Riviera Healthcare Center

Inspectors wroteBased on observation, interview and interview review, the facility failed to ensure infection prevention and control practices were implemented, by failing to: Ensure Resident 9's indwelling urinary catheter (catheter that drains urine from bladder into a bag outside the body) drainage bag was not dragging the floor. Ensure the Treatment Nurse used a disposable cloth (paper towel) to establish a clean field (table) before placing Resident 5's wound care supplies on the bedside table, as indicated in its policy and procedure (P&P) titled Wound Care. The facility had a system in place in the management and care of a resident's pet (dog) within the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure:1. The garbage was properly disposed of in the designated dumpsters.2. The dumpster lids were maintained in a closed position to prevent exposure to the environment.3. Timely removal or management of accumulated trash when scheduled waste collection did not occur. These deficient practices had the potential to contribute to environmental contamination, pest infestation, odors and unsanitary conditions that could negatively impact the health and safety of residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the urine characteristics were appropriately assessed and the urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was kept off the floor for five out of eight sampled residents (Resident 9, Resident 10, Resident 2, Resident 34, and Resident 3). These deficient practices had the potential to lead to delay in treatment and identification of urinary tract infections (UTI- an infection in the bladder/urinary tract) for Residents 9 and 10, and the development of UTIs due to improper urinary catheter management for Residents 2, 3, 9, and 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 12 sampled residents (Resident 103 and Resident 31) were treated with dignity and respect. This deficient practice had the potential to cause Residents 103 and 31 to feel disregarded, humiliated, emotionally distressed, and also had the potential to compromise the residents' dignity and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain and/or renew informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for psychotropic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) for two of six sampled residents (Resident 103 and Resident 41), by failing to:1. Obtain informed consent from Resident 103 and/or their responsible party (RP) for the administration of Olanzapine (a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) 2.5 milligram ([mg]- a unit of dose measurement).2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident rooms in good repair and ensure a functioning television was provided for two of 12 sampled residents (Resident 64 and Resident 76). These deficient practices had the potential to negatively impact Residents 64 and 76's well-being and contributed to an environment that did not promote comfort and homelike atmosphere.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of six sampled residents (Resident 64) was free from the use of an unauthorized physical restraint when the resident's bed was positioned directly against the wall. This deficient practice had the potential to restrict Resident 64's freedom of movement and function as a physical restraint negatively impacting Resident 64's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a PRN (as needed) order for Ativan (a psychotropic medication- drug that affects mental processes, moods, and behaviors) was not continued beyond 14 days for two of six sampled residents (Residents 103 and 83). This deficient practice placed Residents 103 and 83 at risk for continued use of unnecessary psychotropic medication without timely physician reassessment and had the potential for Resident 103 and 83 to be chemically restrained by the administration of unnecessary psychotropic medication, and/or suffer extrapyramidal symptoms (a group of movement disorders that can occur because of certain medications, particularly antipsychotics) due to prolonged use.

Inspectors wroteBased on interview and record review, the facility failed to report an abuse allegation to the State Agency (California Department of Public Health [CDPH]), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement for two of two sampled residents (Residents 7 and 61), after Resident 7 allegedly touched Resident 61's genitals (external reproductive organ). This deficient practice resulted in a delay of an onsite investigation by CDPH and had the potential to result in abuse to all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive, person-centered care plan for four of eight sampled residents (Resident 61, Resident 93, Resident 41, and Resident 14) for the following:1. Resident 61 was allegedly touched sexually and inappropriately by another resident.2. Resident 93, who had out-on pass privileges, and a known history of alcohol use and relapse (resumption of drinking alcohol after a period of abstinence, often involving a return to previous levels of heavy consumption) behaviors.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise two of three sampled residents' (Resident 6 and Resident 104) care plans after testing positive for influenza A (a contagious viral infection that affects the respiratory system). This deficient practice had the potential to negatively affect Residents 6 and 104's physical well-being and had the potential to delay the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to conduct 72-hour monitoring for two of two sampled residents (Resident 61 and Resident 7), after an allegation of sexual abuse. This deficient practice had the potential to result in a decline in Resident 61's psychosocial well being and potential for Resident 7's sexually inappropriate behavior being undetected. Cross Reference F609 and F842.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure intravenous (IV, administered directly into the blood stream) tubing (the tubing that allows medication to flow into the resident's blood stream) was labeled with the date and time for one of three sampled residents (Resident 87). This deficient practice had the potential to result in a bloodstream infection for Resident 87.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post an oxygen in use sign outside the room of one of three sampled residents (Resident 105). This deficient practice increased the risk for injury related to fire hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dialysis (treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit (e-kit, a kit used for the management of emergency bleeding on venous access [catheter or device is inserted into a vein to deliver medications or fluids] was kept at the bedside for one of three sampled residents (Resident 142). This deficient practice placed Resident 142 at risk for uncontrolled bleeding and serious harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide feeding assistance during breakfast for one of seven sampled residents (Resident 31). This deficient practice had the potential to negatively affect the residents' quality of life, and feeling of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration practices were observed when the following occurred for three of five sampled residents (Resident 1, Resident 66, and Resident 132):1. Failed to ensure Ferrous Sulfate (used to treat or prevent anemia [a lower-than-normal number of red blood cells]) Oral Solution 220 milligrams per five milliters (mg/ml, a unit of measurement) 7.4 ml was administered to Resident 1 one to two hours before or after tube feeding (method of delivering liquid nutrients, fluids, and medications directly into the stomach via a flexible tube) in accordance with physician's order for Resident 1.2. Failed to ensure Zinc Sulfate (a medication essential for wound healing) Oral Tablet 220 mg via g -tube was administered to Resident 1 in accordance with physician's order for Resident 1.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was less than five percent (%). Three medication errors out of a total of thirty-six opportunities contributed to an overall medication error rate of 8.33 %, for two of five sampled residents (Resident 1 and Resident 132) observed for medication administration (med pass). The medication errors noted were as follows:1. Failed to ensure Ferrous Sulfate (used to treat or prevent anemia [a lower-than-normal number of red blood cells]) Oral Solution 220 milligrams per five milliters (mg/ml, a unit of measurement) 7.4 ml was administered to Resident 1 one to two hours before or after tube feeding (method of delivering liquid nutrients, fluids, and medications directly into the stomach via a flexible tube) in accordance with physician's order.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was palatable (tastes good and enjoyable to eat) and consistent with resident preferences for one of seven sampled residents (Resident 124). The deficient practice resulted in the residents not eating their food and had the potential to result in nutritional requirements not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents' (Residents 147 and 61) medical records were complete and accurate when:1. Resident 147's hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) record binder and medical record binder contained conflicting Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) forms. This deficient practice had the potential for licensed staff to rely on inaccurate or conflicting information and follow the incorrect POLST during a life-threatening emergency.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control measures for two of 11 sampled residents (Residents 33 and 5) when:1. Certified Nursing Assistant (CNA) 5 failed to implement droplet isolation precautions (infection control measures used to prevent the spread of pathogens transmitted through close respiratory contact) and failed to perform hand hygiene (hand washing with soap or using alcohol-based hand rubs) upon exiting Resident 33's room.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 50 resident rooms accommodated no more than four residents in each room. This deficient practice had the potential to lead to inadequate space to properly care for residents and store residents' belongings and equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet ([sq. ft.])- a unit of measurement) per resident in 31 of 50 residents' rooms (Rooms 1, 2, 3, 4, 5, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 34, 35, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, and 49). This deficient practice could potentially result in residents not being provided with privacy and could potentially affect the residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) wore a cranial helmet (prescribed to residents to protect the head after undergoing a craniotomy [surgery that removes a portion of bone from the skull]) as ordered by the physician. This failure placed Resident 1 at risk for injuries, delayed healing and dehiscence (partial or complete separation of the edges of the resident's surgical incision).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and hazard free environment for two of three sampled residents (Resident 1 and Resident 2), when: 1. Licensed Vocational Nurse (LVN) 1 left Resident 1 unattended and unsupervised at Nurse's Station 3, on 2/14/2025. 2. Activity Staff (AS) 3 left Resident 1 at Nurse's Station 3, without verifying there was a charge nurse present to supervise Resident 1, on 2/14/2025. 3. On 2/25/2025, Resident 1 did not have bilateral fall mats (a cushioned floor pad designed to help prevent injury should a person fall) at her bedside, as ordered by the physician. 4. On 2/25/2025, Resident 1 did not have fall risk indicators outside of her room, or on her Geri-chair (a large, padded chair with a wheeled base, designed to assist individuals with limited mobility), in accordance with Resident 1's care plan. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the primary care physician (PCP), when one of five sampled residents (Resident 2), refused to receive wound care. This failure placed Resident 2 ' s wounds at risk for delayed healing and had the potential for complications such as severe infection, hospitalization, and death, because of the refusal.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Isolation - Categories of Transmission Based Precautions (additional infection control measures used for residents who may have a contagious disease), for two out of five residents (Residents 3 and 4) by failing to: a. Ensure staff wore personal protective equipment ([PPE] protection equipment that includes face shields, gloves, goggles and glasses, gowns, head covers, masks, respirators, and shoe cover to protect against the transmission of germs through contact and droplet routes) prior to entering a contact isolation (a type of infection control precaution used to prevent the spread of infectious diseases that are transmitted through direct or indirect contact with the patient or their environment) room and while inside a contact isolation room. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices in the kitchen when: 1. Dietary Aide (DA 1) did not change gloves between touching food items and nonfood items. 2. Dietary staff did not provide a closed container for the ice scooper. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) and/or implement interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) for five of 27 sampled residents (Residents 39, 65, 72, 92, and 130) by failing to: 1. Implement care plan interventions for floor mats for Resident 72. 2. Failed to ensure Resident 39 was kept clean and dry and did not have to wait five and a half hours to be changed or cleaned, per the care plan. 3. Failed reposition Resident 92 every two hours, per the care plan. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions to prevent formation and/or worsening of pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) were implemented for nine of 27 sampled residents (Residents 39, 92, 24, 83, 72, 6, 19, 120, and 130) when the following occurred: 1. Resident 24's low-air-loss mattress (LALM, an air mattress that's designed to help prevent and treat pressure ulcers) settings did not reflect Resident 24's weight, and Treatment Nurse (TN) 1 failed to clarify Resident 24's LALM orders with Resident 24's physician. 2. Resident 72's LALM settings did not reflect Resident 72's weight. 3. Resident 83's LALM settings did not reflect Resident 83's weight. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP, a resident-centered and activity-based approach for preventing infection spread) for four of 27 sampled residents (Residents 72, 24, 62, and 39). This deficient practice increased the potential for spread of multidrug-resistant organisms (MDROs, a type of bacteria that has become resistant to multiple antibiotics and other antimicrobial agents) among vulnerable facility residents.

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent (process of communication between resident/responsible party and health care provider that often leads to agreement or permission for care, treatment, or services) prior to the administration of psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of bed side rails (metal or plastic bars positioned along the side of a bed for three out of eight sampled residents (Resident 9, 68, and 121). This deficient practice violated Resident 9, 68, and 121's right to make an informed decision prior to the administration of psychotropics and bed siderails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove the identifiable health information (any information that could be used to identify the individual, such as the full name, date of birth , etc.) on the gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, for people with swallowing problems) feeding bottle before the disposition in the trash can for one of 11 sampled residents (Resident 100). This deficient practice had the potential to result in unauthorized disclosure of Resident 100's personal information to unauthorized users.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Revise the care plan when one of 27 sampled residents (Resident 75) did not meet the goals of maintaining her body weight, without additional weight loss. 2. Ensure the Registered Dietician (RD, a healthcare professional who specializes in nutrition and diet) was involved in the care planning for Resident 75's weight loss. These deficient practices increased the potential for Resident 75 to sustain continued and unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 signed the Medication Administration Record (MAR) and Pain Assessment Flowsheet immediately after administering Norco (medication used to treat moderate to severe pain) to one of one sampled resident (Resident 104). This deficient practice had the potential to result in the double administration of medication to Resident 104 that could lead to overdose (ingestion of a drug in quantities greater than recommended which could result in death).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff used a communication board for three of 11 sampled residents (Resident 15, 40, and 84) who did not speak the predominant language of the facility, English. This deficient practice had the potential to negatively affect Resident 15, 40, and 84's physical, mental, and psychosocial needs by preventing the residents from communicating with staff and potentially causing missed or delayed care and/or treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dependent residents were taken out of bed, for three out of eight sampled residents (Resident 5, 14, and 121). This deficient practice had the potential to negatively affect Resident 5, 14, 121's wellbeing, psychosocial status, and potentially cause an isolation of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that floor mats (a cushioned floor pad designed to help prevent injury should a person fall) were placed on both sides of the bed for one of 27 sampled residents (Resident 72). This deficient practice increased the potential for Resident 72, who had a history of falls, to sustain injury from repeat subsequent falls.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure salt alternative seasoning (a product that can be used in place of salt [sodium chloride]) was available for and provided to one of 27 sampled residents (Resident 75), who was on a no added salt (NAS) diet. 2. Refer Resident 75 to the Registered Dietician (RD, a healthcare professional who specializes in nutrition and diet) as ordered by the physician on 9/8/2024. 3. Revise the care plan for Resident 75's weight loss between 8/2024 and 9/2024, when she continued to sustain weight loss. These deficient practices resulted in Resident 75's complaints of unappetizing and flavorless meals, and a self-reported decreased intake of facility-provided meals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services that were in accordance with facility policy for two of 11 sampled residents (Resident 32 and 15), when the facility did not display No Smoking/ Oxygen in Use signs on the outside of the doors of the resident room's or in the room where oxygen was in use for Resident 32 and 15. This deficient practice had the potential to cause fire hazards to all residents, families, visitors, staff, and residents' property, and result in serious harm and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accurate and complete documentation of the administration of Norco (medication used to treat moderate to severe pain) on the Medication Count Sheet for one of one sampled resident (Resident 104). This deficient practice had the potential to result in Resident 104 accidentally being administered an additional dose of Norco before the next dose was due, drug diversion (the act of health care providers stealing prescription medicine for their own use), and/or the potential for medication error to occur.

Inspectors wroteBased on interview and record review, the facility failed to ensure salt alternative seasoning (a product that can be used in place of salt [sodium chloride]) was available for and provided to one of 27 sampled residents (Resident 75), who was on a no added salt (NAS) diet. This deficient practice resulted in Resident 75's complaints of unappetizing and flavorless meals, a self-reported decreased intake of facility-provided meals, and placed Resident 75 at risk for unplanned and undesirable weight loss. This also placed Resident 75 at risk complications of her existing medical conditions, due to seeking out food that was not compliant with her prescribed diet.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified and orders were received prior to providing Tapatio brand hot sauce packets to one of 27 sampled residents (Resident 75), who was on a no added salt (NAS) diet. This deficient practice placed Resident 75 at risk complications of her existing medical conditions due to the high sodium content of the hot sauce packets.

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of three residents (Resident 39, 339 and 107) understood the arbitration (is a way of resolving a dispute without filing a lawsuit and going to court) agreement when Residents 39, 339, and 107 entered a binding contract (an agreement between two or more parties that creates certain obligations that must be adhered to by law) with the facility. This deficient practice resulted in Resident 39, 107, and 339 being unaware that his or her right to resolve a dispute in court was waived due to entering the binding arbitration agreement with the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 50 bedrooms accommodated no more than four residents in each room. This deficient practice had the potential to lead to inadequate space to care for residents, and store residents' belongings and equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms for 31 of 50 residents' rooms. This deficient practice had the potential to result in inadequate space for daily living, and for facility staff to care for the residents.

Inspectors wroteBased on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1), who was transferred to a General Acute Care Hospital (GACH) for refusal of care at the facility and was deemed appropriate to return to the facility. This deficient practice placed the resident at risk for confusion and psychosocial harm related to the inability to return to the facility and unnecessary, extended stay at the GACH.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain was assessed every shift, as ordered, for one of three sampled residents (Resident 1). This deficient practice had the potential to cause avoidable discomfort and distress due to unidentified and untreated pain for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure, one of 3 residents, (Resident 1) was free from injury as indicated in the resident care plan titled, At risk for injuries related to impaired bed mobility, which indicated to provide resident a safe environment. As a result, Resident 1 sled near the edge of the bed during care, resulting to a fracture (broken bone) on the left lower leg that required admission to a general acute care hospital (GACH) for evaluation and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 107 out of the 117 residents in the facility by not: 1. Storing food with received dates, open dates, and use by dates. 2. Discarding expired foods. 3. Properly covering, containing, or wrapping foods exposing them to air and contamination. These deficient practices had the potential to cause food borne illnesses to 107 vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement effective infection prevention measures for two of four sampled residents (Resident 22 and Resident 1) by failing to: 1. Wash or sanitize after the removal of gloves and before putting on a new pair of gloves during the administration of medication for Resident 22. 2. Clean and disinfect a blood pressure (BP) monitor and cuff that was used for more than one resident after each use and prior to storing away in the medication cart (MedCart). 3. Perform hand hygiene upon entering and exiting a room with enhanced standard precautions (an infection control intervention designed to reduce the spread of multidrug resistant organisms in nursing homes) for Resident 1. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignity and feeding assistance during meals to three residents out of 29 sampled residents (Resident 59, 61, and 108) by: 1. Failing to ensure nursing staff fed Resident 59 and Resident 61 at eye level and were not standing over Resident 59 and Resident 61 when assisting the residents with their meal. 2. Failing to provide feeding assistance to Resident 61 and Resident 108 during meals. These deficient practices had the potential to negatively impact Resident 59, 61, and 108's physical needs, nutritional needs, and their psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure that three of 26 sampled residents' (Resident 57, 85, and 97) personal property were protected from loss or theft when: a. Resident 57's clothing was misplaced on three separate occasions. b. Resident 85's cell phone was misplaced. c. Resident 97's yellow necklace and yellow ring were misplaced. This failure had the potential to result in avoidable theft and loss of the residents' personal property, and to negatively affect the residents' psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a resident-centered care plan (document helps nurses and other team care members organize aspects of resident care) with measurable objectives, timeframe, and interventions for seven out of 29 sampled resident (Resident 4, 6, 45, 59, 61, 78, 89, and 108). The facility failed to: 1. Develop a care plan for the prevention of moisture-associated skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, sweat, or wound drainage) for Resident 6, due to the resident's immobility and due to a soiled washcloth being left in the resident's incontinent (inability to control) brief (diaper) for an unknown length of time. 2. Develop a care plan indicating the need for feeding assistance for Resident 59, Resident 61, and Resident 108. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to take preventative measures to prevent skin break down for two out of three sampled residents (Resident 84 and 6) by failing to: 1. Remove a moist, soiled washcloth inside of Resident 6's diaper (incontinence [the inability to control bowel and bladder functions] wear). 2. Reposition Resident 84 every 2 hours. These deficient practices caused Resident 6 to sustain moisture-associated skin damage (MASD, inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, and/or sweat) and had the potential to cause skin breakdown for Resident 84.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's nasal cannula (device used to deliver supplemental oxygen or increased airflow through the nose) was dated and ensure the oxygen concentrator humidifier bottle (medical device that increases the humidity in the nostrils when using supplemental oxygen) was not empty for 3 out of 3 sampled residents (Resident 4, 45, 78). These deficient practices had the potential to cause a negative respiratory outcome and increase the risk for residents to acquire a respiratory infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were properly stored and labeled for three of three residents (Resident 45, Resident 13, and Resident 70). The facility failed to: 1. Ensure Resident 45's expired emergency injectable medication, Glucagon (used to help raise blood glucose [blood sugar] level quickly during an emergency) was removed from the medication cart (MedCart 5) on Nursing Station 3 and replaced. 2. Ensure Resident 13's controlled [high abuse potential] medications, Lorazepam Oral Solution (a psychotropic medication which act on the brain and nerves to produce a calming effect) requiring refrigeration were stored according to the manufacturer's requirements. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device was within reach for one of 26 sampled residents (Resident 37). This failure had the potential to result in a delay or in the inability for Resident 37 to obtain necessary care and services from the facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of a change of condition for one out of six sampled residents (Resident 6) when Resident 6 was exhibiting forceful, rhythmic, sudden, and involuntary (uncontrolled) muscle movements of the torso (shoulders, chest, lower abdomen, back, and buttocks), mouth, arms, legs, and feet. This failure had the potential to cause a decline in Resident 6's health and negatively impact Resident 6's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the responsible party (RP) for one of three residents (Resident 37) was notified and understood the changes to Resident 37's Medicare coverage through provision of the Notice of Medicare Non-Coverage (NOMNC) form and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) form. This failure had the potential to result in Resident 37, or Resident 37's RP, not being able to exercise their right to file an appeal and to choose whether or not to continue with the nursing skilled services.

Inspectors wroteBased on interview and record review, the facility failed to complete the Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) within the regulatory time frame for one of seven sampled residents (Resident 13). This deficient practice had the potential to negatively affect the provision of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's orders for one out of six sampled residents (Resident 6) when the facility did not ensure the following: a. Resident 6's upper bilateral (both sides) bed side rails were padded. b. Resident 6's oxygen concentrator (a machine that delivers oxygen) was set to three liters (l, unit of measurement) per (/) minute (l/min) as ordered. These failures had the potential to cause physical injury and respiratory distress (breathing issues) for Resident 6. Cross Reference F689.

Inspectors wroteBased on interview and record review, the facility failed to follow up on the doctor's referral for an ophthalmology (branch of medicine that deals with the diagnosis and treatment of disorders of the eye) appointment for one out of 29 sampled residents (Resident 108). This deficient practiced caused a delay in treatment for Resident 108 and caused the resident to experience depression (mood disorder that causes persistent feelings of sadness and loss of lowering of a person's mood) due to impaired vision and negatively impacted Resident 108's needs and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement measures to ensure the safety for one out of six sampled residents (Resident 6) when the facility did not pad the left upper rail of Resident 6's bed. This failure had the potential to cause Resident 6 to hit any part of his body against the metal side rail of the bed due to Resident 6's forceful, rhythmic (recurring), sudden, and involuntary (uncontrolled) muscle movements of the torso (shoulders, chest, lower abdomen, back, and buttocks), mouth, arms, legs, and feet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively assess and manage a resident's pain for one of three sampled residents (Resident 69). This deficient practice caused Resident 69 to experience pain while the resident's head of bed was being raised, when repositioned in bed, and when moving her left leg.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who received dialysis treatment (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) was thoroughly and accurately assessed pre and post dialysis treatment in the Dialysis Communication Records for one of one sampled resident (Resident 108) receiving dialysis treatment. This deficient practice had the potential for unidentified complications after dialysis treatment such as swelling, pain, bleeding, and bruising for Resident 108.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accurate and safe pharmaceutical services for one of one residents (Residents 13) when: 1. Resident 13 received one dose of Lorazepam Oral Concentrate medication (a psychotropic medication which act on the brain and nerves to produce a calming effect) stored unrefrigerated inside of a Medication Carts (MedCart) 5 and not in accordance with manufacturer's storage requirement. 2. Resident 13 was administered a PRN (as needed) psychotropic medication (Lorazepam Oral Concentrate) without monitoring documentation to indicated need for use, interventions tried, or effectiveness of therapy. This deficient practice increased the risk for Residents 13 to be exposed to deteriorated and expired PRN medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 106) understood the arbitration (a way of resolving a dispute without filing a lawsuit and going to court) agreement when Resident 106 entered a binding contract (an agreement between two or more parties that creates certain obligations that must be adhered to by law) with the facility. This failure resulted in Resident 106 being unaware that his right to resolve a dispute in court was waived due to entering the binding arbitration agreement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a flying insect from entering one of 26 sampled residents' (Resident 97) room through an open sliding glass door. This failure had the potential to result in the spread of infection to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 50 bedrooms accommodated no more than four residents in each room. This failure had the potential to lead to inadequate space to care for residents, store residents' belongings, and equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms for 31 of 50 residents' rooms. This failure had the potential to result in inadequate space for daily living, and for facility staff to care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their infection control policy and procedure (P&P) by failing to ensure staff donned (put on and use personal protective equipment [PPE, specialized clothing or equipment such as gown and gloves] properly to achieve intended protection) for one of six sampled residents (Resident 1) who was on Enhanced Standard Precautions (an infection control intervention designed to reduce the spread of multidrug resistant organisms [(MDRO) bacteria that are resistant to certain antibiotics). This deficient practice had the potential to cause Resident 1 to get an infection or spread germs to staff and other residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two of eight staff (RCTN and HK 2) wore their face mask properly while inside the facility. This deficient practice had the potential to result in the spread of infection (when viruses, bacteria, or other microbes enter your body and begin to multiply).