Rosemead Healthcare Center

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light (an alerting to assist a resident when needed) was within reach and appropriate to the patient's physical ability for three of three sampled residents (Residents 10, 14, and 26). These failures had the potential to result in a delay in meeting Residents 10, 14, and 26's needs for assistance and placed the residents at risk for a fall, injury or accident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1) was provided with care and services to maintain personal hygiene and nail care, by failing to:1, Ensure Resident 1 was seen by a Podiatrist (a medical doctor who specializes in caring for feet and ankles) as indicated in the resident's care plan.2. Ensure Resident 1's feet were not dry and toenails were trimmed. These deficient practices had the potential to result in a negative impact on Resident 1's health, quality of life and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:a. Provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition/medication directly to the stomach) site as ordered by the physician and as indicated in the plan of care for one of two sampled residents (Resident 53).b. Elevate the resident's head of the bed (HOB) while receiving feeding formula through the GT in accordance with the resident's plan of care and physician's order for one of two sampled residents (Resident 66). These failures had the potential to result in complications related to tube feedings for Residents 53 and 66.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for residents receiving respiratory therapy (a specialized healthcare field focused on assessing, treating, and managing patients with breathing or cardiopulmonary disorders) in accordance with professional standards of practice for two of two sampled residents (Residents 41 and 67) by failing to: a. Ensure Resident 67's bilevel positive airway pressure (BIPAP, a non-invasive ventilator used to assist breathing) mask and nebulizer (a medical device accessory that fits over the nose and mouth to deliver liquid medication directly into the lungs) mask were stored appropriately when not in use. b. Ensure Resident 41's oxygen was set as ordered and nasal cannula tubing was not touching the floor while oxygen was in use. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: a. Ensure three Bisacodyl suppositories (a fast-acting, rectal stimulant laxative used to treat constipation) were labeled with the resident's name and expiration date inside one of one medication storage room refrigerator. This deficient practice had the potential to result in adverse consequences for the residents. b. Ensure one of one E-Kit (Emergency Kit) IV (intravenous) did not have expired Levaquin (antibiotic to treat severe bacterial infections) medication. This deficient practice had the potential to result in harm from administration of expired medication. c. Ensure one of one resident (Resident 15) did not have a bottle of glucose tablets and one tube of diclofenac sodium topical gel (a medication used to relieve joint pain) in the resident's nightstand. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) for one of one facility kitchen. The test strips to measure the concentration of the sanitizing solution inside the red bucket did not have an expiration date. This deficient practice had the potential to result in foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly cover one of three large trash bins as indicated in the facility's Policy and Procedure (P&P) on garbage disposal. This deficient practice had the potential to attract vermin (animals that are harmful and carry diseases) and pests (any living thing that has a negative effect on humans) that could potentially enter the facility, affect the resident care areas, and expose the residents and staff to diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. Keep two of two laundry dryers in a safe and sanitary condition for residents. This deficient practice posed as potential fire hazard.b. Keep electric fans (a powered machine used to create a flow of air to cool and ventilate rooms and control humidity) provided to the residents were in a safe, operating, and sanitary condition for two of two sampled residents (Residents 30 and 90). This deficient practice had the potential to affect Resident 30 and Resident 90's health and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and treat one of one sampled resident (Resident 66) with respect, privacy and dignity in accordance with facility's policy titled Resident Rights - Quality of Life. This deficient practice had the potential to cause psychosocial (mental and emotional well-being) decline and low self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure policies and procedures (P&P) on Advance Directive (AD, a legal document indicating resident preferences on end-of-life treatment decisions) were implemented for one of one sampled resident (Resident 93) by failing to ensure Resident 93's AD information was available in the medical record. This failure had the potential for the facility staff to provide medical treatment and services against the will of Resident 93.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 41) Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment was accurately coded regarding supplemental oxygen (is extra oxygen [a gas essential for life] given to a person to help them breathe when their body is not getting enough oxygen on its own) use. This failure had the potential to result in a delay of necessary care and treatments, incorrect plan of care, and interventions for Resident 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the integrity and proper labeling of a peripheral intravenous (IV, within a vein, a small, flexible tube [catheter] inserted into a vein to deliver fluids, medications, or nutrients directly into the bloodstream) site in accordance with professional standards of practice for one of one sampled resident (Resident 99). This failure had the potential to result in infection and accidental IV dislodgement for Resident 99.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its infection control policy for one of five sampled residents (Resident 91) by failing to ensure Resident 91's urinal filled with urine was not placed on top of Resident 91's side table. This deficient practice had the potential to result in Resident 91 developing an infection.

Inspectors wroteBased on interview and record review, the facility failed to complete a Surveillance Data Collection Form (SDCF) dated 3/24/2026 for one of five sampled residents (Resident 96) receiving antibiotics. This deficient practice had the potential to result in increased antibiotic resistance and providing antibiotics without justification for Resident 96.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy and procedure to conduct a post-fall evaluation and prevention meeting within 72 hours of two unwitnessed falls for a resident who was rated at moderate risk for falls for one of four sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for future additional falls and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) Falls Committee met to review and document findings and interventions addressing the resident's falls on 4/19 and 4/22/2025 for one of two sampled residents (Resident 2) These failures had the potential to result in Resident 2 sustaining injury and/or harm due to falling while in the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical record for one of two sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 failed to document details of Resident 1's fall at the facility on 5/8/2025. This failure resulted in Resident 1's medical record containing incomplete information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a care plan for one of three sampled residents (Resident 1) as indicated in the facility's policies and procedures titled, Care Planning, and Fall Management Program, by failing to: 1. Ensure facility staff implemented Resident 1's care plan for falls dated 10/16/2023 to keep personal items within reach and complete quarterly fall risk assessment per facility's fall protocol. 2. Ensure facility staff developed a comprehensive resident-centered care plan for Resident 1's rights, preferences, and autonomy to be in the dining room during mealtimes. These failures resulted in Resident 1's falls on 3/20/2025 and 4/9/2025. Resident 1 sustained redness to Resident 1's cheek from the fall on 3/20/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan (a plan that outlines resident-specific interventions used to guide a resident ' s care for a given area of concern) for one of three sample residents (Resident 1), a known fall risk, who sustained two falls from the bed on 3/20/2025 and 4/9/2025. This failure resulted in Resident 1 not receiving appropriate care treatments and services and sustaining recurrent falls, which caused Resident 1 to sustain bruising (an injury through unbroken skin resulting in discoloration) to Resident 1 ' s face from a recurring fall on 4/9/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the resident's right to choose where to eat during mealtimes for one of three sampled residents (Resident 1). This deficient practice had the potential to violate Resident 1's rights to self-determination and dignified existence.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the resident's dignity for two of two residents (Residents 75 and 80) by failing to: a. Ensure facility staff provided privacy while putting on the undergarment and pants onto Resident 80 that Resident 80 had removed. b. Ensure facility staff provided privacy when providing peri-care to Resident 75. These failures resulted in Residents 75 and 80's privacy not being maintained and Residents 75 and 80's dignity not being protected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of residents' needs for three of three sampled residents (Residents 20, 50, and 55) by failing to ensure the resident's call light was always within reach. These failures had the potential to result in residents to not receive care and a delay in services to meet the residents' needs and could result in a fall or injury.

Inspectors wroteBased on interview and record review, the facility failed to provide information regarding an Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) for four of six sampled residents (Residents 24, 36, 55 and 190) in accordance to the facility's policy titled Advance Directives. These failures had the potential to result in the facility staff to provide medical or surgical treatment against Residentd 24, 36, 55, and 190's will.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one resident (Resident 238) received care and services for the provision of a midline intravenous (IV) catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm used to safely administer medication into the bloodstream, similar to a cannula [a small tube that is inserted into a vein]) consistent with professional standards of practice, in accordance with the facility's policy and procedure (P&P) titled Midline Dressing Changes and the resident's care plan (a care plan details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the facility's policy titled, Oxygen Administration, for three of three sampled residents (Residents 24, 43 and 292) by failing to: a. Ensure Resident 292's Nasal Cannula (NC, thin flexible tube that delivers oxygen through the nose) tubing was dated. b. Ensure Resident 43's inhalation tubing set was dated and create a care plan (CP) for oxygen use and breathing treatments for Resident 43. c. Place the NC in both nostrils for Resident 24 and post a no smoking sign outside of Resident 24's room when Resident 24 required the use of oxygen. These failures had to the potential for Residents 24, 43 and 292 to experience complications related to oxygen therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of three sampled residents (Residents 36, 66 and 292) who received dialysis (process of removing waste products and excess fluid from the body) had a dialysis emergency kit (E-kit) at the bedside in accordance with standards of practice. These failures had the potential to delay in emergency treatment from complications of the dialysis access site for Residents 36, 66 and 292.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of grab bars (bars installed on the side of the bed)/bed rails/side rails (adjustable metal or rigid plastic bars attached to the bed) for two of two sampled residents (Residents 7 and 8). These failures placed Residents 7 and 8 at risk for entrapment (an event in which resident was caught, trapped, or entangled in the tight spaces around the bed), and injury from the use of grab bars.

Inspectors wroteBased on interview and record review, the facility failed to provide a 24-hour sufficient nursing staffing on seven of thirteen Saturdays and eleven of thirteen Sundays for Quarter 4 of 2024 (July 1 - September 30) consistent with Payroll Based Journal (PBJ, a system for collecting and reporting staffing information from nursing homes and other long-term care facilities) Staffing Data Report. The facility did not meet the required 3.5 nursing hours per patient day on 7/6/2024, 7/7/2024, 7/13/2024, 7/14/2024, 7/21/2024, 8/11/2024, 8/18/2024, 8/25/2024, 8/31/2024, 9/1/2024, 9/8/2024, 9/15/2024, and 9/22/2024. The facility also did not meet the required 2.4 CNA direct care hours per patient day on 7/6/2024, 7/7/2024, 7/13/2024, 7/14/2024, 7/20/2024, 7/21/2024, 8/4/2024, 8/10/2024, 8/11/2024, 8/18/2024, 8/24/2024, 8/31/2024, 9/8/2024, 9/14/2024, 9/15/2024, and 9/22/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post actual nursing information for three of three recertification days inspected (2/4/2025, 2/5/2025 and 2/6/2025). These failure had the potential to misinform the residents and visitors of the actual staffing information and potentially affect the quality of nursing care provided to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for four of five sampled residents (Residents 66, 190, 238 and 294 ) by failing to: a. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a signed Informed Consent from the resident's responsible party (RP) prior to the administration of Ativan (medication used to treat anxiety disorders) 1 milligram (mg), for one of five sampled residents (Resident 26). This deficient practice violated Resident 26 and the RP's right and had the potential for Resident 26 to receive medication Resident 26's RP did not desire.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 85) discharge destination was coded correctly. Resident 85 was discharged to home or community. Skilled Nursing Facility (SNF - care provided by trained registered nurses in a medical setting under a doctor's supervision) but was coded in the Minimum Data Set (MDS - a federally mandated resident assessment tool) as being discharged to a short-term general hospital. This deficient practice resulted in an inaccurate reporting to the Centers of Medicare and Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential to result in Resident 85 to not receive interventions to address specific care concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 189) was provided with a communication device with the language that the resident understood. This failure had the potential to affect Resident 189's communication with the staff and the potential to delay the provision of care, treatment, and services the resident needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice for one of one sampled resident (Resident 292) by failing to turn and reposition Resident 292 every two hours. These failures had the potential for Resident 292 to develop pressure ulcers/bedsores (PU, injuries to the skin and underlying tissue that are result of pressure on the skin for long periods of time).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services in accordance with professional standards to prevent the development of pressure ulcers (PU, injuries to the skin and underlying tissue that are result of pressure on the skin for long periods of time) for one of two sampled residents (Resident 27) by failing to: a. Ensure bilateral heel protectors were on Resident 27 per Medical Doctor (MD) order. b. Ensure Resident 27's low air loss mattress (LAL, medical mattress designed to reduce pressure on the skin to help prevent the development of PUs) was on the correct setting. These failures had the potential for Resident 27 to develop a PU.

Inspectors wroteBased on interview and record review, the facility failed to provide pain management for one of one resident (Resident 140) as indicated in Resident 140's care plan for pain by falling to: 1) Provide non-pharmacological interventions/measures for pain. 2) Notified Resident 140's Medical Doctor (MD) when Resident 4's pain was uncontrolled with the current pain medication/pain management. These failures resulted in Resident 140 experienced pain on the abdomen and had to wait for more than one hour to received pain medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen when expired chicken nuggets were observed in the refrigerator. This failure had the potential to result in foodborne illness if served to the residents.

Inspectors wroteBased on interview and record review, the facility failed to complete a Surveillance Data Collection form for one of 12 sampled residents (Resident 66) receiving antibiotics. This deficient practice had the potential to result in increased antibiotic resistance and providing antibiotics without justification.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedures (P&P) titled, Communication - Call System, for eight of 35 resident rooms (Rooms 7, 20, 21, 24, 25, 26, 29, and 36) by failing to: a. Ensure call lights in the resident rooms were functioning. b. Ensure call bells were provided for the residents in the seven of the eight rooms that did not have a functioning call light. c. Ensure resident safety check rounds were conducted and documented when the residents' call lights were inoperable (not functioning). These deficient practices had the potential to result in the delay of care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered timely for one of seven sampled residents (Resident 3) by failing to ensure Resident 3 received Resident 3's morning medications in a timely manner as indicated in the facility's policy and procedure (P&P), titled, Medication-Administration. This deficient practice had the potential to affect Resident 3 negatively and result in a physical decline to Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure smoking devices were stored in a secure area for one of seven sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) and Resident 1's untitled care plan (CP), dated 6/20/2024, that addressed Resident 1 smoking, when on 8/27/2024, Resident 1 had an electronic smoking device resting on Resident 1's lap. This deficient practice had the potential to result in accidents and resulted in compromised safety to all residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices for 1 of 7 sampled residents (Resident 2) were followed. On 8/26/2024, Resident 2 accessed the meal cart unsupervised, without performing hand hygiene (procedures that include the use of alcohol-based hand rubs [containing 60%-95% alcohol] or hand washing with soap and water) and was able to obtain Resident 2's meal tray without assistance from staff. This deficient practice had the potential to result in transmission of infectious microorganisms (an organism that is seen through a microscope) and increased the risk of infection for the residents whose food trays were in the meal cart.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of two sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 provided two-person physical assistance (help from two persons) to transfer (moving a resident from one place to another) Resident 1 from the bed to the shower chair (a seat for the tub or shower) when CNA 1 used the Hoyer lift (a mechanical device used by staff to lift and transfer residents from a bed to a chair or one location to another). 2. Ensure CNA 1 followed the facility's policy and procedure titled, Total Mechanical Lift, dated 10/1/2023 when CNA 1 transferred Resident 1 with the Hoyer lift/mechanical lift. [...]

Inspectors wroteBased on interview and record review, the facility failed to readmit three of five sampled residents (Residents 2, 3, and 4) to the facility from the General Acute Care Hospital (GACH) after Residents 2, 3, and 4 were cleared by GACH to return to the facility. This deficient practice had the potential to violate Residents 2, 3, and 4's rights to return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), received the copy of the resident's medical records within two working days upon request as indicated in the facility's policy and procedure (P&P) titled, Resident Access to PHI. This deficient practice resulted in a delay of obtaining a copy of Resident 1's medical records for Resident 1's Requesting Party (RP).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Mitigation Plan regarding visitation guidelines for Coronavirus (COVID-19, highly contagious disease caused by the SARS-CoV-2 virus that is spread through inhalation or contact of droplet particles into eyes, nose, or mouth) for one of four sampled residents (Resident 4) by allowing two family members (FM 1 and FM 2) to be inside Resident 4's Novel Respiratory Precaution (newly identified respiratory organism that causes acute respiratory infections which require the use of a N95 [PPE that is used to provide a tight seal on the person's face to prevent particles or liquid contamination of the face], face shield, gown and gloves prior to entering the room) room without donning (put on) on personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision during a smoking session (when a group of residents gathered to smoke) for two of two sampled residents (Residents 1 and 2), while Residents 1 and 2 were smoking at the facility's patio area. Resident 2 pushed a metal table and hit Resident 1's right lower leg and the facility's staff (Receptionist 2) did not notice/intervene. As a result, on 2/19/2024 at 9:15 pm, Resident 1 sustained a laceration (a wound when skin, tissue, and/or muscle was torn or cut open) on Resident 1's right lower leg measuring 14.3 centimeter (cm-unit of measurement) in length, by 1.9 cm in width and by 0.2 cm in depth. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect its resident from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of six sampled residents (Resident 1) when Resident 2 physically assaulted (the act of causing physical harm) Resident 1 on 2/19/2024 at 9:15 pm. Resident 2 pushed the patio metal table and hit Resident 1's right lower leg. As a result, on 2/19/2024 at 9:15 pm, Resident 1 sustained a laceration (a wound when skin, tissue, and/or muscle was torn or cut open) on Resident 1's right lower leg measuring 14.3 centimeter (cm-unit of measurement) in length, by 1.9 cm in width and by 0.2 cm in depth. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to meet professional standard of practice of administering medications through a gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach for medication/food) for one of one sampled resident (Resident 74). This failure had the potential to result in G-tube occlusion and unnecessary tube replacement for Resident 74.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and monitor interventions based on the resident's care plan (a care details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom) and physician (MD) orders for four of four sampled residents (Residents 57, 82,25 and 39) by failing to: a. Follow aspiration (accidental swallowing of food or liquid into the lungs) precautions during feeding for Resident 57; b. Notify the MD of significant vital sign (measurements of the body's most basic functions) changes when Resident 82 had an oxygen (O2) saturation (amount of oxygen circulating in the blood) of 85 percent (%); c. Turn and reposition Resident 25 every two hours per Policy and Procedure (P&P); and d. [...]

Inspectors wroteBased on interview and record review the facility failed to include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Controlled Medication Count Sheet (also known as Controlled Medication or Controlled Substance [CM/CS]- medications which have a potential for abuse) or Individual Resident Controlled Drug Record or Controlled Drug Record for 17 of 17 sampled logs reviewed. The control and accountability of CS awaiting final disposition (process of returning and/or destroying unused medications) did not follow the facility's Policy and Procedure on Documentation of Controlled Medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 6) met the criteria for the use of antibiotic (medication to treat infection) before it was administered. Resident 6 was administered Azithromycin (an antibiotic) Oral Tablet 250 milligrams (mg) without meeting the criteria for the use the antibiotic to ensure it has an adequate indication. This deficient practice had the potential to result in adverse consequences for Resident 6 for the use of antibiotic.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was free of medication error rate of five percent (5%) or greater, as evidenced by the identification of five medication errors out of 29 opportunities for error, to yield a cumulative error rate of 17% for one of five residents during medication administration observation (Resident 74). This failure had the potential for adverse consequences for Resident 74. Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to ensure the Binding Arbitration Agreement (contract that requires the parties to resolve disputes using an arbitrator instead of going to court) provided a selection of a venue convenient for the resident or their representative for three out of three sampled residents (Residents 20, 48, and 57). This failure resulted in residents signing a binding arbitration agreement that is not in compliance with applicable federal and state laws.

Inspectors wroteBased on observation, interview, and record review, the facility failed to disinfect the blood pressure cuff for one of two residents after use from Resident 74 to Resident 65. This failure had the potential to place Resident 65 and other residents at the facility at risk for an infection or disease.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident and/or responsible party (RP) were informed of the risks and benefits of psychotropic medications (a drug that changes brain function and results in altercations in perception, mood, consciousness, or behavior) for one of four sampled residents (Resident 49). This deficient practice resulted in the violation of Resident 49's and/or RP's right to make an informed decision regarding the use of psychotropic medications.

Inspectors wroteBased to observation, interview, and record review, the facility failed to provide privacy while providing bedside care for one of one sampled resident (Resident 74). This failure resulted in the violation of Resident 74's right for personal privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a complete set of window blinds in Resident 65's room to maintain privacy and comfort for one of eight sampled residents (Resident 65). This failure resulted in a lack of privacy and absence of a safe, homelike environment for Resident 65.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a resident's change of condition (COC, a sudden clinical change from a resident's baseline in physical, cognitive, behavioral, or functional domains) after a significant vital sign change (measurements of the body's most basic functions) for one of three sampled residents (Resident 82) when Resident 82 had an oxygen (O2) saturation (amount of oxygen circulating in the blood) of 85 percent (%.) This failure had the potential to result in Resident 82 to develop a respiratory complication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven residents (Resident 70) reviewed for Limited Range of Motion [ROM, full movement potential of a joint (where two bones meet)] was assessed accurately. For Resident 70, the Range of Motion for the upper extremities was not accurately assessed to reflect resident's limitation in the range of motion on her right upper extremity (wrist and hand). This deficient practice had the potential risk for Resident 70's activities of daily living (ADL, such as bed mobility, eating, dressing, and hygiene) to decline resulting from limitation in range of motion of the resident's right hand/fingers .

Inspectors wroteBased on interview and record review, the facility failed to develop a specific and individualized person-centered care plan (details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom) to meet the residents' needs for two of two sampled residents (Residents 43 and 56). a. A care plan was not developed for Resident 43 who was assessed as high risk for fall upon admission on [DATE]. b. A care plan was not developed for Resident 56 who was assessed as high risk for fall prior to Resident 56's incidents of fall on 7/31/23 and 11/15/23. These deficient practices had the potential for Residents 43 and 56 not to receive necessary care, treatment, and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an effective communication method to one of two non-English speaking sampled residents (Resident 74). This deficient practice had the potential for Resident 74 not to receive necessary care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of four sampled residents (Resident 70) reviewed for nutrition, the necessary assistance in a timely manner during a lunch dining observation. This deficient practice placed Resident 70 at risk for weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the low air loss mattress (LAL, a bed that alternates pressure to help heal and prevent pressure injuries) was set correctly for one of one sampled residents (Resident 4). This failure had the potential to prevent healing and worsen Resident 4's facility acquired pressure ulcer (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled residents (Resident 74) who was receiving tube feeding (TF, liquid form of nutrients given to people who cannot eat or drink by mouth safely) through a gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach, can be used to give nutrition and/or drugs), had the head of bed (HOB) elevated to at least 30 degrees during tube feeding. This failure had the potential to result in aspiration (when small particles of food or drops of liquid are breathed into the lungs) leading to aspiration pneumonia (an infection that occurs in the lungs due to aspiration), other complications and death to the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to post accurate staffing information of actual hours worked by staff directly responsible for resident care per shift daily. The staffing information included the actual worked hours of the Minimum Data Set (MDS) nurse that was not directly responsible for resident care. This deficient practice of posting inaccurate staffing information could mislead the residents and visitors that may affect the quality of nursing care provided to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four sampled residents (Residents 12 and 64) on psychotropic drugs (any drug capable of affecting the mood, emotions, and behavior) were free from unnecessary medication, by failing to ensure: a. Staff attempt Gradual Dose Reduction (GDR-tapering down the medication dose) of Resident 12's Seroquel (antipsychotic drug) 25 milligram ([mg] unit of measurement) since ordered on 11/29/22. b. The use of PRN (as needed) orders for psychotropic drugs were limited to 14 days. Resident 64's PRN order for Trazodone HCL (antidepressant drug) 50 milligrams ([mg]unit of measurement) at bedtime was beyond 14 days from 12/20/23 through 1/30/24 (41 days) without documented rationale (a logical basis for a course of action) from the prescribing physician for the extended use of Trazadone HCL. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Binding Arbitration Agreement (a contract that requires the parties to resolve disputes using an arbitrator instead of going to court) indicated the resident or their representative had a right to rescind (withdraw) the agreement within 30 calendar days of signing it for one of three sampled residents (Resident 57). This failure had the potential to result in Resident 57 signing a binding arbitration agreement that is not in compliance with the applicable federal and state laws.