Riverbank Post-Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to provide a safe and sanitary environment for one of four sampled residents (Resident 1) when a bloody bandage and trash was found on the floor of Resident 1's room on 7/22/2026 and on 7/20/2026 Resident 1 was found to have ants on his bed, neck and shoulder. This failure resulted in an unsanitary environment and had the potential to result in cross contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect). During a concurrent observation, interview, and record review with Resident 1 on 7/22/2026, at 10:30 a.m., Resident 1 stated the nurse woke him up Monday morning (7/20/2026) saying he had ants on him. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when Licensed Nurses did not complete an accurate physical assessment upon admission for one of three sampled residents (Resident 1) when Resident 1 was admitted to the facility on [DATE] with bilateral (both sides of the body) nephrostomy tubes (thin, flexible tube placed through the skin of a person's back into the kidney to drain urine into an outside bag) and an abdominal accordion drain (a small tube placed into an abscess [pocket of pus/infection] to drain fluid using a collapsible plastic bulb that creates gentle suction) site that were not documented. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Nurses received competency skills on the assessment and care of nephrostomies when three of three sampled Licensed Nursing staff (Registered Nurse [RN] 1, Licensed Vocational Nurse (LVN) 2 and the Treatment Nurse [TN]) did not receive competency training and skill set evaluate in assessing and providing nephrostomy (thin, flexible tube placed through the skin of a person's back into the kidney to drain urine into an outside bag) care. This failure had the potential to place residents with nephrostomies at risk for care to not be provided in a safe and competent manner. During an interview on 4/13/26 at 10:17 a.m. with LVN 2, LVN 2 stated there were residents at the facility with nephrostomy tubes. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan was developed and implemented to meet the identified needs for one of three sampled residents (Resident 1) when Resident 1 did not have a care plan for bilateral (both sides of the body) nephrostomy tubes (thin, flexible tube placed through the skin of a person's back into the kidney to drain urine into an outside bag) and abdominal accordion drain (a small tube placed into an abscess [pocket of pus/infection] to drain fluid using a collapsible plastic bulb that creates gentle suction) site. This failure had the potential for Resident 1's care needs to go unmet and resulted in a delay in care for dressing changes to the nephrostomy tubes and drain sites, placing the resident at risk for infection and dislodgement of the tubing. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the ice machine was in safe operating condition when the ice machine malfunctioned and the facility did not provide the residents with ice for two days, 3/21/26 and 3/22/26. This failure had the potential for the residents to decrease the amount of fluid they consumed risking dehydration (condition when body loses more fluids than it takes in) and urinary tract infections (UTI-infection caused by bacteria entering the urinary system [bladder, urethra, or kidneys] leading to painful urination). During a concurrent observation and interview on 3/23/26 at 10:51 a.m. with Resident 6, Resident 6 was lying in bed, there was an indwelling catheter bag hanging at her bedside. Resident 6 pointed to her cup on the overbed table and stated she had not received any ice since Friday 3/20/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide medically related social service needs for three of seven sampled residents (Residents 1, 2, and 3) when the Social Services Director (SSD) did not schedule physician ordered consultations and diagnostic testing from outside entities and failed to document any attempts to schedule the appointments or contact with the responsible parties (RP) in the electronic medical record (EMR). These failures caused a delay in care and had the potential for the residents' needs to go unmet. [...]

Inspectors wroteBased on interview and record review, the facility's Administrator (ADM) failed to provide effective oversight and necessary resources to ensure resident care services were met to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for four of seven sampled residents (Residents 1, 2, and 3) when the Administrator did not provide oversight and supervision of the Social Services Director (SSD) and Residents 1, 2, and 3's physician ordered consultations and testing as outside entities were not scheduled timely and there was no documentation of a follow up or reason in the electronic medical record (EMR). This failure had the potential for residents' needs to go unmet. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a complete and accurately documented medical record in accordance with acceptable professional standards of practice and the facility policy and procedure for three of seven sampled residents (Residents 1, 2, and 3) when the Social Services Director (SSD) did not document her attempts to schedule physician ordered consultations and diagnostic testing or contact and follow up with the responsible parties (RP) in the residents' electronic medical record (EMR). These failures had potential for Residents 1, 2, and 3 care needs to go unmet due to inaccurate documentation. (cross reference F745)During a concurrent interview and record review on 2/23/26 at 12:28 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's physician's order dated 10/9/26, was reviewed. The order indicated, . 10/9/3025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the facility employed an infection preventionist (professionals who works to stop the spread of infections within a healthcare facility) to meet the facility's infection control needs when the facility did not have a trained and certified infection preventionist for over two weeks and the staff failed to follow proper infection control procedures including failing to follow the facility's infection control policy and procedure for performing fingerstick blood glucose, one of three CNA's did not perform hand hygiene when entering and exiting a resident room after touching the residents environment and enhanced barrier precaution signs were not hung by the PPE carts for two rooms. These failures had the potential to have an outbreak of infectious disease throughout the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when:1. Two out of three Licensed Vocational Nurses (LVN 1 and 3), did not follow infection control measures while checking fingerstick (pricking a fingertip with a small needle to obtain a sample of blood) blood glucose (measures the level of sugar in the blood) on residents 4, 5 and 7. This failure had the potential to spread germs from the residents environment to other residents and expose residents to other resident's blood. 2. One of three Certified Nursing Assistants (CNA) failed to perform hand hygiene before and after providing resident care and contact with the resident's environment. This failure had the potential to spread infections between residents.3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) was developed and implemented for two of five residents (Resident 1 and Resident 4) when:1. Resident 1's care plan was not implemented for refusal of care and notification of Resident 1's Responsible Party (RP) and physician.2. Resident 4's care plan was not developed and implemented for refusal of care. These failures had the potential to result in Resident 1 and Resident 4 receiving inadequate person-centered care and put Resident 1 and Resident 4 at risk of not having their needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice for two of five sampled residents (Resident 1 and Resident 4) when the physician and Resident Responsible Party (RP) were not notified of Resident 1 and Resident 4's refusal of care with having their nails trimmed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide foot care and treatment, in accordance with professional standards of practice for two of four sampled residents (Resident 1 and Resident 4) when Resident 1 and Resident 4 had long, overgrown toenails. This failure had the potential to result in Resident 1 and Resident 4 cutting their skin with their long toenails, leading to poor wound healing, infection, and hospitalization.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the safety and well-being for 1 (Resident #37) of 1 sampled resident reviewed for smoking. Specifically, the facility failed to failed to implement further interventions to ensure the safety of the resident and others when the resident continued to smoke after there was indication that the resident agreed to smoking cessation and failed to implement interventions when the resident refused to turn in their lighter. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Immediate Jeopardy was related to State Operations Manual, Appendix PP, 483.25 (d) Accidents, at a scope and severity of J. On 03/12/2025 at 4:38 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician that 1 (Resident #6) of 1 sampled resident reviewed for dialysis did not receive their ordered medications when they were out of the facility at dialysis three days each week.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a new level I preadmission screening and resident review (PASARR) was completed for 2 (Resident #53 and Resident #75) of 2 sampled residents reviewed for PASARR, who remained in the facility after 30 days.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a resident's care plan reflected the resident's refusal to sign the smoking policy and interventions for staff to obtain a cigarette lighter from the resident for 1 (Resident #37) of 1 sampled resident reviewed for smoking.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5 percent (%) or less. There were 2 errors out of 26 opportunities, which resulted in a medication error rate of 7.69% for 1 (Resident #12) of 8 residents observed for medication administration.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #6) of 19 sampled residents did not experience significant medication errors. Specifically, Resident #6 did not receive their antidepressant, diuretic, anticoagulant, and blood pressure medications as ordered by the physician three days each week when the resident was out of the facility at dialysis.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1), was free from verbal abuse when his roommate Resident 2, verbally assaulted him with a racial epithet on multiple occasions. This failure resulted in Resident 1 being a victim of continued racially based verbal abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of verbal abuse for one of six sampled residents (Resident 1), when Resident 1 had complained to facility staff that his roommate, Resident 2, was continuously calling him a racial epithet. This failure resulted in Resident 1 being subjected to further verbal abuse from Resident 1. [Cross Reference F600].

Inspectors wroteBased on interview and record review, the facility failed to: 1. Report an allegation of verbal abuse to the California Department of Public Health for one of six sampled residents (Resident 1) when Resident 2 called him a racial epithet on multiple occasions, and 2. The facility did not report the results of the abuse investigation to the California Department of Public Health within five days. These failures resulted in the verbal abuse of Resident 1 to go uninvestigated, subjecting Resident 1 to continued verbal abuse.

Inspectors wroteBased on interview and record review the facility failed to develop a safe and effective discharge plan for one of three sampled residents (Resident 1) when Resident 1 was discharged to an assisted living facility (ALF-type of residence for older adults who need daily care) without an interdisciplinary team (IDT-variety of medical professionals who plan and coordinate patient care) meeting to develop discharge goals and post discharge care needs involving the resident's Public Guardian Conservator (PGC-a resident representative responsible for managing financial and medical decisions for a person who is incapacitated [physically or mentally unable to manage one's affairs]), and did not review a post discharge plan with the PGC prior to discharge according to the facility's policy and procedure. This failure placed Resident 1 at risk for his medical needs to go unmet after discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment for two of six sampled residents (Residents 1 and 2) with a Wander guard bracelet (system which triggers an alarm to alert staff when a resident at high risk for elopement [when a person leaves a safe area unattended and unsupervised] is close to an exit door) when Residents 1 and 2 did not have a Wander guard bracelet on and the Licensed Nurses (LN) failed to check the Wander guard for placement and functionality every shift according to the physician ' s order. This failure resulted in Resident 1 leaving the facility in his wheelchair, crossing a busy highway unattended and without staff knowledge on 4/28/24, which placed him at risk for serious injury and Resident 2 was at risk for elopement. (cross reference F921)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and functional environment when one of four exit door alarms tested did not function (to alert staff) properly. This failure had the potential for residents to leave the facility undetected by staff, which placed residents at risk for serious injury, accidents and/or death. (cross reference F689)

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program for two of six sampled residents (Residents 4 and 6) when the Treatment Nurse (TN) failed to follow infection control precautions during wound care. These failures placed Residents 4 and 6 at risk for wound infections.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for one of six sampled residents (Resident 1) when Resident 1 did not have a care plan with measurable goals and interventions after testing positive for Coronavirus disease 2019 (COVID-19-a highly contagious infectious disease caused by a virus from respiratory droplets that can spread from person to person) on 11/10/23 and Licensed Nurses did not develop a care plan for oxygen therapy since her admission to the facility on [DATE]. These failures had the potential for Resident 1's COVID-19 and oxygen therapy care needs to go unmet.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of practice for one of six sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 2 did not follow professional standards for the administration of oxygen (O2- an odorless gas that is present in the air and necessary to maintain life) on 11/14/23 when she administered oxygen to Resident 1 with a non-rebreather mask (a special mask placed over the nose and mouth to provide oxygen in emergencies) without a physician's order. This failure placed Resident 1 at risk for suffocation (die from being unable to breathe) from improper usage of a non-rebreather mask.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan that included interventions for one of four sampled residents (Resident 1) to prevent choking. There was no care plan developed or implemented for Resident 1's known behavior of rapidly stuffing food in her mouth. On 11/19/23, Resident 1 had a choking incident and was hospitalized . This failure resulted in an avoidable second choking incident resulting in Resident 1 expiring on 12/02/2023.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain patient care equipment in safe operating condition when: 1. Shower room was not functional for over a month, for residents requiring a shower gurney (shower bed) for three of three sampled residents (Resident 1, 2 and 3) This failure resulted in Residents 1, 2, and 3 not receiving a shower for over a month. 2. Call lights were not operational for two of three sampled residents (Resident 2 and 3). This failure resulteds in Resident 2 and 3 not being able to use the call light to ask for assistance when needed and in the event of an emergent situation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity consistent with enhancing each resident's quality of life and recognizing each resident's individuality for three of 10 sampled residents (Residents 52, 59 and 64) when the facility failed to provide group activities and communal dining for 18 days. This failure resulted in the facility not promoting the rights of Residents 52, 59 and 64 to a dignified and respectful existence and had the potential to compromise their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing activity program to meet the needs and interests for three of 10 sampled residents (Residents 52, 59 and 64) when Residents 52, 59 and 64 were not provided their activities of interests and had no communal dining for 18 days due to the ongoing construction in the facility's dining room. This failure resulted in Residents 52, 59 and 64's activities needs to go unmet.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure menus were followed by [NAME] 2 (CK) 2 during the lunch meal preparation on 9/20/23 for 83 of 91 residents who received food from the kitchen when the lunch menu had an unplanned vegetable substitute. This failure had the potential for residents to receive inadequate nutrients in their meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure eight of 45 sampled residents (Residents 9, 16, 46, 70, 2, 27, 51 and 66) received pureed foods that were prepared by methods to conserve the nutritive value of food when on 9/20/2023, [NAME] 2 (CK) 2 did not follow the pureed consistency for the preparation of lunch meal in accordance with the pureed policies and procedures. This failure placed residents receiving a pureed diet at risk for compromised nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food safety when: 1. Food particles that were brownish in color lay on the bottom shelf of the stand-up freezer and two open, uncovered plastic bins which held serving/cooking utensils were under the sink area by the stove. 2. A scoop was left inside the flour bin. 3. Two-five-pound bags of cake mix had sticky substance in between the bags. 4. A soiled blanket with black and brown discoloration was on the floor at the storage room where the emergency water supplies were located. 5. Water pitchers were stacked and stored in a cupboard and there was moisture in between the water pitchers. 6. Two green buckets with gray colored water and had soiled cleaning cloths with brownish discoloration sat on the floor under the dishwasher. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage under sanitary conditions when one of three garbage containers in the kitchen was uncovered. This failure had the potential to attract rodents, insects and flies and spread infection which place residents at risk of foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to follow its Hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) policy and procedures for five of five sampled residents (Residents 9, 29, 34, 72, and 87) when the facility failed to ensure that Hospice personnel caring for residents under Hospice services were provided orientation to the facility's policies and procedures (P&P). This failure had the potential to place Residents 9, 29, 34, 72, and 87 at risk of not receiving appropriate medical, physical, psychosocial, and spiritual support to manage symptoms associated with terminal illness.

Inspectors wrote2. During a review of Resident 3's admission record, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD- lung diseases that make it hard to breathe and get worse over time). During a concurrent observation and interview, on 9/19/23 at 10:25 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 3's room, Resident 3's foley catheter bag was placed inside a privacy cover (a bag which discreetly conceals a urine drainage bag from public view) and was observed on the floor underneath Resident 3's bed. CNA 1 stated, .Yes, it [foley catheter bag] is on the floor . and stated the foley catheter bag should not be on the floor. During an interview on 9/21/23 at 9:49 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly maintain the ice machine in safe operating condition when the ice machine had been out of service multiple times since May 2023 and had been shut down for use beginning the week of 9/10/2023 due to the ongoing construction project in the dining room. This failure placed residents at risk of developing food borne illness (illness caused by consuming contaminated food) and had the potential to compromise availability of ice for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was sufficient space to accommodate group activities and communal dining for five of 12 sampled residents (Residents 32, 43, 52, 59 and 64) when the facility's dining room/activities room was under renovation since September 5, 2023 to present. This failure resulted in Residents 32, 43, 52, 59 and 64 to not participate in group activities and communal dining for two weeks and placed residents at risk to feel isolated and depressed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment when: 1. The facility dining room was renovated without first notifying the California Department of Healthcare Access and Information (HCAI, a government agency for the State of California in charge of safety regulations for health care facilities, financial assistance to health care institutions, collecting healthcare data and more) and the California Department of Public Health (CDPH, a government agency for the State of California in charge of protecting the public's health and helps shape positive health outcomes for individuals, families and communities) and the facility did not obtain an alteration permit from HCAI. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the personal privacy for one of 21 sampled residents (Resident 244) when the window in Resident 244's room overlooked the common smoking area and was not covered with a curtain or blinds. This failure violated Resident 244's right to privacy and confidentiality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided meet professional standards of practice for one of 32 sampled residents (Resident 294) when the facility failed to obtain a physician's order to remove the eight surgical staples (used to close incisions after surgery) on Resident 294's left forehead surgical incision (a cut made through the skin and soft tissue). This failure placed Resident 294 at high risk for infection and complications from a delay in suture removal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled in accordance with acceptable professional standards of practice for one of four sampled medication carts (Station B medication cart) when Resident 89's tiotropium bromide inhaler (a medication which is inhaled through the mouth to help people with damaged lungs breath better) did not have a resident identifier or label. This failure had the potential for the medication to be given to the incorrect resident which could cause adverse reactions (harmful unintended result caused by a medication) and or cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another).

Inspectors wroteBased on observation during the survey period of 9/19/23 to 9/22/23, the facility failed to provide and maintain a minimum of at least 80 square feet of space per resident in 6 resident rooms (Rooms 7, 9, 11, 19, 21 and 23). This failure had the potential for residents to not have reasonable privacy or adequate space.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a comfortable and homelike environment for two of three sampled residents (Resident 66 and Resident 20) when: 1. The bottom part of the door had crusted and peeled paints. 2. There were eight holes in the wall near the television that was approximately one millimeter (mm- a unit of dry measurement) in length in Resident 66 and Resident 20's room. 3. The bathroom sink was loose and approximately 2.5 centimeters in length off the wall. These failures resulted in an environment which is not homelike for Resident 66 and Resident 20.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the resident's transfer or discharge notification to the state long term care Ombudsman office for two of seven sampled residents (Resident 445 and Resident 2) when Resident 445 and Resident 2 were transferred to the General Acute Care Hospital (GACH). These failures resulted in the long term care Ombudsman not being aware of Resident 445 and Resident 2's transfer and discharge circumstances should appeals be filed by the residents or their representative.

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status) every 3 months for one of two sampled residents (Resident 29). This failure had the potential to delay the review and revision of the ongoing comprehensive care plan necessary to provide individualized care and services to Resident 29.

Inspectors wroteBased on interview and record review, the facility failed to meet the required timelines for encoding, completion and transmission of Minimum Data Set (MDS) assessments (evaluation of cognition, care needs and functional abilities) for six of six sampled residents (Resident 66, Resident 17, Resident 15, Resident 12, Resident 18 and Resident 79). This practice resulted in not placing the most up to date MDS assessment information in the residents' clinical record and not communicating to CMS required quality data.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 92) baseline care plans were developed within 48 hours of admission to facility when: Resident 92's use of hypnotic medication (medication used to sleep) was care planed eight days following admission to facility. This failure placed Resident 92 at risk to experience difficulty with sleep during the initial nights following his admission to the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide toenail and foot care for one of three sampled residents (Resident 20), when Resident 20's toenails were untrimmed and curled over her ten toes. This failure resulted in Resident 20's care needs going unmet and placed Resident 20 at risk for developing injury and or infections to her feet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive services to maintain vision for one of one sampled resident (Resident 14) when: The Social Service Director (SSD) did follow up with recommendation for Resident 14 to be seen by an ophthalmologist (specialist in the treatment of disorders and diseases of the eye) referral. This practice resulted in Resident 14's visual needs to go unmet and a potential to affect Resident quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staff with the appropriate competencies and skill sets to provide nursing services to assure residents receive services to maintain their highest practicable physical, mental, and psychosocial well-being when: 1. Three of five nursing staff (Licensed Vocational Nurse [LVN 2], LVN 3 and the Registered Nurse [RN]) did not receive a competency skills check after being hired. 2. LVN 4 did not receive competency training on the completion of Dialysis [a process that removes waste products from the blood when the kidneys do not function] Communication document. These failures had the potential for the needs of the elderly and dementia residents going unmet. Findings 1. During a concurrent interview and record review with the DSD, on 9/10/19, at 2:18 p.m, she reviewed LVN 2, LVN 3, and RN employee record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food met the nutritional needs of the residents taking into consideration the resident's preferences when: 1. Resident 49 was not served 4 ounces (oz) of juice according to the resident's meal ticket. 2. Resident 24 was not served 4 oz of juice according to the resident's meal ticket . These failures had the potential to result in residents not receiving their dietary needs when the residents' beverage preferences were not provided which can further compromise their medical status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the chemical sanitizing solution used for dishes, utensils and kitchen working surfaces met the recommended sanitation concentration when expired chemical test strips were used. This practice failed to ensure the required level of sanitation was followed and placed the residents and staff of the facility at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two of two sampled residents (Resident 24 and 49) beverages appropriate to meet the residents' needs when: 1. Resident 49 was served a glass of water not thickened according to the physician's orders. 2. Resident 24 was not served glass of water not thickened according to the physician's orders. These failures placed Residents 24 and 49 at risk of choking (liquid that could be caught in the throat blocking airway and making it difficult or impossible to breathe).

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate medical record consistent with professional standards and practices for two of seven sampled residents (Resident 66 and Resident 29) when: 1. Resident 66's comprehensive care plan on anticoagulant therapy did not address the anticoagulant medication she was prescribed. 2. Resident 29's Dialysis (process of removing waste from the kidney artificially)Communication document did not contain Pre-dialysis assessments. These failures resulted in a medical records that did not reflect the resident's condition and treatments of the care and services required by the resident's and their care needs.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective infection control program when: 1. Tuberculosis (TB) (a contagious infection of the lungs) skin test was not provided on an annual basis for three of three sampled residents (Resident 20, Resident 4, Resident 3). 2. Staff did not perform hand hygiene during the lunch observation conducted on 9/8/19 for 2 residents in the assisted dining room (Resident 49 and Resident 24) when: a. Restorative Nursing Assistant (RNA) 2 and Certified Nurse Assistant (CNA) 10 failed to provide Resident 49 and Resident 24 wet hand towels to clean the residents' hands before meals. b. CNA 10 did not wash or sanitize hands before meal set up for Resident 49 and before providing feeding assistance to Resident 24. c. RNA 2 did not wash or sanitize hands before providing feeding assistance to Resident 49. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 39) were treated with respect and dignity when: Certified Nusing Assistant (CNA 2) did not provide Resident 39 with adequate incontinent care and left Resident 39 with dry smeared stool in her perineal (peri) area (diamond-shaped area that includes the anus and, in females, the vagina). This failure resulted in Resident 39 feeling embarrassed and humiliated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately reflect the status for one of three sampled residents (Resident 14) when Resident 14's vision impairment was not accurately coded on the Minimum Data Set (MDS) assessment (evaluation of care and functional needs). This failure resulted in an inaccurate vision assessment for Resident 14 which placed Resident 14's vision needs unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 28) receive the necessary services when staff did not provide a urinal for Resident 28's use after he requested. This failure resulted in Resident 28's urine incontinent spells on the night shift of 9/6/19 and 9/8/19.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement care and services in accordance with the facility policy and procedures for one of 33 sampled residents (Resident 63) when: the interdisciplinary team (IDT- members of the care team made up of nurses, social workers, doctors, dieticians and other appointed staff) did not implement or revise interventions to prevent Resident 63's significant weight loss. The Certified Dietary Manager (CDM) and the nursing staff failed to accurately document and monitor the consumption of nutritional supplements ordered for Resident 63 unintended weight loss. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a psychotropic medication (used to affect the mind, emotions, and behavior) for one of one sampled resident's (Resident 68) was not administered beyond a fourteen day period when ordered on a PRN (Whenever needed) basis without a documented rationale by the physician. This failure placed Resident 68's health and safety at risk due to the continuous administration of the unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely dental services to one of one sampled resident's (Resident 36) when the Social Service Director (SSD) did not follow up Resident 36's dental recommendation. This failure resulted in the delayed meeting of the ongoing dental needs of Resident 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store food in accordance with professional standards for food service safety when an opened rectangle block of butter was not dated. This failure to ensure safety in food service placed the residents at risk for food borne illness and the growth of microorganisms.

Inspectors wroteBased on observation during the survey period of 9/8/19 to 9/11/19, the facility failed to provide and maintain a minimum of at least 80 square feet per resident in multiple resident rooms. This failure had the potential for residents to not have reasonable privacy or adequate space.