Temperature Control for Safety (TCS- any food that that require time and/or temperature controls to ensure food safety) Foods, to prevent the outbreak of foodborne illness (an infection or irritation of the gastrointestinal tract caused by consuming food or beverages contaminated with bacteria, viruses, parasites, or chemical toxins) for 110 of 149 residents receiving food from the kitchen by failing to ensure: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate communication, verification and documentation of medical records, in accordance with accepted professional standards and practices, for three of six sampled residents (Residents 106, 176, and 168). 1. For Resident 176, LVN 2 failed to ensure accurate communication and verification of a physician order dated 2/5/2026 when LVN 2 documented an order that was not confirmed with the physician. Record review revealed that LVN 2 documented that Resident 176's attending physician (MD 1) had been informed and had provided an order to extend Resident 176's morning medication pass by two hours on 2/5/2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed implement the facility's infection control policy and procedures by failing to: 1a. Ensure the facility's infection control policies binder is readily available to staff as resources to know the list of reportable communicable diseases to the department of health and the state agencies. 1b. Implement the local county's Department of Public Health's recommendation for Influenza (an infection of the nose, throat and lungs) outbreak: 1c. To offer Tamiflu (an antiviral medication used to treat and prevent influenza A and B) to two of two sampled Residents (Resident 128 and 137), who were in close contact with Resident 96 (who tested positive for influenza). 1d. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 170) who was transferred to the GACH on 12/12/2026 was provided written information regarding the facility and state bed-hold policies which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave) as indicated in the facility's policy and procedure. As a result of this deficient practice Resident 170's rights to return to the facility after hospitalization could be violated.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of resident's admission to the facility for one of three (3) sampled residents (Resident 176) reviewed for baseline care plans for Type 2 Diabetes Mellitus (DM-an adult-onset disease in which the blood glucose or sugar levels are too high). This deficient practice had the potential for Resident 176 not to receive the appropriate resident specific interventions, treatments and medications necessary for Resident 176's care.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a resident specific comprehensive, person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for three of four sampled residents (Resident 1, Resident 14, and Resident 44) by failing to: a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to assist three sampled residents (Resident 28, 24 and 73) who needed assistance with grooming such as haircut. These deficient practices had resulted in residents not maintaining good personal hygiene and clean appearance which could negatively affected their self-image and dignity.

Inspectors wroteBased on interviews and record review, the facility failed to provide care and services to ensure the licensed staff reviewed Resident 176's General Acute Hospital (GACH) records for all appropriate discharge orders in accordance with professional standards of practice and the facility's policy and procedure (P&P) titled Reconciliation of Medication on Admission. This failure occurred for one of one sampled resident (Resident 176), who had a diagnosis of Type 2 diabetes mellitus (a disease in which blood sugar levels are too high). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to prevent pressure injury ( a skin injury due to prolonged unrelieved pressure and friction) for one of three sampled residents (Resident 21), who was unable to carry out activities of daily living (ADLs) to maintain ADLs mobility and assisted with transferring from bed to chair for two hours as tolerated with pressure relieving cushion as ordered by the physician. This deficient practice had the potential for Resident 21 to develop pressure injury

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent CAUTIs (catheter-associated urinary tract infections, urinary tract infections caused by the improper use of urinary catheters) as indicated in the facility's policy and procedure and resident's care plan for one out of four sampled residents (Resident 151) with suprapubic catheters (a urinary tube inserted through the lower abdominal wall into the bladder that connects to a bag to collect urine) who was observed on top of resident's bed next to his left leg. This deficient practice placed Resident 151 at an increased risk of developing a urinary tract infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure that post dialysis assessments were conducted and documented in the treatment record, including required vital signs (temperature, pulse, respiration, and blood pressure), for one of two sampled residents (Resident 70). This deficient practice had the potential to delay identification of abnormal vital signs, dialysis access site complications, or adverse treatment reactions-such as untreated hypotension, excessive bleeding, or other serious conditions requiring emergency intervention.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the attending physician visit one of three sampled residents (Resident 21) once every 30 days for the first 90 days after admission. This deficient practice had the potential for poor continuity of care and follow-up on Resident 21's status.

Inspectors wroteBased on observation and interview, the facility did not ensure medications were prepared and administered according to professional standards of practice and in accordance with physician orders, as required under F755 Pharmacy Services. On 2/5/2026, between 8:30 AM and 8:45 AM, during a medication administration observation for Resident 147, LVN 1 prepared 8.5 milliliters (mL) of Levetiracetam oral solution instead of the prescribed 5 mL. The surveyor intervened prior to administration. In addition, LVN 1 did not follow the physician ordered G tube flushing protocol. Required water flushes of 30 mL prior to medication administration and at least 15 mL after each medication were not performed during the administration of Amlodipine, Cholecalciferol, Lisinopril, Multivitamin liquid, and a probiotic capsule. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nursing staff and the attending physician acted upon the Pharmacist Consultant's recommendations identified during the monthly Medication Regimen Review (MRR, a comprehensive evaluation of a resident's medication regiment intended to promote positive outcomes and minimize adverse effects)) for one of two sampled residents (Resident 1). Specifically, the facility did not: Update Resident 1's physician orders to include administration instructions for carvedilol (Coreg) to give with food/meals, as recommended by the pharmacist. Obtain current informed consents for the use of trazodone hydrochloride (HCL) and Ativan, as identified by the pharmacist. These failures had the potential to place Resident 1 at risk for adverse drug effects and violation of resident's rights to be informed of treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 3 sampled residents reviewed with pressure ulcers (Resident 6) and admitted without a pressure ulcer (skin damage due to prolonged unrelieved pressure and skin friction) received treatment and services to protect skin integrity (the state of skin being intact, healthy, and free from damage), promote healing, and prevent the development and worsening of pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor Resident 3's right to exercise choice and autonomy when staff did not provide the resident with a shower on her regularly scheduled shower date (1/13/2026). This failure interfered with Resident 3's ability to participate in decisions about her daily routine and preferences and resulted in the resident expressing feelings of neglect and sadness.

Inspectors wroteBased on interview and record review the facility failed to monitor and establish a system to implement the facility's policy and procedure (P&P) titled Visitation which indicated that visitation may be subject to reasonable clinical and safety restrictions to protect residents, including denying or limiting access to individuals suspected of bringing illegal substances into the facility for one of three sampled residents (Resident 1), who has a history of alcohol and substance abuse (harmful or hazardous use of psychoactive substances [any chemical that changes brain function, affecting mood, perception, consciousness, and behavior]). The facility failed to increase supervision and reassess visitation access for Resident 1's family member (FM 2) or other visitors of Resident 1, despite previous incidents of visitor-introduced contraband on 7/15/2025, 11/27/2025, and 1/4/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve a grievance for one of two sampled residents (Resident 3) reviewed for resident's rights under the grievance process. Furthermore, the facility failed to keep Resident 3 informed of progress toward resolution of the grievance from 12/22/2025 and provide a written resolution within 72 hours, in accordance with the facility's policy and procedure titled Grievance/Concern. This deficient practice violated the resident's right to be informed of the resolution of a grievance filed by the resident and had the potential to negatively impact Resident 3's psychosocial well-being and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify, investigate, report to appropriate agencies, and initiate protective measures for an allegation of abuse for one of two sampled residents (Resident 2) reviewed for abuse, in accordance with the facility's policy and procedure titled Abuse Prohibition Policy and Procedures. On 1/11/2026, Resident 2's family member (FM 4) reported to Licensed Vocational Nurse (LVN 5) that Certified Nursing Assistant (CNA 2) had handled Resident 2 roughly during care and requested that CNA 2 not be reassigned to Resident 2. The facility did not identify the allegation as potential abuse, failed to initiate protective measures, and reassigned CNA 2 to care for Resident 2 the next day, on 1/12/2026, before completing an investigation. These failures placed Resident 2 at risk for further abuse, retaliation, and psychosocial harm. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to report an allegation of abuse within two hours after the allegation was made for two of two sampled residents (Resident 2), as required by the facility's policy and procedure (P&P) titled Abuse Prohibition Policy and Procedures. The allegation should have been reported to the California Department of Public Health (CDPH) and other state agencies (local law enforcement, Ombudsman). On 1/11/2026 at 10:00 AM, Resident 2 and Resident 2's family member (FM 4) reported to Licensed Vocational Nurse (LVN) 5 that Certified Nurse Assistant (CNA) 2 was rough during care and hurt Resident 2. LVN 5 failed to report the allegation of abuse to CDPH and other state agencies as required by the facility's P&P. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment was as free of accident hazards as possible and that residents received adequate supervision and assistance. This failure affected one of 15 residents (Resident 1) reviewed for accidents. Resident 1 was admitted to the facility on [DATE] with a history of alcohol abuse and fentanyl overdose (an excessive amount of a potent drug that could lead to death). The facility did not identify potential hazards, implement interventions to provide supervision and increased monitoring, or establish a system to limit and supervise access to an individual (Family Member [FM] 2) with a history of bringing illegal substances into the facility. These failures placed Resident 1 at risk for accidental illegal substance use and alcohol intoxication while in the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide medically related social services support to one of three sampled residents (Resident 1), a paraplegic resident who requested and had a physician order for an electric wheelchair to maintain or improve resident mobility. The facility's failure to obtain and provide the prescribed electric wheelchair limited Resident 1's freedom of movement, increasing risk of isolation and compromising his right to functional mobility

Inspectors wroteBased on interview and record review, the facility failed to treat one of three sampled residents (Resident 2) with respect and dignity when Certified Nursing Assistant (CNA) 2 and 3 made derogatory (offensive and disrespectful) comments around Resident 2 while CNA's 2 and 3 were assisting Registered Nurse (RN) 1 perform disimpaction (the manual removal of hardened stool from the rectum using a gloved, lubricated finger, usually performed when severe constipation or fecal impaction cannot be relieved by other methods) procedure on Resident 2. This deficient practice resulted in the violation of the resident's rights for Resident 2 who reported feeling uncomfortable, upset and yelling at the staff, which could significantly compromise Resident 2's psychosocial well-being.

Inspectors wroteBased on observations, interview and record review the facility failed to implement the care plan of one of three sampled residents (Resident 3) to ensure placement of bolster pillows (a long firm and raised pillows placed on the edges of the bed) on the mattress while in bed to prevent the resident from recurrent fall. Resident 3 had a history of unwitnessed falls from bed on 8/17/2025 and 9/22/2025. As a result of this deficient practice Resident 3 had the potential for recurrent falls that could result in pain, major injuries and a decline in residents' wellbeing.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure the resident's responsible party (RP) was informed and participated in the plan of care meetings for one of three sampled residents (Resident 1) reviewed for pressure ulcers and developed a Stage 4 pressure ulcer (a skin damage resulting from prolonged unrelieved pressure that is very deep, open sore to the skin tissue down to the muscle, bone, or tendon) in the facility. This deficient practice violated the residents' rights to be an active participant and be fully informed of Resident 1's care.

Inspectors wroteBased on interviews and record reviews, the facility failed to administer nystatin (a skin cream with a specific dose of medicine that was used to treat fungal infections), Zoryve (Roflumllast, a prescription medication, in the form of a cream or foam that treated inflammatory skin conditions reducing inflammation instead of using steroids), and normal saline (NS, a sterile, medical-grade saltwater solution) medications as ordered by the physician for one of three sampled residents reviewed for medication and treatments administration (Resident 2). [...]

Inspectors wroteBased on interview and record review the facility failed to maintain current detailed and consistent medical records readily available for one of three sampled residents reviewed for documentation (Resident 1), who did not have a documented evidence of turning and repositioning every two hours to prevent worsened pressure ulcer ( skin injury resulting from prolonged unrelieved pressure on the skin) in accordance with the physician's order to turn resident on the side every two hours, document and chart in the folder at bedside, every shift for wound healing. This deficient practice had the potential to have a negative impact on the residents' healing process and for Resident 1's wound to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure a pest-free environment for one of two resident rooms (Resident 3's room) sampled for pest infestation. Specifically, the facility failed to prevent and promptly address a fly infestation in Resident 3's room. This failure had the potential to compromise Resident 3's health, safety, and quality of life and posed a risk for infection. During a review of the facility's policy and procedure (P&P) title Pest Control dated May 2008, the P&P indicated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents and garbage and trash are not permitted to accumulate and are removed from the facility daily. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that accurate and current nurse staffing data [total number and actual hours worked by licensed (Registered Nurses [RNs], License Vocational Nurses [LVNs]) and unlicensed nurses (Certified Nursing Assistant [CNAs])] were posted daily at the beginning of each shift (11 PM - 7 AM, 7 AM - 3 PM, and 3 PM - 11 PM). These deficient practices of posting inaccurate and outdated nurse staffing data had the potential to mislead and prevent residents and families from verifying the facility's daily staffing levels. This could result in distrust and a perceived lack of accountability in maintaining accurate and adequate staffing necessary for timely resident care.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to treat residents with dignity and respect for 2 of 3 sampled residents (Resident 3 and Resident 4) reviewed for resident's rights by failing to: 1. Ensure timely staff response after Resident 3 activated the call light. Resident 3, who is cognitively intact but physically dependent on staff for all activities of daily living (ADL), was observed waiting at least 19 minutes for assistance after pressing the call light on 9/16/2025. During this time, facility staff were observed standing at the Nurses' Station while the call light remained illuminated. Resident 3 reported frequent delays in staff response-sometimes waiting up to an hour-and stated that he often had to rely on his roommate to leave the room to seek help. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans, in accordance with the facility's policy and procedure (P&P) titled Care Plan Comprehensive, for 1 of 3 sampled residents (Resident 2) reviewed for comprehensive care plans. The facility failed to: Develop and implement a comprehensive person centered care plan to address Resident 2's inappropriate physical contact with other residents and clearly define the behaviors to be monitored during one-to-one (one-to-one) supervision; 2. Consistently implement the one-to-one supervision as outlined in Resident 2's care plan until it could be modified or discontinued. These deficient practices had the potential to result in Resident 2 not receiving the supervision necessary to ensure his safety and well-being. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that pain management was provided to one of three sampled residents (Resident 1), consistent with professional standards of practice and in accordance with its policy and procedure titled Pain Management. The facility failed to: 1. 1. Ensure Resident 1's pain was accurately assessed for the type, frequency, intensity, and duration of the pain, re-evaluate the effectiveness of the intervention to determine what increase or decrease in the frequency, intensity, duration of pain after the resident's fall on 7/28/2025. 2. 2. Ensure that Resident 1 was accurately assessed and evaluated for continued complaints of right leg pain and refusal to ambulate due to pain during Physical Therapy (exercise to promote, maintain, and restore physical movement and function) from 8/2025 to 9/2025. 3. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 8/19/2025 when food items listed on the resident menu were not available and were replaced by alternative menu without the Registered Dietician's (RD) approval for 21 of 21 residents who did not receive the roasted cauliflower listed in the menu item in the residents meal trays during lunch. This deficient practice had the potential to result in residents dissatisfaction with the meal, not receiving the basic nutritional needs and/or receiving food preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and monitor three of four sampled residents (Resident 84, 27, 26 and 103) with indwelling catheter (foley catheter, a thin, flexible tube that goes into the bladder to drain urine into a collection bag outside of the body) for sediments (free floating solid particles in the urine) in the drainage tubing and drainage bag as indicated in the resident's plan of care, the physician's order and the facility's policy and procedures. In addition, for Resident 26 and Resident 103 with suprapubic catheter drainage bag (a medical device, typically a bag with a tube, that collects urine) the facility failed to ensure the catheter bag was kept below the level of the residents bladder. [...]

Inspectors wroteBased on interviews and record reviews, the licensed nursing staff and physician failed to act upon the Pharmacist's recommendations documented in the Medication Regimen Review (MRR)-a comprehensive evaluation of a resident's medication regimen intended to promote positive outcomes and minimize adverse effects-for four of seven sampled residents (Residents 4, 7, 8, and 100 ) reviewed for MRR. The facility failed to: 1. Follow the pharmacist's recommendation to include the manifested behavior related to the use of Escitalopram (a type of antidepressant medication, used to treat depression and anxiety) for Resident 100. 2. Follow the pharmacist's recommendation to monitor orthostatic hypotension (a sudden drop in blood pressure that occurred when one stood up from lying or sitting, causing symptoms like lightheadedness or dizziness) for Resident 4 in relation to Risperdal use. 3. [...]

Inspectors wroteBased on observation and interview and record review the facility failed to ensure food are stored properly for one of one of the facility's kitchen, in accordance with the facility's policy and procedure titled Food Storage- Cold Foods, by failing to label the ice cream with an open and used by date and storing onions properly to prevent mold growth and fruit flies. This deficient practice had the potential to cause food stored past safe storage time/ period, and place residents who consume this food at risk for foodborne illness (food poisoning or food illness due to pathogens [harmful organisms that cause illness such as bacteria, viruses, or parasites] and toxins that contaminate food).

Inspectors wroteBased on interview and record review the facility failed to ensure the facility obtained an informed consent (a written document signed by the physician or designee that indicated the resident/responsible party was informed about the risk and benefit of the proposed treatment) with the use of psychotropic medications (medications that affects mood and behavior), from two of two sampled residents (Resident 8 and 100) reviewed for the use of psychotropic medications by failing to: 1. Obtain a consent from Resident 8 or the resident's responsible party prior to administration of Mirtazapine (a medication used to treat depression or an antidepressant). 2. Obtain a consent from the Resident 100 or the responsible party prior to administration of Ativan (a medication used to treat anxiety [the fear of the unknown that interfere with one's daily activities}). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's needs were accommodated by the facility staff according to resident's needs and preferences for one out of 9 sampled residents (Resident108) reviewed for accommodation of needs, by failing to ensure Resident 108's call light was in reach while in bed for for call light observation, in accordance with the facility's policies and procedures (P&P) titled Answering the Call Light. This deficient practice had the potential to prevent Resident 108 from receiving personal and medical assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy and procedure (P&P) titled Notification of Change in Condition to notify the physician for one of five sampled residents (Resident 84) with significant change of condition related swelling on bilateral lower extremities (edema) and presence of urine sediment (solid particles like crystals, cells, or debris, which can be caused by dehydration, a urinary tract infection (UTI), kidney stones, or other underlying health conditions). This deficient practice had the potential for Resident 84 not to receive care and services needed for the significant change in condition and for the representative party to be unaware of the significant change of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper documentation, tracking, and safeguarding of residents' personal property for one (1) of two (2) sampled residents (Resident 71 ) reviewed for concerns related to personal property. Specifically, the facility failed to ensure that residents' personal belongings were properly documented and safeguarded in accordance with facility policy and Procedure (P&P) titled Resident's Personal Property. For Resident 71, the facility failed to update the Inventory of Personal Effects form to include personal belongings brought into the facility after admission by failing to ensure that Resident 1's hearing aids (electronic devices designed to amplify sound for individuals with hearing loss) were properly accounted for and replaced in a timely manner. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of seven sampled residents reviewed for unnecessary medications are free from unnecessary use of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) by failing to: 1. Ensure that PRN (as needed) orders for psychotropic medications were limited to a duration of 14 days, for Resident 80 who was receiving psychotropic medications, specifically an active order of Ativan (lorazepam- a medication used to treat anxiety) initiated on 7/27/2025, with no documented stop date or evidence of physician re-evaluation to justify continued use beyond 14 days. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Pre admission Screening and Resident Review II (PASARR 11- a follow up assessment that ensures residents with mental disabilities receive appropriate care) after the PASARR I (initial PASARR assessment) was completed for one (1) out of three (3) sampled residents (Resident 27) reviewed for PASARR completion. This deficient practice had the potential to put Resident 27 at risk of not receiving appropriate mental health care and placement to appropriate facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of two sampled residents (Resident 71 and 84) reviewed for comprehensive, person-centered care planning had their medical, nursing, mental, and psychosocial needs appropriately identified, assessed, and addressed through individualized care plans. 1. For Resident 71, the facility failed to develop and implement a comprehensive care plan to address the resident's hearing impairment. Resident 71 used bilateral hearing aids but was unable to independently insert or manage them and the facility had no interventions to address the need of the resident. As a result of this deficient practice Resident 71 had difficulty communicating with staff his needs that could lead to not receiving the needed care and assistance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed nursing staff followed the facility's own Policy and Procedure (P&P) titled Blood Pressure, Monitoring and the professional standard of practice when measuring blood pressure for one of four sampled residents (Resident 1) observed during medication pass. This failure placed Resident 1 at risk for inaccurate blood pressure readings, which could result in inappropriate medication administration, discomfort, or potential harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision of care and services in accordance with professional standards of practice for one of one sampled resident, reviewed for physical restraints (Resident 80). Resident 80 was found to have a Wanderguard device applied to his wrist without a physician's order, a documented risk assessment, or an individualized care plan to justify its use. The absence of clinical justification and interdisciplinary care planning for the use of a device that may potentially restrict freedom of movement failed to meet professional standards of practice and placed the resident at risk for unnecessary restriction, and psychosocial harm

Inspectors wroteBased on interviews and record reviews, the facility failed to adequately assess one of two sampled residents (Resident 8) reviewed for Restorative Nurse Assistant (RNA - help patients recover after an illness or injury by working to restore their physical abilities and independence) Services, in accordance with the physician's order, by not evaluating and documenting the resident's tolerance and wear time (in hours) during the provision of RNA services. This deficient practice had the potential to negatively impact Resident 8's plan of care, interventions, that included increased risk of injury or fatigue, unnoticed pain or discomfort, and/or incomplete resident's records that could compromise interdisciplinary communication and decision making.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a hazard free environment and implement the facility's policy and procedure titled Falling Star Program Protocol (a measure used by the facility to identify residents at risk for fall with the use of star) and implement documented interventions by placing a floor mat next to the resident's bed for one of two sampled residents (Resident 31) reviewed for accident and supervision due to being identified as high risk and with history of falls. This deficient practice had the potential to cause a repeat fall and safety risks for Resident 31.

Inspectors wroteBased on observation, interview, and record review, the facility to failed to promote resident safety in administering oxygen for two (2) of 2 sampled residents (Resident 103 and 133) reviewed for oxygen therapy, in accordance with the facility's policy and procedure by failing to: Ensure the oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was changed every 7 days per Physician's order for Resident 100. 2. Ensure Resident 103's nebulizer mask was stored in a plastic bag with residents name and dated with open date, in accordance with facility policy titled Administering Medications through a Small Volume(Handheld) Nebulizer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 24) observed during medication pass was administered Carvedilol (medication used to treat high blood pressure) with food, as ordered by the physician. In addition, the facility failed to have systems ensuring records of disposition of drugs in sufficient detail to enable an accurate reconciliation in accordance with the facility's policy and procedure for Medication Destruction. This failure increased the risk of Resident 24 experiencing side effects (undesirable effect of a drug or medical treatment) from Carvedilol, that include sudden drop in blood pressure (orthostatic hypotension) which may lead to dizziness, light-headedness, fatigue (tiredness) and fainting.

Inspectors wroteBased on interview and record review, the facility failed to document complete and accurate information on the informed consent (a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) form about psychotropic medications (medications that affects mood and behavior), in accordance with accepted professional standard of practice for four of four sampled residents (Residents 7, 57, 83, and 100) reviewed for resident's rights by failing to ensure: Resident 100's, informed consent for the use of Escitalopram (medication used to treat depression [feeling of severe sadness and hopelessness and anxiety [the fear of the unknow] was signed by the healthcare practitioner who discussed the risks and benefits of the medication with the resident or responsible party. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's infection control program to prevent, identify, report, investigate an infection outbreak (OB-an unusual increase of disease among a specific population in a geographic area during a specific period) for 9 out of 22 sampled residents (Resident 6, 7, 8, 9, 10, 11, 12, 13, 14) in accordance with the facility's policy and procedures and standard of professional practice. The facility failed to: 1. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one of five sampled residents (Resident 1) reviewed for falls, who was identified at risk for falls, and assessed as dependent for bed mobility with the use of a mechanical lift (a sling placed under or around the resident to lift or transfer a resident using a mechanical equipment), received adequate assistance to prevent accidents while laying on a low air loss mattress (LAL; a special type of mattress) for alternation therapy (also called alternating pressure therapy on a LAL mattress that involves a system that inflate [increase in size when filled with air] and deflate [decrease in size when filled with air] in cycles, redistributing pressure across the patient's body), by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered as prescribed and appropriately monitored for one of six sampled resident's (Resident 2) reviewed for medication administration. During an observation conducted on 6/30/2025 at 11AM, a plastic medication cup containing unadministered medications was found on the resident's bedside table. Review of the Medication Administration Record (MAR) indicated that the medication had been documented as administered at 9:23AM, although it remained untouched over 90min later. This deficient practice had the risk of medication errors, missed doses, and adverse health outcomes.

Inspectors wroteBased on observations, Interviews and record review the facility failed to ensure that trash, debris and clutter did not accumulate for one of six sampled residents' (Resident 5) rooms observed for clean and sanitary environment, in accordance with the facility's policy and procedures (P&P) titled Homelike Environment. This failure had the potential to increase the risk of infection, attract pests such as ants, and cockroaches, and increased Resident 5's fall risk which could compromise the resident's health, safety, and overall quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2) reviewed for the use of a mechanical lift (a device used to assist with transfers and movement of individuals who require support for mobility beyond manual support), implemented interventions, provided adequate supervision and assistance to prevent falls and injury, while transferring from chair to bed to prevent accidents/ hazards by failing to: 1. Ensure Certified Nurse Assistants (CNAs) 2 and 3 provide Resident 1 with a full body, extra-large size sling (a flexible strap or belt used in the form of a loop to support or raise a weight) while using the mechanical lift, in accordance with the resident's Lift Transfer Assessment, during the resident's transfer from chair to bed on 5/16/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement an effective pain management (the process of alleviating pain), in accordance with the physician's order, the resident's goals and comprehensive care plans for pain for one of three sampled residents (Resident 3) reviewed for pain, who has a diagnosis of chronic pain syndrome (persistent pain that lasts weeks to years) by: 1. Failing to ensure licensed nurses follow up with Resident 3's physician to sign a required medication order refill form (a document used to request a new supply of a medication that has previously been prescribed by the physician), after the resident missed the scheduled dose of fentanyl patch (a pain patch that applied on the skin and delivers pain relief through the bloodstream. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of five sampled certified nurse assistants (CNAs 1, 2, 3, 4 and 7) reviewed for skills competencies, were trained and competent in using the mechanical lift device (a piece of equipment designed to safely and easily take the whole weight of an individual with limited mobility from one place to another), in accordance with the facility ' s Policy and Procedure (P&P) titled, Lifting Machine, Using a Mechanical. As a result, Certified Nurse Assistants (CNAs) 2 and 3 did not provide Resident 1 with the correct sling (a flexible strap or belt used in the form of a loop to support or raise a weight), in accordance with Resident 1 ' s assessment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for two of two sampled residents (Resident 1 and 2), who required the use of a mechanical lift (device used to assist with transfers and movement of individuals who require support for mobility beyond manual support) for transfers. Resident 1 had experienced a fall from the mechanical lift on 5/16/2025 when Certified Nurse Assistants (CNAs) 2 and 3 did not provide Resident 1 with the correct sling (a flexible strap or belt used in the form of a loop to support or raise a weight), in accordance with Resident 1 ' s assessment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Potassium Chloride (KCL-a mineral supplement to replenish the loss of potassium in the body to maintain normal body function) was administered for one of two sampled residents reviewed for medication administration (Resident 5) as ordered by the physician and in accordance with the facility ' s policy and procedure titled, Administering Medications. The facility documented KCL was administered on 6/5/25 to 6/9/25 but there were three KCL packets remaining in Resident 5 ' s supply that were not administered. These deficient practices had potential for Resident 5 to be at risk for medication error or hypokalemia (low KCL level in the blood) that can lead to cramping, irregular heartbeat and cardiac arrest (heart ceases in functioning).

Inspectors wroteBased on observation, interview and record review the facility failed to safely store and discard drugs and biologicals in accordance with the professional standard of practice for one of eight sampled residents reviewed for medication storage (Resident 4) who expired on [DATE]. Resident 4 who was no longer at the facility but medications were still stored in the Medication Room in a locked box with code that the facility could not unlock and the facility had no record of the drug contents in the box. This deficient practice had potential to lead to drug diversion and/or misuse of Resident 4's medications.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete Inventory of Personal Effects (form used that list the personal belongings that was [NAME] in by the residents in the facility), upon admission and discharge from the facility, of one of three sampled resident's (Resident 1) by failing to ensure Resident 1 have signed the Inventory of Personal Effects. This deficient practice had resulted to inaccurate inventory of Resident 1's belongings and placed the resident potential for theft and loss of property.

Inspectors wroteBased on observation and interview, the facility staff failed to provide a safe and comfortable environment for residents, when one of three sampled residents' (Resident 1) abandoned car was left unattended for an extended period (approximately two years) in a state of disrepair and neglect at the facility parking lot. As a result, Resident 1's abandoned car caught on fire on 5/13/2025 at 4 pm. The facility staff and the Fire Department responded immediately to extinguish the fire. This deficient practice placed 159 residents, facility staff and visitors at risk for injury from burns due to a fire hazard (anything, including actions, materials, or conditions, that can start or contribute to the spread of a fire).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, revise and implement an individualized comprehensive care plan that included measurable and timetables to meet the resident's medical, physical, mental, and psychosocial needs, with an ongoing resident assessments and revisions as information about the resident and the resident's condition changed in accordance with the facility's policy and procedures for: 1a. Resident 3 with chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing)/oxygen (O2) therapy. 1b. Resident 3 with reddish/purplish discoloration/hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) to her right trunk area upon readmission to the facility from the General Acute Care Hospital (GACH) on 4/12/2025. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for prevention and management of skin breakdown in accordance with the resident's care plan, standard of practice, care plan and facility's policy for two of two sampled residents (Resident 1 and 3) who were at risk for skin breakdown by failing to ensure: 1a. Resident 1 was checked for incontinence (involuntary loss control of urination or bowel movement) and changed as needed due to moisture associated skin damage (MASD- caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus) upon re-admission to the facility. 1b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility ' s infection prevention and control program (IPCP) to prevent the development and transmission of communicable disease and infections for one of two sampled residents (Resident 4) who has diagnosis of Extended Spectrum Beta Lactamase (ESBL - an enzyme produced by bacteria that are resistant to a wide range of antibiotics making the bacteria more difficult to treat and transmitted through direct contact with infected individuals or by touching contaminated surfaces) resistance in the urine by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse, for one of three sampled residents (Resident 2) who reported being punched on the leg by an unnamed nurse on 4/5/25, to the California Department of Public Health (CDPH), Ombudsman (a person who investigates, reports on, and helps settle complaints) and local law enforcement immediately or within two (2) hours in accordance to the facility ' s Policy and Procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. This deficient practice had the potential for facility staff to under report allegations of abuse placing Resident 2 at risk for further abuse and resulted in a delay in the investigation for Resident 2 ' s abuse allegation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent accident and hazard as indicated in the facility's policy and care plan by ensuring the wheelchair was properly locked to prevent accidental fall and ensure the resident was assessed for pain and injury after a fall of one of three sampled residents (Resident 3). As a result of this deficient practice Resident 3 had a fall without major injury but the deficient practice had the potential to result in the resident to have major injury or delayed and/or no care and treatment after the fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services in accordance with the facility's policy and procedures and standards of practice for one of three sampled residents (Resident 3) with COPD (Chronic Obstructive Pulmonary Disease- a progressive lung disease that causes shortness of breath and difficulty breathing), congestive heart failure (CHF, a heart disorder which caused the heart to not pump the blood efficiently causing shortness of breath) by failing to: 1. Indicate the justification for the use of Resident 3's oxygen therapy. 2. Ensure physician's order for prn (as needed) oxygen therapy outlines oxygen parameters to determine the appropriate level of supplemental oxygen to be delivered to Resident 3. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, treat, and evaluate pain for one of two sampled residents (Resident 4), who showed signs of pain and verbalized severe pain to the left leg on 4/21/2025 at 9:22 PM and up to 2:10 PM the next day on 4/22/2025 (16 hours), in accordance with the facility ' s policy and procedure (P&P) titled Pain Management. As a result, Resident 4 verbalized hopelessness for experiencing horrific pain and sleeplessness on 4/21/2025 until the next day on 4/22/2025. This has the potential to result in Resident 4 ' s unmet needs and affect the resident ' s cognitive processes and significantly affect quality of life.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure adequate supervision is provided and residents are free of accident hazards to prevent injuries for 5 of 13 sampled residents (Residents 7, 8, 9, 10 and 11) in accordance with the facility's policy and resident's care plan for smoking by failing to: 1. Prevent a smoking-related incident in which Resident 7's linens were burned inside the resident's room while three roommates were in the room. 2. Provide supervision and monitoring to Residents 3, 4, 5 and 6 for safely smoking by conducting an Interdisciplinary Team (IDT- a group of facility staff that plan the care for the residents) to discuss about risk and benefit of smoking safely prior to allowing the residents keep in their possession and/or access to smoking materials. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who displayed psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem and provided behavioral health services for one of two sampled residents (Resident 1), whose primary diagnosis was alcoholic cirrhosis (a serious liver condition caused by heavy alcohol consumption, where healthy liver tissue is replaced by scar tissue) and had a behavior of going out of the facility to the liquor store. 1. Social Services Director (SSD) 1 failed to refer Resident 1 to a psychiatrist and/or psychologist for appropriate counseling and behavioral services for alcoholism, in accordance with Resident 1 ' s written Behavioral Contract. 2. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that one of two sampled residents (Resident 1), who had a diagnosis of Diabetes Mellitus ([DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin [a hormone that regulates blood sugar levels in the body]) and history of hypoglycemia (a condition were blood sugar levels drop below normal), received treatment and services, in accordance with professional standards of practice, the care plan, and physician orders for the management of DM and hypoglycemia. The facility failed to: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of two sampled residents (Resident 3 and Resident 5) were free from physical abuse from Resident 4 by failing to: 1. Protect Resident 3, who required moderate assistance with activities of daily living (ADLs), from Resident 4. On 3/22/25, Resident 4 threw water at Resident 3 and hit Resident 3's left elbow with a metal bar which was removed from the arm rest of Resident 4 ' s wheelchair. Resident 3 experienced bruising and redness on their elbow, and stated that they felt anxious, angry, and upset after being hit by Resident 4. 2. Protect Resident 5, who was legally blind, from Resident 4, after facility staff moved Resident 4 to Resident 5 ' s room following the physical altercation between Residents 3 and 4 on 3/22/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly investigate, take appropriate corrective action/steps, by not obtaining statements from residents involved in a physical altercation, and maintain documentation of the facility's thorough investigation to prevent further abuse, for one of two sampled residents (Resident 3) in accordance with the facility's Policy and Procedure (P&P) on Abuse Prohibition Policy and Procedure. This deficient practice resulted in an incomplete investigation of physical abuse and had the potential to place other residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 7's gastrostomy feeding tube (GT - a tube that is passed through the abdominal wall to the stomach used to provide nutrition) removal was implemented as ordered by the physician on 2/8/2025, for one of three sampled residents (Resident 7) by failing to: 1. Timely follow up following a recommendation from Physician Assistant (PA) 1 when PA1 could not remove R7's GT. PA1 referred Resident 7 to a gastrointestinal (GI) specialist (doctor who specializing in stomach issues) on 2/10/2025. Facility staff failed to refer Resident 7 to a GT specialist until 3/14/2025 (32 days after PA 1's recommendation). Resident 7's GT specialist appointment was scheduled for 4/25/2025, over two months after PA1 made the original referral. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 6) who was receiving hemodialysis (HD - process of removing waste products and excess fluid from the body) treatments received care in accordance with professional standards of practice and in accordance with the facility's Policy & Procedure (P&P) on Dialysis Care, by failing to: 1. Ensure that facility staff completed Resident 6 Post Hemodialysis Treatment status, in accordance with the facility's P&P on Dialysis Care. 2. Ensure to assist Resident 6 ready for scheduled HD, three days a week, with a scheduled transportation and pick up time of 12:30 PM at the facility, every Mondays, Wednesday and Fridays. This deficient practice resulted in frequent delays in the resident's dialysis treatment sessions and had the potential to result in serious health complications.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate documentation in accordance with accepted professional standards and practices for one of three sampled residents (Resident 6) by ensuring Residents 8's weight was accurately recorded in the resident's records on 2/8/2025 and 3/6/2025. Resident 6's weight on 2/8/2025 was recorded as 169.4 lbs. (unit of measurement) on the Hemodialysis Communication Record - Post (after) Dialysis Treatment but the Weight Vitals Summary Record indicated on 3/6/2025 Resident 6's weight was 116.4 lbs. which was a 53 lbs. difference. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement an ongoing infection prevention and control program (IPCP) to prevent, control the onset and spread of scabies for two of five sampled residents (Resident 1 and Resident 2) in accordance with the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program by failing to: 1. Implement Resident 1's dermatology orders to apply medication, Permethrin (medication to treat scabies) 5% topical cream, after Resident 1 was diagnosed of scabies (itchy skin rash caused by a tiny burrowing mite called Sarcoptes scabiei) on 3/6/25. 2. Place Resident 2, (Resident 1's roommate) under contact isolation (prevent transmission of infectious agents) for seven (7) days, as indicated in the physician orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 4 of 9 residents reviewed with pressure ulcer (Resident 186, 9, 121 and 55) received treatment and services to protect skin integrity (the state of skin being intact, healthy, and free from damage), promote healing, and prevent the development and worsening of pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to ensure: 1. Resident 186, who did not have a pressure ulcer on admission to the facility, developed a Stage 2 (partial-thickness of skin, presenting as a shallow open sore or wound) coccyx (tailbone) pressure ulcer that worsened to a Stage 3 pressure ulcer (full-thickness loss of skin, dead and black tissue may be visible). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a hazard free environment and adequate supervision (an intervention and means of mitigating the risk for accidents) for three of five sampled (Residents 29, 128 and 491) who were assessed at high risk for falls in accordance with the facility's policy titled, Fall Management, effective 5/26/2021 by failing to: 1. Evaluate and analyze hazard and risk factors to reduce recurrent falls for Resident 29 who had multiple incidents of falls on 10/9/2024, 10/21/2024, 11/6/2024, 11/25/2024 and 11/26/2024. 2. Identify environmental hazard and risk of an accident for Resident 128 who slipped onto the floor due from Nystatin powder (medication to treat fungal or yeast infections of the skin) that was left on the ground. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent new and recurrent urinary tract infection (UTI an infection in any part of the urinary system, the kidneys, bladder, or urethra)) infection, blockage (an obstruction or flow which makes movement or flow difficult or impossible) or bleeding for five of five sampled residents Resident 180,10, 57, 14 and 25) by failing to: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs of the residents by failing to ensure the resident ' s call light (a device used by residents to signal his or her needs for assistance) is accessible to the residents at all times, in accordance with their resident assessments on functional abilities and the facility ' s policy and procedure (P&P) on Answering the Call Light, for three of four sampled residents (Resident 56, 15, and 73). These deficient practices resulted in Residents 56, 15 and 73 not able to use their call light devices to call the facility staff to ask for help or assistance for basic needs of activities of daily living (ADLs). These deficient practices also had the potential for other residents to have delay in care and services, avoidable falls, and accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform one of one sample resident (Resident 44), including 11 of 12 residents alert and oriented residents who were present during a group interview, of their rights and responsibilities. This failure had the potential for the residents to feel uninformed and unable to fully exercise their rights while residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the most recent State and Federal survey inspection results were posted in a manner that was clear and visible for residents that included 11 of 12 residents who attended a group meeting, and their families. This failure had the potential to prevent the residents and their families from viewing the survey inspection results without having to ask the facility ' s receptionist.

Inspectors wroteBased on interview and record review, the facility failed to inform, explain and follow up with the residents' representatives (RP) and offer to assist the residents and their RPs with formulating an Advance Directive (AD- legal documents that express a person's wishes regarding their medical care in the event they become unable to make decisions for themselves due to illness, injury, or incapacity ) upon admission for three of three sampled residents (Resident 63, 180, and 391). As a result of this deficient practice Resident 63, 180 and Resident 391 was not able to exercise their resident's rights to express their wishes to meet the care and medical treatment decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three of four sampled residents (Resident 43, Resident 128, and Resident 54) in accordance with the facility's policy and procedure on Care Plan Comprehensive by failing to: 1. Develop a care plan for Resident 43's psychotropic medications, Lithium and Risperidone (medications that affects mood and behavior) since 11/27/2024. This failure had the potential for Resident 43 not to receive monitoring and interventions related to the adverse (undesired) side effects of psychotropic medications. 2. Develop a care plan for Resident 128 after a fall, resulting in a left shoulder fracture (break in bone) on 12/23/2024. This failure had the potential for Resident 128 to experience another fall which could lead to further physical injury. 3. [...]

Inspectors wrote2. During a review of Resident 186 ' s admission Record, the facility admitted Resident 186 on 1/31/2025 with diagnoses that included acute respiratory failure (ARF, when the lungs have trouble getting enough oxygen [odorless gas needed for plant and animal life] into the blood) with hypoxia, muscle weakness, and peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 186 ' s H&P, dated 1/31/2025, Resident 186 had the capacity to understand and make decisions. The H&P indicated Resident 186 had no skin breakdown and skin was intact. [...]

Inspectors wroteBased on interview, and record review, the facility failed complete a performance review of every nurse aide at least once every 12 months and must provide regular in-service education based on the outcome of the areas concern at the facility by failing to: 1. Complete a performance/competency review for two sampled Certified Nurse Assistants (CNAs) and one Licensed Vocational Nurse (LVN). The CNAs and LVN did not have a completed Annual Core Clinical Competencies (ACCC, an assessment and training on the nursing staffs the ability to perform clinical nursing care). 2. Develop a system to keep track of the facility ' s ACCC to make sure all CNAs and LVNs to be evaluated annually. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent or (5%) or less during medication pass for two of four observed residents (Residents 111 and 113) in which eight (8) medication errors were identified out of 29 opportunities which yielded a cumulative error rate of 27.59 %. The facility failed to ensure: 1. The Licensed Vocational Nurse (LVN) 3 did not mix Keppra (medication given to treat seizures-[sudden, uncontrolled electrical discharges in the brain that can cause changes in behavior, movement, sensation, or consciousness]), multivitamins and Phenytoin (medication given to prevent seizures) in a 5 oz cup before administering via gastrostomy tube (GT- a tube inserted into the stomach through a surgical incision use for feeding and administration of medication for a resident unable to swallow) to Resident 133. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two out of four residents (Resident 111 and 113) were free from significant medication errors as indicated in the physician's order, pharmacy recommendation and facility's policy and procedures by failing to ensure: 1. The Licensed Vocational Nurse (LVN) 3 did not mixed Keppra (medication given to treat seizures-[sudden, uncontrolled electrical discharges in the brain that can cause changes in behavior, movement, sensation, or consciousness]), multivitamins and Phenytoin (medication given to prevent seizures) in a 5 oz cup before administering via gastrostomy tube (GT- a tube inserted into the stomach through a surgical incision use for feeding and administration of medication for a resident unable to swallow) to Resident 133. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 2/25/2025 when food items listed on the resident menu were not available and were replaced by alternative menu without the Registered Dietician (RD) approval. This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake, weight loss in 14 residents out of 142 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow proper sanitation and safe food handling by failing to: 1. Ensure pre-made cheese sandwiches found in the facility ' s walk-in refrigerator were dated and labeled with the prepared and used by dates, as indicated in the facility ' s policy and procedure (P&P) titled, Food Storage: Cold Foods. 2. Ensure the ice scoop used for scooping ice found in the ice machine was stored in a separate container when not in use, to limit exposure to dust and moisture retention, as indicated in the facility ' s P&P titled, Ice. 3. Staff wear gloves when preparing resident apple sauce cups. These deficient practices had the potential for cross contamination and put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteDuring observation, interview, and record review, the facility failed to implement infection control practices as indicated in the facility ' s policy and procedure titled Infection Prevention and Control Program for four of nine residents (Residents 14, 166, 54 and 63) by failing to: 1. For Residents 14 and 166, the Treatment Nurse (TXN) 4 and TXN 5 provided wound care treatments to the residents with pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) without performing hand hygiene. 2. For Resident 54, and 63 who had a physician order for oxygen use by failing to ensure the nasal cannula (NC- a tube with small opening used to deliver oxygen to the nares) was labeled of when the NC was first used and when to be changed or discarded was on the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 138, 110, and 166) bedframes and mattresses gaps were compatible and identified areas for possible bed entrapment (when a resident becomes trapped in a hospital bed, usually in the space between the mattress and the bedrail [the metal or plastic bars along the side of the bed]). This failure had the potential to result in Residents 138, 110, and 166 becoming entrapped between the bedframe and the mattresses gaps and may result in serious injuries such as cuts, bruises, pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) or even death. Findings. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain three of four residents sampled (Resident 126, 159 and 171) call light (device used by the resident to communicate needs) in functional and operating condition. This deficient practice had the potential for unmet resident ' s needs and calls for assistance that, may cause negative outcomes such as accidents/injury and/or anxiety (fear of the unknow) and depression (a severe feeling of hopelessness and sadness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 392), was provided privacy and treated with dignity when being changed on 2/25/2025 at 11:13 AM. This failure resulted in the violation of residents right for privacy and dignity that resulted in the resident feeling upset and a potential to result in Resident 392's emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician for two of two sampled residents (Resident 14 and Resident 25) of sediment (accumulation of particles or debris that settle at the bottom of the urine bag) of the indwelling catheter (flexible tube that collects urine) bag between 2/25/25-2/28/25. This failure resulted in the delay of Resident 14 and Resident 25's Change of Condition (CoC), which had the potential to result in the delay in treatment for urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, bladder, or urethra) and reoccurrence of UTIs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy during incontinent (no control bladder and bowel) care for one of one sampled resident (Resident 19). Certified Nursing Assistant (CNA) 18 did not close the privacy curtain while performing perineal care (cleaning the private areas of the body, including the genitals and the area around the buttocks) for Resident 19. This failure violated Resident 19's right to personal privacy and dignity, exposed Resident 19's private area to Resident 19's roommate (Resident 10) and caused both Residents 10 and 19 felt uncomfortable.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility ' s policy and procedure titled, Grievance/Concern, dated 8/25/2021, to ensure prompt receipt and resolution of Resident/Representative grievance/concern by failing to: 1. Ensure that information on how to file a grievance or complaint was made available to the resident in accordance with the facility's policy and procedure (P&P) titled Grievance/Concern by posting the information on each unit's prominent locations. 2. Provide prompt efforts to resolve the grievances and provide a written copy of the grievance resolutions (10/3/2024, 10/11/2024, 10/16/2024, 10/21/2024 and 10/22/2024) for one of five sampled residents (Resident 44) reviewed for grievances during the Resident Council Meeting. [...]

Inspectors wrotehe facility failed to complete a significant change Minimum Data Set ([MDS] a resident assessment tool) assessment after Resident 128's fall on 12/23/2024 which resulted in a left shoulder fracture (break in bone). This failure resulted in the facility's failure to develop and implement interventions to Resident 128's care plan to prevent another fall. Cross reference F656 and F689.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan for one of one sampled resident (Resident 491) who was identified as at risk for fall since admitted to the facility on [DATE]. This failure resulted in Resident 491 sustaining three recurrent falls from his bed within two weeks and has the potential to place Resident 491 for recurrent falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 130) with care and services to residents unable to carry out Activities of Daily Living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) independently in accordance with the care plan. This deficient practice resulted to Resident 130 verbalizing feelings of helplessness and had the potential to result in skin redness and irritation to Resident 130 ' s skin due to the facility ' s inability to attend timely to the resident ' s perineal care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to store prescription medications in a safe place for one of 8 sampled residents (Resident 391), who was found with prescription medications on top of the bedside drawer on 2/25/2025 in accordance with the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated 2008, This failure had a potential to result in accidental consumptions and result in adverse reactions (undesired effects) from medication and harms for any residents and visitors who walked into Resident 391 ' s room and take the prescription medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure no delay in informing the physician about critical lab results for one of three sampled residents (Resident 180), who had critical lab values of white blood cell (WBC, a type of blood cell that helps fight infection and disease) count and low blood glucose (BG, the main sugar found in the blood), which were reported on 2/23/2025 at 11:48 PM as evidenced by the critical lab results were not followed up with Resident 180 ' s covering physician [Nurse Practitioner (NP) 1] until 2/24/2025 at 2:36 PM (approximately 14.5 hours when the critical lab results were reported). This deficient practice had a potential to result in a delay in care, interventions and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop specific policies regarding freezer storage and implement the facility ' s current policy of storing foods brought in by residents and family members, that included one of two sampled residents (Resident 96) who use the residents ' refrigerator for food storage. This deficient practice had the potential to promote miscommunication among facility staff, residents, and families about frozen food storage and prevent frozen food from safe and sanitary storage, handling, and consumption.

Inspectors wrote2. During a review of Resident 180's admission Record (AR), the AR indicated the facility admitted Resident 180 on 1/29/2025 with diagnoses that included pneumonia (a severe an infection of the lungs that may be caused by bacteria, viruses, or fungi), sepsis (a life threatening infection in the blood which could lead to decreased in blood pressure (BP), increased heart rate (HR), shortness of breath and altered level of consciousness, that can damage the body organs). During a review of Resident 180 ' s Minimal Data Set (MDS-a federally mandated resident assessment), dated 2/4/2025, indicated Resident 180 ' s cognition (ability to think, remember, and reason with no difficulty) was intact and needed partial assistance (helper does less than half the effort) in eating and personal hygiene. [...]

Inspectors wroteBased on interview and record review, the facility ' s Quality Assessment and Assurance (QAA) committee failed to develop a Quality Assurance Performance Improvement (QAPI-a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve quality in nursing homes) to maintain an effective system to identify, monitor and evaluate implement the facility ' s plan to address care areas of concern that were substantiated during the previous year recertification survey, complaint and facility reported incident (FRI) during the period from 3/2024 to 3/2025 in accordance with the professional standards of practice, physician's orders and facility ' s policy and procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care, treatment and interventions to prevent the development and worsening of pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure) and moisture associated skin damage (MASD- skin irritation and damage caused by prolonged exposure to moisture like urine, sweat, stool, wound fluid) to one (1) of two (2) sampled residents (Resident 1), who was admitted to the facility on [DATE] without pressure ulcer and MASD. The facility failed to: 1. Provide Pressure Ulcer Prevention Measures, in accordance with Resident 1's initial admission assessments on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and the facility's policy and procedure (P&P) on Documentation of Medication Administration for one (1) of two (2) sampled residents (Resident 2) by failing to document the reason for the refusal of four (4) medications and two (2) nutritional supplements on 1/3/2025 and 1/14/2025 for the 5 PM dose. This deficient practice placed Resident 2 at risk for not receiving the necessary care and services and develop a comprehensive plan of care due to licensed nurses not accurately documenting the reasons for resident's refusals of medications and nutritional supplements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's an infection control program and the Department of Public Health recommendation ensure a safe, sanitary, and comfortable environment and to help prevent transmission of disease for 3 of 21 sampled residents (Resident 1, 3 and 7) by failing to: 1. [...]

Inspectors wroteBased on interview and record review the facility failed to assess, monitor, evaluate the wound and notify the physician and wound consultant physician's assistant (WCPA) of a significant change in condition for one (1) of four (4) sampled residents (Resident 1) by failing to: 1. Notify Resident 1's physician (Physician 1) when Resident 1's posterior neck incision (surgical cut made in the skin) was noted to have dehisced (something that had split open or come apart along a seam or line) and the wound size increased from 0.5 cm by 0.5 cm (unit of measurement) on 12/19/2024 to 4 cm by 4 cm on 12/21/2024, in accordance with the resident's care plan titled Posterior Neck Incision Dehiscence Care Plan. 2. Notify Resident 1's WCPA and obtain new orders when Resident 1's posterior neck incision was noted to have dehisced on 12/21/2024. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain and implement an ongoing and effective infection prevention and control program (IPCP) during an influenza outbreak (when there are [NAME] disease cases of influenza than what is usually expected), for 13 of 164 sampled residents and one facility staff, from 12/19/2024 to 12/30/2024 (10 days) by failing to: 1. Ensure signage of outbreak notification at the entrance to inform visitors and family members of the influenza outbreak and masking requirements was posted. 2. Ensure compliance with mask-wearing for residents who tested positive for influenza (Residents 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13) or those at risk of exposure (Residents 1, 2, and 3), in accordance with professional standard of practice for respiratory virus in nursing homes. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve a grievance for one of two sampled residents (Resident 1) and keep Resident 1 apprised of progress towards resolution and a written resolution within 72 hours in accordance with the facility's policy on Grievance/Concern. This deficient practice violated the resident's rights to be updated of the resolution of his/her grievance that was filed by the resident and may have a negative psychosocial impact on Resident 1's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide needed care and services to perform wound treatment and administer Mupirocin External Ointment 2 % [antibiotic ointment] every day and evening shifts, for one of three sampled residents (Resident 1), in accordance with the physician's order for wound treatment, wound care plan, and the facility's policy & procedure [P&P] on Administering Medications. This deficit practice had a potential to result in Resident 1's worsening of the cellulitis (a skin infection that causes swelling and redness) in the left lower extremity.

Inspectors wroteBased on observations, interview and record review, the facility failed to develop resident centered care plans (means to focus on the resident and support the resident in making their own choices and having control over their daily lives) that includes measurable objectives and timeframes to meet the needs and preferences for three of three sampled residents (Residents 2, 5 and 6) by failing to: 1. Ensure the facility developed a care plan for Resident 2, who had requested facility staff and preferred a different time scheduled for morning blood sugar checks (measures the amount of sugar in blood). 2. Ensure the facility developed a care plan for Resident 6's activities of daily living that indicated the resident's need for two facility staff assistance during bed mobility. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account, provide and obtain pharmaceutical services, including the provision of routine medications, for three of three sampled residents (Resident 1, 5 and 2) by failing to: 1. Reorder simvastatin (a medication used to treat high cholesterol) on a consistent basis by ordering 56 tablets to cover an 81-day period between 8/6/24 to 10/29/24 totaling 25 missed doses for Resident 1. The facility was not able to account for the discrepancy of the medications [simvastatin] not delivered by the pharmacy, contrary to the licensed nurses' documentation of administration in the MAR. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a clear indication for the simultaneous use of levothyroxine (a medication used to treat low thyroid levels) and methimazole (a medication used to treat high thyroid levels) in one of eight sampled residents (Resident 1). The deficient practice of failing to document an adequate indication for the simultaneous use of two medications [levothyroxine and methimazole] whose actions oppose each other, increased the risk that Resident 1 would experience adverse effects related to the use of unnecessary medications or an unmanaged thyroid (a hormone that regulates metabolism and other bodily functions) condition possibly leading to a decline in quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility ' s policy and procedure (P&P) titled, Abuse Prohibition, for one of six sampled residents (Resident 1) and failed to followed its P&P titled, Background Screening Investigations, for four of four sampled employee (Certified Nurse Assistants [CNAs] 1, 2, 3 and 4) by failing to: 1. Prevent Resident 1 from verbal and mental abuse by Certified Nursing Assistant (CNA) 1, when CNA 1 raised his voice over Resident 1. CNA 1 also used obscene [something that is morally offensive in a sexual way] language while talking to Resident 1 and threatened to record and report Resident 1 on [DATE]. 2. Conduct employment background screening checks and license/certifications from the State Registry on all applicants for positions with required direct access to the residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing staff to provide routine Activities of Daily Living [ADL] to meet the residents needs for five of seven sampled residents (Resident 9, 10, 11, 12, 13) assigned to a certified nurse assistant [CNA 2] on 10/18/2024 from the 11 PM to 7 AM shift. On 10/18/2024, CNA 2, who was on suspension, was assigned to care for residents [Residents 9, 10, 11, 12, 13] during the 11 PM to 7 AM shift. There was no evidence of another CNA assigned to care for Residents 9, 10, 11, 12, and 13 the night of 10/18/2024. This deficient practice resulted to Residents 9, 10, 11, 12, 13 potentially not receiving routine ADL care and services during the night shift on 10/18/2024 and had the potential to result in unmet resident ' s needs, which can result to a decline in physical and emotional well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances verbalized by one of two sampled residents (Resident 7) to appropriately apprised (inform) of progress regarding Resident 7 ' s missing food items on 10/14/2024. In addition, the facility failed to inform Resident 7 verbally and in writing of the findings of the investigation and the actions taken by the facility to correct any identified problems from the grievance, in accordance with the facility ' s policy & procedures [P&P] titled Grievance/Complaints, Filing. This deficient practice violated Resident 7 ' s rights to voice grievances and ensure facility process the grievance and made prompt efforts to resolve the grievance according to established facility P&P. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement pre-employment procedures and ensure not to employ individuals who have been found guilty by a court of law with convictions that included theft [robbery], for one of four sampled employees (Certified Nursing Assistants [CNA]) in accordance with the facility ' s policy and procedures titled Background Screening Investigations. CNA 1 was identified with a background history of a convicted felon [a person who was guilty of a serious crime] on 4/30/2002 and was hired and employed at the facility from 1/25/2024 to 10/22/2024. This deficient practice increased the risk of applicants and employees with possible criminal convictions had direct access to all residents in the facility and the potential for occurrences of misappropriation of property for the residents by CNA 1. Cross referenced to F607.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 of three sampled residents (Residents 3, 4, and 5) were free from neglect (the failure of the facility, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) and mistreatment (inappropriate treatment or exploitation of a resident) by facility staff failing to assist Residents 3, 4 and 5 with activities of daily living (ADLs, routine tasks, activities such as bathing, dressing, and toileting a person performs daily to care for themselves) and not respond to their call lights (also known as a call bell or nurse call button; a device typically found near a patient's bed or within reach. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management (the process of alleviating pain) for one of two sampled residents (Resident 2), by failing to: 1. Notify Resident 2 ' s physician when Resident 2 repeatedly complained of neck and head pain with a pain level above a 4 out of 10 (mild pain) and obtain alternate pain medication to manage and relieve the resident ' s excruciating (intense or agonizing) and uncontrolled pain. 2. Implement the facility ' s policy & procedure (P&P) titled Pain Management by not alleviating Resident 2 ' s pain to a level that is acceptable to the resident while minimizing negative effects on the resident to the extent possible. As a result, Resident 2 experienced excruciating and unrelieved pain resulting in the resident being transferred to the General Acute Hospital (GACH). [...]

Inspectors wroteBased on interview and record review the facility failed to administer medications as ordered by the physician for one (1) of three (3) sampled residents (Resident 6), by failing to: 1. Notify the physician when Resident 6's Carbamazepine (Tegretol, used to treat certain types of seizures), Levetiracetam (a drug used to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain] medicine), Clopidogrel Bisulfate (Plavix, used to treat blood clots, a mass of blood that stick together) and Atorvastatin Calcium (drug used to lower the amount of cholesterol in the blood) were unavailable and unable to administer the resident's medications as ordered on 10/4/24 and 10/5/24. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure [P&P] titled Change in Condition: Notification of and Care Planning-Interdisciplinary Team for one of three sampled residents (Resident 1) by failing to: 1. Notify Resident 1 ' s primary physician [Physician 1] of the resident ' s ongoing rashes and unrelieved itchiness, and coordinate with Physician 1 that the treatment ordered by the Dermatologist (a physician who specializes in wounds and skin diseases) was ineffective and had not resolved Resident 1 ' s ongoing rashes and itchiness from March 2024 to October 2024 [6 months]. 2. Ensure Resident 1 ' s family and representatives participated in the development and revisions of the resident ' s comprehensive care plan with regards to ongoing rashes and unrelieved itchiness from March 2024 to October 2024 [6 months]. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure, Resident 1 was provided with comfortable and homelike environment, in accordance with the facility's policy and procedure [P&P] titled Homelike environment by failing to ensure Resident 1 had extra linens/blankets and pillows after the facility performed deep cleaning of Resident 1's bedroom on 10/03/2024. This deficient practice led to Resident 1 who was bed bound (someone who is unable to move around safely or comfortably and is confined to their bed) to repeatedly ask facility staff for linens/blankets and pillows from facility staff to cover herself on 10/03/2024 from 12 noon to 4:45 PM, because she was cold.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medically related social services by the Social Services Director [SSD] is provided to one of two (Resident 2) sampled residents, in accordance with the facility's policy and procedure titled Social Services, by failing to: 1. Provide medically related social services that included coordination in discharge planning when Resident 2 was accepted to a residential care facility (a licensed community care facility that provides non-medical care and supervision for people who need assistance) on 9/3/2024 and 9/25/2024. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision for one of two sampled residents (Resident 4), who was assessed at risk for elopement (a form of unsupervised wandering [to move/walk aimlessly without a purpose or definite destination] that leads to resident leaving the facility) dated 7/10/2024, due to a history of elopement and resident ' s wandering behavior. As a result, Resident 4 eloped from the facility on 9/24/2024, and was missing until 9/26/2024 [2 days]. Resident 4 was found at a location, 8.4 miles away from the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of three sampled residents (Resident 1) with meals that accommodated the resident's food preferences. As aresult of this deficient practice, Resident 1 ' s psychosocial wellbeing was affected and had the potential to alter the residents' health status.

Inspectors wroteBased on interview, and record review, the facility failed to ensure three licensed nurses had sufficient competency and skill sets in proper Fentanyl Transdermal patch (a pain medication administered on the skin via patch) administration, removal, rotation of site placement and disposal as indicated in the facility's policy and procedure titled, Controlled Medication Disposal, dated 01/2013, for one of two sampled residents (Resident 2). This failure resulted in Resident 2's skin irritation around the application site (chest area), and had a potential for the facility's residents, staffs and visitors to exposed toFentanylpatches that were not disposed correctly according to the facility's protocol.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2), fentanyl (narcotic/controlled substance with a high risk for addiction and dependence used to treat severe pain) Transdermal (supplying a medication in a form for absorption through the skin into the bloodstream) patch placement was rotated, routinely monitored, and application, removal and disposal was accurately documented. This failure resulted in Resident 2 ' s fentanyl patch being removed by Resident 2 and placed on objects at Resident 2's bedside, such as bedside table and water bottles. [...]

Inspectors wroteBased on the observation, interview, and record review, the facility failed to ensure the call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach as indicated in the facility's policy and procedure for one out of two sampled residents (Resident 1) who needed to request for assistance to be cleaned after urinating and bowel movement on 8/2/2024. This deficient practice resulted in Resident 1 feeling upset because he was not able to use the call light while having a soaking wet diaper which could lead to skin breakdown, accident and injury, and/or not able to receive needed care timely in an event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), who was dependent with the staff with hygiene care and was incontinent (no control of bladder and bowel) was not assisted with care timely. Resident 1 stated he felt upset and discomfort lying on a soaking wet diaper with his urine and stool and waited for at least thirty minutes, to be cleaned on 8/2/2024. This failure resulted in Resident 1 feeling frustrated and upset. This failure also had a potential to result in Resident1 1 and other potentially affected resident to be at risk for urinary infection (a condition in which bacteria invade and grow in the urinary tract), and skin breakdown (tissue damage caused by friction, shear, moisture, or pressure and is limited to the top layer of skin).

Inspectors wroteBased on interview and record review, the facility failed to act upon the consultant pharmacist ' s recommendations from 6/1/2024 and 6/20/2024 to ensure accountability of fentanyl (narcotic/controlled substance with a high risk for addiction and dependence used to treat severe pain) Transdermal (supplying a medication in a form for absorption through the skin into the bloodstream) Patch, removal, and disposal for one of two Resident (Resident 2). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility ' s policy and procedure by failing to provide clean and sanitary environment and ensure the oxygen nasal cannula (NC, a flexible tube that provides oxygen through the nose) was not reused after it was observed on the floor for one of two sampled residents (Resident 1). This failure had a potential to result in Resident 1 ' s respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to implement with policy and procedure for abuse prevention when Certified Nursing Assistant (CNA) 2, was allowed to work and take care of residents without a completed background screening (a step in the employment process used to screen individuals for criminal records) for one of two sampled CNA records reviewed. This deficient practice placed the facility ' s residents at risk of harm or abuse from CNA 2.

Inspectors wroteBased on interview and record review, the facility failed to develop resident specific comprehensive care plan for one of two sampled residents (Resident 2) to address resident safety and behavior management after Resident 2 allegedly hit Resident 3 to address specific interventions and goals to prevent further incidents of altercation. As a result of the deficient practice, Resident 2 and other residents safety were at risk for an altercation.

Inspectors wroteBased on interview and record review, the facility failed to monitor the behavior of one of two sampled residents (Resident 2) who suffered extreme paranoia (unrealistic distrust of others or a feeling of being persecute [punishment from a crime]) leading anger to determine the effectiveness of Quetiapine Fumarate (a psychotropic medications or type of medication that affects brain activities associated with mental processes and behavior). This failure had the potential for Resident 2 to receive inappropriate treatment and place other residents at risk of altercations with Resident 2 or unnecessary use of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to facility ' s policy and procedure for Enhanced Standard/Barrier Precaution (ESP- the use of gown and glove during high-contact resident care activities for residents known to be colonized or infected with disease causing organisms such as MDRO (multi-dose resistant organisms) that are resistant to antibiotics ( medications used to treat infection). Certified Nursing Assistant (CNA) 1 was observed providing patient care to one of one sampled residents (Resident 1), who had a wound and urinary catheter (tube inserted through the urinary tract to drain urine into a bag) without wearing an isolation gown (a type or personal protective equipment [PPE], a disposable gown made of paper-like material or plastic that helps in protecting the user ' s clothes). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were adequate licensed nurses to provide wound care for three of four sampled residents (Resident 1, Resident 2, and Resident 3) with treatment orders for wound care. The deficient practices had placed the residents at risk for skin breakdown, poor wound healing, and deterioration of current pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary treatment and services were documented for one of three sampled residents (Resident 1). This deficient practice had the potential for the resident to not receive medications and treatments as prescribed, which could cause a decline in health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its infection control policy to wear approproiate Personal Protective Equipment (PPE) to help prevent the spread and transmission of infections to residents, staff members, visitors in accordance with the facility ' s policy and procedure on infection control by failing to: 1. Ensure Certified Nursing Assistant (CNA1) wore the N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of air particles) that covered the nose and mouth while in the facility during an active Coronavirus (COVID-19, an infectious disease caused by the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2 virus)) outbreak. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from neglect (the failure to provide good and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) for three of three sampled residents. 1. Resident 1 verbalized that on 6/11/24, at around 6 PM during the evening shift (3 PM to 11 PM) when Resident 1 asked Certified Nursing Assistant (CNA) 1 for assistance with toileting. Resident 1 sat on soiled urine on 6/11/24 from 6:20 PM to 11 PM (evening shift - 4 hours and 40 minutes). This deficient practice resulted in Resident 1 verbalizing feeling upset, disrespected, and inhumane having to experienced neglect from CNA 1 on 6/11/24. 2. Resident 3 verbalized how CNA 1 was rude on 3/11/24 during the evening shift. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Investigate Resident 2 ' s complaint of Certified Nursing Assistant 1 (CNA 1) being rude on 5/9/24 during the 3 PM to 11 PM shift. 2. Provide Resident 2 a written grievance decision within 5 working days, in accordance with the facility ' s policy titled Grievances/Complaints, Recording and Investigating and dated 8/25/21. This deficient practice violated the residents' right to be provided with a written resolution. As a result, another resident, Resident 1, complained about CNA 1 on 6/11/24, and experienced being upset and disrespected. These deficient practices have the potential to negatively affect the resident ' s psychosocial impact.

Inspectors wroteBased on interview and record review, the facility failed to provide care that meets the professional standards of quality for one of four sampled Residents (Resident 4) by not documenting a psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication administered to Resident 4 on his Medication Administration Record (MAR) in accordance with the facility ' s policy and procedure titled, Administering Medications. This deficient practice had the potential to result in medication errors and can lead to adverse reactions (any unexpected or dangerous reaction to a drug) for Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision for one of four sampled residents (Resident 4) when Resident 4 had exited the facility ' s premise without the facility's knowledge on 6/8/24. As a result, Resident 4 was found outside of the facility at a liquor store and was brought back to the facility. This deficient practice had placed Resident 4 at risk for cold exposure, dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake) and other medical complications, and being struck by a motor vehicle.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label food brought by resident at bedside for one of two sampled residents (Resident 1) in accordance with the facility's policy and procedure titled Safe Handling of foods from Visitor. This deficient practice had the potential to result in food-borne illnesses (food poisoning) for Resident 1, with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications (a medical problem that occurred during a disease) and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to post accurate Nurse Staffing Information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift/daily. In addition, the Nurse Staffing Information was not posted in a prominent location readily accessible to residents and visitors for viewing, in accordance with the facility ' s policy and procedure titled Nursing Department - Staffing, Scheduling and Posting. This deficient practice of posting inaccurate Nurse Staffing Information could mislead the residents and visitors that may affect the quality of nursing care provided to the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one of one sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1 ' s unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to identify the provision of monitoring and supervision to prevent abuse and intoxication of illicit drugs ([street drugs] refers to the use and misuse of illegal and controlled drugs) for one of two sampled residents (Resident 119) with a recent history of polysubstance abuse ([Drug Abuse] when an individual develops the habit of using multiple substances and becomes dependent on them) and an existing intravenous (IV- through the vein) line, in accordance with the facility ' s policies and procedures on Behavioral Management and Out on Pass, by failing to: 1. Identify and assess the risks of Resident 119 leaving the facility without notification for the potential of obtaining illicit drugs. 2. Monitor the use of Resident 119 ' s intravenous (IV-through the vein) line to prevent use for self-administration of illicit drugs. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to address, obtain necessary services (drug counseling and surveillance) and develop person centered care plans for the behavioral healthcare needs of one of two sampled residents (Resident 119) diagnosed with polysubstance abuse ([Drug Abuse] when an individual develops the habit of using multiple substances and becomes dependent on them), in accordance with the facility ' s policy and procedure titled Behavioral Management, by failing to: 1. Develop and implement behavior health care plans upon admission to the facility on [DATE] to meet the needs of Resident 119 for the diagnoses of polysubstance abuse and drug abuse counseling and surveillance of drug abuser. 2. Attempt to perform voluntary inspections when facility staff had reasonable suspicion of possession of illicit drugs and refer to local law enforcement. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 63)'s rights to accept visitors in the facility. Resident 63 was denied the visitation rights to be visited by family member (FM) 1. The deficient practice violated Resident 63's right to accept visitors and resulted Resident 63's verbalizing emotional distress and stated he had felt very sad because he could not see FAM 1 who was very important to him.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from abuse for one of two sampled residents (Residents 1) when Certified Nursing Assistant (CNA) 1, a CNA from Hospice (care focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life) 1, continued providing sponge bath in bed to Resident 1 in a rough manner while Resident 1 cried, on 3/6/2024, as witnessed by CNA 2 (Facility CNA) and Resident 2 (Resident 1 ' s roommate). This deficient practice had a potential for Resident 1 to suffer negative psychosocial outcome such as anger, fear, anxiety, or loss of self-esteem

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from abuse according to the facility ' s policy and procedure (P&P) for one of two sampled residents (Residents 1) when Certified Nursing Assistant (CNA) 1, a CNA from Hospice (care focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life) 1, continued providing sponge bath in bed to Resident 1 in a rough manner while Resident 1 cried, on 3/6/2024, as witnessed by CNA 1 (Facility CNA) and Resident 2 (Resident 1 ' s roommate) stood by Resident 1 ' s roommate's (Resident 2) bedside, outside Resident 1 ' s privacy curtain while hearing roughness and crying and did not intervene while Resident 1 was being cared for by Hospice CNA 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control policy and procedure for six of 16 sampled residents (Residents 1, 2, 3, 4, 5, 6) identified with rashes at the facility by failing to: 1. Establish a surveillance system (an ongoing systematic collection, analysis, and interpretation of data, that allows the facility to track, analyze and interpret the data), and identify a concern that there was an unusual increasing number of residents with new and ongoing rashes every month from 1/2024 to 3/2024 (a total of 3 months). 2. Identify an outbreak (an increase of disease among a specific population in a geographic area during a specific period) when Resident 1 was diagnosed with scabies (an infestation of the skin by the human itch mite. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident ' s right to be free from abuse, but not limited to mental abuse (the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation) and corporal punishment (physical punishment; and used as a means to correct or control behavior) for one of three sampled residents (Resident 2). On 2/12/2024, during the night shift (11 PM to 7 AM), Certified Nurse Assistant (CNA) 1 tilted Resident 2 ' s shower chair forward and pushed Resident 2 ' s head down to make Resident 2 pick up a diaper on the ground. CNA 1 yelled at Resident 2 to pick up the diaper from the floor because CNA 1 would not pick it up for Resident 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown source to the Department and other officials immediately, but not later than two hours for one of three sampled residents (Resident 1) in accordance with the mandated Federal and State regulatory guidelines. On 2/13/2024, a report was received indicating Resident 1 had a discoloration on right side of forehead from an unknown source. This deficient practice had the potential for the facility to under report allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, which could lead to failure to investigate in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to assess the use of side rails for two of three sampled residents (Resident 1 and 6) to prevent accident and injury. This deficient practice had the potential for Resident 1 and 6 to sustain serious injuries.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication error by: 1. Failing to administer lacosamide (a medication used to treat seizure [a burst of uncontrolled electrical activity between brain cells, causing changes in behavior, movements, feelings and levels of consciousness]), and is a federally controlled substance) 200 milligram (mg, a unit measurement) oral one tablet at 9 PM on 1/1/24 and 1/4/24. 2. Failing to administer Keppra (a medication used to treat seizure) 750mg oral one tablet at 9 PM on 1/1/24 and 1/4/24. 3. Failing to administer fish oil supplement (derived from the tissues of oily fish, to improve inflammation and lower blood pressure and fats in the blood) at 500mg oral one capsule at 10 PM on 1/1/24 and 1/4/24. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to answer the call light and assist the resident in turning and repositioning timely, in accordance with the facility ' s policy and procedure (P&P) titled, Skin Integrity Management, for one of three sampled residents (Resident 1), who had paraplegia (the inability to voluntarily move the lower parts of the body) and a stage four pressure ulcer (most serious bed sore that caused by something putting pressure on or rubbing the skin) to the right ischium (a bone forms the lower and back part of the hip bone). These deficient practices had place Resident 1 ' at risk for poor wound healing and deterioration of current pressure ulcer.

Inspectors wroteBased on interview and record review, the facility failed to follow up on the physician's order for ophthalmology (a medical specialty within medicine that deals with the diagnosis and treatment of eye disorders) consultation and otolaryngology (ENT, a medical specialty which is focused on the ears, nose, and throat) follow up upon readmission for one of three sampled residents (Resident 1). These deficient practices had the potential for a delay in the delivery of care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide one of three sampled residents (Resident 1), who had a diagnosis of seizure (a burst of uncontrolled electrical activity between brain cells, causing changes in behavior, movements, feelings, and levels of consciousness) and was on anticonvulsant (medications used to treat seizure) medications with laboratory (lab) services as ordered by the physician. This deficient practice had placed Resident 1 at risk for receiving anticonvulsants in the dosage that were not within the therapeutic range and had the potential to result in recurrent seizure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 7) received treatment for bowel movements (process of expelling waste, including stool) by failing to: 1. Administer a rectal suppository [medication in a solid, cone-shaped form that is inserted into the rectum (last part of the large intestine where waste material is stored before elimination from the body through the anus) where is dissolves or melts to release the medication] to Resident 7 on 12/10/2023 upon Resident 7 ' s request and in accordance with the physician ' s order; and 2. Accurately document administered suppositories to Resident 7 for the months of 10/2023, 11/2023, and 12/2023, including 12/21/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Maintain accountability of 25 doses of Norco (a medication used to treat pain) 10/325 milligrams (mg - a unit of measurement for mass) between 12/17/23 and 12/21/23 for one of three sampled residents (Resident 1.) 2. Ensure licensed staff do not prepare medications for more than one resident at a time during the evening medication administration on 12/17/23 affecting one of three sampled residents (Resident 1.) 3. Ensure licensed staff signed the Ongoing Inventory of Controlled Drugs (a document transferring accountability of controlled medications [medications with a high potential for abuse] between nurses during shift change) a total of six times between 12/9/23 and 12/20/23. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a communication care plan for one of three sampled residents (Resident 6). This failure had the potential to prevent Resident 6 from receiving services, including the recommendation on 6/21/2018 for additional Speech Therapy (ST, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) intervention, to improve and maximize Resident 6 ' s ability to communicate.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) care plan was revised based on the resident ' s current condition. This deficient practice had the potential to result in the decline of Resident 1 ' s psychosocial status which included self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two laundry staff wore a face covering, including an N95 respirator (nationally approved face mask that filters at least 95% of airborne particles), in the facility's clean linen room while the facility had an open outbreak (sudden rise of disease) of Coronavirus-19 (COVID-19, a highly contagious viral disease that can cause respiratory illness). This failure had the potential to spread disease throughout the facility.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered by the physician and document the reason on the resident's Medication Administration Record (MAR) for one of five sampled residents (Resident 1). The facility was unable to find out who the specific assigned licensed nurse to follow up on for appropriate reeducation because the resident assignments were not kept and filed for each shift. This deficient practice can prevent the resident from benefiting from the optimal effects of the medications and the facility not able to provide reeducation and follow through with the specific licensed nurses involved.

Inspectors wroteBased on interview and record review, the facility failed to follow nursing professional standards of care (Essentials of nursing, its activities, and its accountabilities. Establishes the scope, status, and prospect of nursing) for two of four sampled residents (Resident 1 and Resident 2) failing to ensure Resident 1 and 2 was administered medication timely in accordance with the residents physician's orders. These deficient practices had the potential to negatively affect the delivery of care and services related to the Resident 1 and 2's health condition and place the residents at risk for serious illness and/ or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4), was assessed, provided interventions for pain relief and comfort, and reevaluated for pain relief as indicated in the resident ' s care plan. This failure had a potential to result in Resident 4 ' s inability to maintain his highest practicable level of well-being and to prevent pain.

Inspectors wroteBased on interview and record review, the facility failed treat one of 7 sampled residents (Resident 1) with respect and dignity by honoring the resident's right to not to be disturbed during sleep, and to keep his meal tray at the bedside according to his preference, without interference (invading or interfering) or reprisal (act of retaliation) as indicated in the facility's policy and procedure titled Dignity. Resident 1 stated while he was asleep when Certified Nursing Assistant (CNA1) woke up him to eat his meal so that he could collect the meal tray. Resident 1 stated he told CNA3 to leave him alone and told him to leave his food tray at the bedside because he fell asleep during lunch, and he preferred his meal tray remain in the room. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure one of two sampled residents (Resident 1) who is receiving antiseizure medications (medications that lowers electrical activity in the brain that causes seizures [uncontrolled body movements]) was given the medications (Keppra or Levetiracetam) to control and manage seizure activity and a medication reconciliation (The process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider) is performed to prevent omission of medications. Resident 1 ' s antiseizure medication, Levetiracetam (Keppra) was discontinued on 3/19/23 and 3/20/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer 47 doses of anti-seizure medications (Lacosamide, Keppra, Phenytoin) at the correct/scheduled times indicated on the physician's orders between 9/1/2023 and 9/26/2023 for one of two sampled residents (Resident 1) receiving anti-seizure medications. The failure of the facility to administer anti-seizure medications at the correct times increased the risk that Resident 1 could have experienced seizures resulting in hospitalization, coma (definition), or death.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for two of nine sampled residents (Residents 6 and 7) while in facility's Smoking Patio. This deficient practice resulted in Resident 6 rammed the wheelchair into Resident 7. This had the potential for skin injury and preventable accident.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the facility ' s policy for one of two sampled residents (Resident 1) with a diagnosis of diabetes mellitus (a disease in which the blood sugar levels are too high), when it failed to ensure all appropriate discharge orders from General Acute Care Hospital (GACH) 1 were verified with the attending physician (Physician 1) upon readmission to Skilled Nursing Facility (SNF) 1 on 7/14/2023. This deficient practice resulted to Resident 1 not receiving the care and services to continue diabetic management and medications for the resident ' s diagnosis while in the facility from 7/14/2023 to 7/28/2023 (14 days) and upon transfer to another Skilled Nursing Facility (SNF 2) on 7/28/2023. [...]

Inspectors wroteBased on observation,interview, and record review the facility failed to develop a comprehensive, resident specific care plan for one of two sampled residents (Resident 1) upon readmission back to the facility on 7/14/2023. Resident 1 did not have a care plan developed on 7/14/2023 to 7/28/2023 for the management of Type 2 Diabetes Mellitus and hyperglycemia. This deficient practice resulted in the resident 1 ' s diagnosis Type 2 Diabetes / blood glucose levels not properly monitored for the changes in condition and a potential to develop complications from the disease.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that facility staff implement the facility's Abuse Prohibition Policy and Procedure during the provision of care and services for six of six sampled residents (Residents 1, 2, 3, 4, 5, and 6). The facility failed to: 1. Prevent sexual abuse when facility staff did not identify and intervene with Resident 1's sexually inappropriate behaviors that included lying on top of another resident with pants down, masturbating, and wandering (moving around inside the facility or home without awareness of personal safety, potentially putting themselves in harm's way) to Residents 2, 3 and 5's bedside. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 2 and 3) were free from sexual abuse on 8/24/2023 around 2 AM when Resident 1 laid on top of Resident 2 while in bed, with pants and underwear down as observed by Resident 6. In addition, the facility failed to ensure Resident 3 was free from sexual abuse when Resident 1 wanders (a behavior characterize by aimless, repetitive walking without purpose) frequently to Resident 3's bedside and masturbates (when a person stimulates their genitals for sexual pleasure), as observed by Resident 4 after the facility staff moved Resident 1 to Resident 3 and 4's room. These deficient practices resulted in Resident 2 and 3 experiencing sexual abuse and unwanted nonconsensual sexual contact from Resident 1. Resident 2 verbalized feeling angry and afraid of Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there is always sufficient qualified nursing staff available to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, in accordance with the resident's assessment, resident's plan of care, and facility assessment. The facility's failure included: 1. Ensure to employ sufficient certified nursing assistants (CNA) to provide care and services in assisting residents on 8/4/23, 8/5/23, 8/6/23, 8/12/23, 8/13/23, 8/14/23, 8/15/23, 8/20/23, and 8/25/23. 2. Not ensuring licensed staff were consistently assigned to each of the facility's three Nursing Station across the shifts. [...]

Inspectors wroteBased on interview and record review, the facility ' s Quality Assurance and Performance Improvement (QAPI) committee failed to develop and implement policies and procedures which included how the facility ensures that data were collected, monitored, and appropriate action plans were implemented to identify quality of care issues regarding abuse. As a result of this deficient practice, the facility had no distinct performance improvement for abuse prevention

Inspectors wroteBased on observation, interviews and record review, the facility failed to report allegations of sexual abuse from another resident to the Department and other officials immediately, but not later than two hours for two of three sampled residents (Residents 2 and 3). Resident 2 and 6 reported to facility staff that Resident 1 was observed lying on top of Resident 2 while in bed, with pants and underwear down on 8/24/2023 around 2 AM. This deficient practice had the potential for the facility to under report allegations of abuse, neglect, exploitation or mistreatment which could lead to failure to investigate all types of abuse in a timely manner and protect residents from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 9 and 10), received restorative nursing services (to maintain a person ' s physical abilities to perform activities of daily living (ADLs) that promote independent living) as ordered by the physician. This failure had the potential to cause further decline in Resident 9 and Resident 10 ' s physical abilities and contractures (the shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on interview and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices for 1 out of 2 sample residents (Resident 7) by failing to document the administration of intravenous accurately and completely (IV - within the vein) antibiotics (medication to fight infection) in the Resident 7 Infusion Medication Administration Record (IMAR). 1. Resident 7 ' s IV treatment administration record did not indicate all staff who administered IV medications. 2. Resident 7 ' s IV medications fluid volume was not documented. 3. Resident 7 ' s IV medication rate of infusion was not documented. This failure had the potential to negatively impact the delivery of care and services.