Royal Palms Post Acute

Inspectors wroteBased on interviews and records review, the facility failed to ensure a safe and appropriate discharge for one of two sampled residents (Resident 1), who left for an out-on-pass (OOP- temporary leave an admitted patient has official, temporary permission from their doctor to leave a hospital or care facility for a short, set amount of time before returning to finish treatment) on 7/27/2026 by failing to: Ensure Resident 1 signed out of the facility onto the out on pass log on 7/27/2026 in accordance with the facility's Policy and Procedure (P&P) titled, Signing Residents Out. Inform Resident 1 the clinical risks for discontinuing care at the facility in accordance with the facility's P&P titled, Discharging a Resident Against Medical Advice. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a facility does not discharge a resident in an unsafe manner, to a location that does not meet the resident's needs, does not provide needed support and resources, and does not meet the resident's preferences for one of three sampled residents (Resident 1) on 5/14/2026, after Resident 1 was discharged from General Acute Care Hospital (GACH) 1 with an order to discharge to a Skilled Nursing Facility (SNF) level of care. The facility did not follow required processes for a safe and appropriate discharge by failing to: 1. Ensure effective discharge planning to support a safe and appropriate transition to a lower level of care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide physical therapy, (a healthcare specialty focused on restoring movement, reducing pain, and improving overall function) five (5) times a week in accordance with the physician's order for one of two (2) sampled residents (Resident 4). This deficient practice had the potential to place Resident 4 at risk for decline in functional mobility.

Inspectors wroteBased on interview and record review the facility failed to ensure informed consent (the process in which a healthcare professional explains the risks, benefits, and alternatives of a procedure to a person, ensuring they fully understand it before agreeing to participate was obtained prior to the use of psychotropic medications for one of two sampled residents (Resident 2) in accordance with the facility's policy and procedure (P&P) titled Informed Consent for Psychotropic Drugs. This deficient practice had the potential to violate resident' rights to be informed prior to administering medications without their knowledge or approval. This also placed the resident at risk for unnecessary chemical restraint (the use of medication to intentionally slow down, sedate, or control a person's movements and behavior) that limit their ability to participate in care decisions.

Inspectors wroteBased on interview and record review the facility failed to prevent a physical abuse (a type of abuse that uses physical force) one of two sampled resident (Resident 1) when: The facility did not follow physician order to send Resident 2 to the General Acute Community Hospital emergency room for psychiatric evaluation on 4/30/2026. Certified Nurse Assistant (CNA 1) left Resident 1 alone with Resident 2 (Resident 1's roommate) after Resident 2 had attempted to hit Resident 1 on 5/28/2026. CNA 1 did not separate Resident 2 from Resident 1 when Resident 2 was actively hitting Resident 1 with the water pitcher on 5/28/2026. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 4) who was assessed as a high risk for pressure injury (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result pressure in combination with shear) received services to protect skin integrity (state of being intact, healthy, and free from damage), promote healing, and prevent development and worsening of pressure injury by failing to ensure toileting hygiene was done after Resident 4 had a bowel movement and not wait for one hour in accordance with Resident 4's care plan to keep skin clean and dry. This deficient practice had the potential to result in a delay in promoting healing of a pressure ulcer.

Inspectors wroteBased on observation, interview and record review the facility failed to administer continuous oxygen (O2) therapy (a treatment that provides you with supplemental, or extra, oxygen. The administration of O2 at concentrations greater than that in ambient air [20.9%] with the intent of treating or preventing the symptoms and manifestations of hypoxia [decreased perfusion of oxygen to the tissues] and respiratory therapy [services that are provided by a qualified professional such as respiratory therapists or respiratory nurse] for the assessment, treatment, and monitoring of residents with deficiencies or abnormalities of pulmonary function) as ordered by the physician for one of four sampled residents (Resident 5). This failure had the potential to put Resident 5 at risk of breathing difficulty including respiratory arrest (completely stop breathing) due to the lack of oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and comfortable environment for one of two sampled residents (Resident 3) as indicated on the facility policy by failing to provide resident with a comfortable and safe bed. This deficient practice resulted in Resident 3 experiencing discomfort which could negatively affect Resident 3's overall well-being and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to assess and monitor in accordance to the facility's policy and procedures and professional standard of practice for one of three sampled residents (Resident 1) who was readmitted to the facility and transferred to a Board & Care (B&C) by failing to: Ensure Registered Nurse (RN) 1 assessed and monitored Resident 1's condition by checking the blood pressure (BP), heart rate (HR), respiratory rate (RR), oxygen saturation level, and pain level and documented in Resident 1's clinical record when resident was readmitted to facility and transferred to a B&C.Ensure RN 1 conducted a full head to toe assessment when Resident 1 was readmitted to facility and transferred to a B&C.Ensure RN 1 notified Resident 1's responsible party to inform them of Resident 1's readmission to facility and transfer to B&C. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure physician's order for rehabilitation (Rehab- therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) physical therapy (PT- helps improve strength, flexibility and mobility) was implemented or one for three sampled residents (Resident 4), who had impaired functional mobility in the lower extremities. This deficient practice had the potential for Resident 4 to have a decline in strength and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: a. One (1) of four (4) dumpsters (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts) was not completely closed and was overflowing with trash when not actively in use. b. The garbage container by the preparation area was not completely covered when not actively being used in the kitchen. These failures had potential to attract birds, flies, insects, pests and potentially spread infection to 124 of 124 facility residents.

Inspectors wroteBased on interview and record review, the facility failed to complete the Advance Directive Acknowledgment Form (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) with signature to indicate whether an advance directive has been executed, for three of three sampled residents (Resident 7, 9, and 87). This failure had the potential to result in a lack of clarity regarding the residents' healthcare wishes and may impact on the facility's ability to honor those wishes.

Inspectors wroteBased on staff interview and record review, the facility failed to provide sufficient nursing staff to meet the resident needs for five (5) of five (5) sampled residents (Resident 10, 43, 44, 46, 104) in accordance with the facility's policy and procedure titled Staffing, Sufficient and Competent Nursing. On 4/4/2026, during 11PM-7AM shift, only two (2) out of seven (7) scheduled Certified Nursing Assistants (CNAs) reported to work and were responsible for providing care for all of the residents in the facility while five (5) other CNAs were no call/no show (when an employee misses a scheduled work shift without notifying their employer). This deficient practice resulted in the residents' dissatisfaction and getting upset due to delays in assistance with activities of daily living (ADLs). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when pureed (a smooth, thick liquid or paste made by mashing, blending, or straining cooked food) cream of rice was flat on the plate and did not hold its shape. These failures had the potential to result in difficulty in swallowing, decrease in food and nutrient intake to 15 of 15 residents on puree diet (food that are soft and pudding like consistency), resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: Kitchen equipment and utensils were not free from dirt, dust and food debris. Reach-in freezer bottom shelves by the walk-in refrigerator had dirt and cardboard boxes debris. Reach-in freezer bottom shelves by the ice machine had dirt, dust and cardboard boxes debris. Dry storage floor had dirt and trash accumulation in the corner. Kitchen utensils drawer and pots and pans storage area had food debris. Pots and pans storage area had dirt and food debris. 2. Reach-in freezer temperature was at 15 degrees Fahrenheit ( F, a scale of temperature) on 4/6/2026, and 7 F on 4/7/2026 and blank on 4/3/2026 in the afternoon shift. Two trays of sandwiches were not labeled and dated. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe storage (refrigerator) designated for resident's leftovers or food coming from the outside source to 124 of 127 residents. This failure had the potential to result in spoiled food and food borne illness (a disease caused by consuming food and drinks that are contaminated by germs or chemicals) to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 wore an isolation gown when providing high-contact resident care activities (activity of daily living or ADL tasks that require close, prolonged physical interaction between staff and residents, likely to transfer germs to a caregiver's hands or clothing) for one of four sampled residents (Resident 84) who was placed on Enhanced Barrier Precautions (EBP-an infection prevention and control intervention to reduce the spread of multidrug resistant organisms [MDRO- disease causing organism resistant to medication used to treat infection]) due to multiple vascular ulcers (a slow-healing, open sore on the leg or foot caused by poor circulation) on the resident's left foot. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain or enhance resident dignity for 2 of 6 sampled residents (Resident 121 and Resident 93) by failing to ensure: 1. A privacy bag/cover was placed over Resident 121's urinary drainage container (a bag/container that stores urine after it leaves the body), which exposed the contents and compromised the resident's dignity. 2. The Certified Nursing Assistant (CNA 4) did not stand while assisting Resident 93 with meals to maintain an eye level during a meal service. These deficient practices have the potential to cause embarrassment, loss of dignity, privacy, and emotional distress for residents and not promoting a dignified dining experience could make residents feel rushed, disrespected, or uncomfortable during care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an informed consent for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) drug for one of five sampled resident (Resident 14) who was prescribed Zyprexa (medication used to treat a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). This deficient practice had violated Resident 14's rights to be informed when choosing the type of care or treatment to be received, make informed decisions on alternative measures the resident or responsible party preferred, which can negatively affect Resident 14's quality of life.

Inspectors wroteBased on observations, interviews, and records facility failed to notify the primary physician for significant change in condition to one of one sampled resident (Resident 140) who refused to have the laboratory blood test drawn for PT (Prothrombin time) / INR (International Normalized Ratio-a test that measures how quickly blood clots) for three consecutive days (3/31/2026, 4/1/2026 and 4/2/2026) while on warfarin ( a medication use as blood thinner to prevent development of blood clots) therapy for chronic pulmonary embolism (life-threatening condition due to sudden blockage in the arteries in the lungs). In addition, the facility did not have notify the physician that Resident 140 did not receive Warfarin on 4/1/26 and 4/2/26 due to refusal of blood draw in accordance with the facility's policy and procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 6 sampled residents (Resident 30) was free of unnecessary physical restraints (any manual method that is attached or adjacent to a residents body that restricts freedom of movement or ability to move independently) in accordance with the facility's policy and procedure titled Use of Restraints. Resident 30 was observed with pillows on both sides of the bed tucked under mattress sheet creating a concave surface which restricted Resident 30's ability to reposition self independently. This deficient practice has the potential for increased risk for pain, decreased range of motion, and loss of functional mobility from restricted freedom of movement and inability to independently reposition. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive, resident-centered care plan (CP, a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for two of three sampled residents: 1. Resident 22, who was assessed as high risk for wandering. Resident 22's care plan included generalized interventions that were not individualized or specific to effectively address or prevent the resident's continued wandering throughout the facility. 2. Resident 141, who had a history of epilepsy (a brain condition that causes recurring seizures [abnormal electrical activity in your brain]) that addressed the risks for injury. The resident CP did not specify the interventions on how to keep the place safe and hazard free. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of eight sampled residents (Resident 17) had a correct identification (ID) band that was not attached to the right-side bed rail of the resident, in accordance with professional standards of practice. This failure had the potential to place the resident at risk for receiving the wrong medication, the wrong meal, and incorrect treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 11) with limited range of motion (ROM- the extent of movement of a joint) on his left fourth (4th ) and fifth (5th) fingers received appropriate treatment and services to maintain mobility and/or improve mobility by failing to ensure: 1. The certified nurse assistants (CNAs) assigned to Resident 11 reported to the licensed staff in charge of the resident's decline in ROM during daily care. 2. The licensed nurse completed a change of condition (COC) report and developed a Care Plan (CP) to prevent/minimize contractures (a stiffening/shortening at a joint, that reduces the joint's range of motion) as indicated in the resident's care plan and in the facility's policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a hazard free environment to one of three sampled residents (Resident 141), who had a history of epilepsy (a brain condition that causes recurring seizures [abnormal electrical activity in your brain]) when Resident 141's bed had no padded side rails and was not kept at the lowest position on 4/8/2026. This deficient practice had the potential to result in Resident 141's injury in the event of falls while a seizure occurs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically-related social service in accordance with the facility's policy and procedure titled Social Services- Referrals for one of thirteen sampled residents (Resident 11), who had missing teeth and had requested new dentures (removable oral appliances that replace missing teeth). The facility failed to follow up with the dental clinic for Resident 11's X-ray (a fast, painless imaging test that uses special, invisible type of light to take pictures of the inside of a human body) results and follow up with the resident's primary physician for medical clearance (an official, written authorization stating that a person is healthy enough to undergo a specific procedure) to proceed with his teeth extraction and denture fabrication procedure as recommended by the resident's dentist. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 11) received necessary care and laboratory services to confirm diagnosis when Resident 11 experienced signs and symptoms of urinary tract infection (UTI- an infection in the bladder/urinary tract) by failing to perform in and out catheterization (a procedure used to drain the bladder and collect urine with a straight tube that is taken out right after it is used) and obtain urine specimen for urinalysis (UA- a test of urine), culture and sensitivity (C&S- the standard test for revealing the causative microorganism for a UTI) as indicated in the physician's orders. This deficient practice had the potential to delay necessary treatment to Resident 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and temperature when hot foods were not in palatable temperature and pork chops were hard and overcooked. These failures had potential to result in 124 of 127 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff accurately reflect actual Wander Guard (a type of wearable device used in healthcare facilities, to prevent residents from wandering or eloping) function testing documentation in one of two sampled residents (Resident 15), who was identified at risk for elopement (when a person with cognitive [thought process] impairment leaves a safe area, such as a care facility or home, without awareness of the potential dangers). Licensed Vocational Nurse (LVN) 2 did not perform Wander Guard function test but signed Resident 15's Medication Administration Record (MAR) for Monitor Wander Guard Functioning Q shift (every shift) 7-3 shift on 4/2/2026, 4/3/2026, and 4/9/2026. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement its antibiotic (medicines that fight bacterial infections) stewardship program (facility protocols for managing infections) for one of three sampled residents (Resident 11) who was prescribed Bactrim (a common prescription antibiotic used to treat various bacterial infections) DS (double strength) for suspected urinary tract infection (UTI- an infection in the bladder/urinary tract) by failing of the Infection Prevention Nurse (IPN) tracked the physician' order on 4/4/2026 for Resident 11's urine specimen collection, confirmed that the specimen was sent to laboratory, and followed up on lab results for urinalysis (UA- a test of urine), culture and sensitivity (C&S- the standard test for revealing the causative microorganism for a UTI) in a timely manner to ensure appropriate antibiotic treatment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of eight sampled residents (Resident 122 and Resident 155) were able to utilize their call light. This failure had the potential to affect the residents' ability to request assistance when needed. Fingins: 1. During a review of Resident 122'sFace Sheet, the Face Sheet indicated the resident was admitted on [DATE], with the diagnosis that include metabolic encephalopathy (a sudden or gradual decline in brains function caused by chemical, metabolic or organ problem), epilepsy (a chronic brain disorder characterized by recurring, unprovoked seizures caused by sudden, abnormal electrical activity) and transient ischemic attack (a temporary blockage of blood flow to the brain, causing stroke like symptoms). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a care plan was developed and implemented for one of two sampled residents (Resident 1) who was at risk for falls. This deficient practice had the potential to place Resident 1 at risk for fall and injury from a fall.

Inspectors wroteBased on interview and record review the facility failed to develop a resident centered care plan with specific interventions for one of three sampled residents (Resident 1) to address behaviors of wandering into other resident' rooms. This deficient practice had the potential to compromise the safety, privacy and dignity of other residents and increased the risk for resident - to resident altercations and psychosocial distress. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP, extra protective steps staff use during hands- on care to prevent the spread of germs) as ordered by Physician on 11/18/2025 for one out of three sampled residents ( Resident 3). This deficient practice of not implementing physician's orders had the potential to result in the spread of infectious bacteria or other disease - causing organisms to other residents and staff, development of healthcare - associated infections, worsening of existing wounds, sepsis, and possible hospitalization. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's infection prevention and control program (IPCP) for four of four sampled residents (Residents 1, 2, 3, and 4) by failing to: 1. Initiate and monitor a Line List (a tool used for data collection and systemic case tracking and surveillance during outbreaks) for residents and staff suspected of having scabies on 2/4/26 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility's Policy and Procedure (P&P) for Administering Medications and Documentation of Medication Administration for three of five sampled residents (Resident 2, 3, and 4) by failing to:Administer ordered medications within one hour before or one hour after the physician's ordered time. Document medications after, and not prior to medication administration. This deficient practice resulted in the delay of medication administration for Resident 2, 3, and 4, and had the potential for residents' health to be compromised.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and a hazard free, safe and secure environment for three (3) of three sampled residents' (Resident 1, 2, and 3) at risks of falling by failing to: 1. Ensure that Resident 1 with unsteady gait was monitored and not left unsupervised while in the bathroom. 2. Ensure that Resident 2's bed was kept in lowest position for risks for fall. 3. Ensure Resident 3's call light was always within reach and was monitored by other staff while Certified Nursing Assistant (CNA) 1 was on break. As a result, Resident 1 sustained a four (4) centimeter (cm- a unit of measurement of length) hematoma (blood in the tissues) on right forehead, transferred to GACH 1 and was diagnosed with left non-traumatic intracranial hemorrhage (ICH- brain bleeding) due to a fall on 10/29/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 3), who was unable to carry out activities of daily living (ADLs), was assessed and changed timely for wet and soiled incontinence brief (an undergarment used when one has no control bladder and bowel) as indicated in the resident's care plan. Resident 3 was observed with soiled incontinence brief with urine and feces at 2 PM, Certified nurse assistant (CNA) 1 explained Resident 3 was last checked for incontinence at 8 a.m. on 12/30/2025. This deficient practice resulted in Resident 3 developed skin irritation and had the potential for skin breakdown and urinary tract infection (an inflammation in the bladder/ urinary tract). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of one sampled resident (Resident 1), who was assessed as self-responsible and capable of making decisions was accurately documented in the medical record. Resident 1's discharge to the facility was incorrectly recorded as leaving against medical advice (AMA- defined as those residents who chose to leave before the treating physician determined it was medically safe or appropriate), on 12/22/2025. Resident 1's records did not indicate the basis of the discharge, in accordance with the facility's policy and procedure (P&P) titled Transfer of Discharge Documentation and Transfer or Discharge, preparing a Resident for. This failure resulted in violating Resident 1's rights and was involuntarily discharged from the facility on 12/22/2025. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to develop and implement resident centered care plan interventions and interdisciplinary team involvement for one of two sampled residents (Resident 1), who had a behavior and history of leaving the facility without permission and failing to return from out on pass, in accordance with the physician's order. The facility did not initiate behavioral interventions, or document strategies to address repeated non-compliance and unsafe behaviors of leaving facility without permission. Resident 1 left the facility without permission on 12/16/25 with no documented evidence of Resident 1's status when he came back to the facility. Resident 1 left the facility after being dropped off to the Dialysis center on 12/20/25 and did not come back to the facility until 12/31/25. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure infection prevention and practices were implemented for three of three sampled residents (Resident 1, 2, and 3) in accordance to the facility ' s Policy and Procedure (P&P) titled Infection Prevention and Control Program, by failing to: 1. Ensure Resident 1 was immediately placed on isolation (the separation of a patient from others to prevent the spread of infections or to protect them from potential harm due to their own vulnerabilities) after the physician ordered Resident 1 to be transferred to the General Acute Care Hospital (GACH) for a diagnosis of impetigo (a contagious skin infection). 2. Ensure Resident 2 and Resident 3 were placed on isolation after being exposed to Resident 1. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement the facility's Infection Prevention and Control Program (IPCP) for 27 of 129 residents (Residents 1 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30) when: 1. The facility failed to initiate surveillance tracking and interventions for the 26 affected residents when the Local Health Officer's Public Health Nurse (PHN 1) informed the facility's Director of Nursing (DON) on 3/27/2025 that Resident 1 tested positive for Carbapenem-Resistant Acinetobacter baumannii (CRAB) Tier 2 (an antibiotic resistant, communicable rare disease) right leg wound. 2. The facility failed to notify Resident 1's Primary Medical Doctor (PMD) 1 that Resident 1 had a positive right leg wound culture (CRAB) Tier 2. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse (food waste, scraps) properly by not having a lid on one of four metal dumpsters (large trash container designed to be emptied into a truck) which was overflowing with boxes, and garbage area with food waste on the ground and littered with rubbish such as dirty crates, broken chairs, broken carts, broken shelves, etc. This deficient practice had a potential to attract insects and harbor pests, attract birds, flies, insects, pest, rodents, which could spread infection to residents and staffs in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of one out of four sampled residents (Resident 31) by ensuring the resident's call light (a device used to alert staff to the resident's room) was within their reach (within arm's reach) as indicated in the resident's plan of care. This deficient practice had the potential for Resident 31 not to receive or receive delayed care and services that could result in accidents and falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow up a Preadmission Screening and Resident Review (PASRR - a federally required screening for mental health; PASRR Level I identify suspected mental illness, intellectual/developmental disability, or related condition; Level II screening determines if the individual would benefit from specialized mental health services) evaluation for one of three sampled residents (Residents 10) who was assessed as having a positive level I screening on 11/15/2023, that indicated a level II mental health screening. This failure had the potential to result in Resident 10 not to receive care and services in the most integrated setting appropriate to his mental needs, which can negatively affect his quality of life.

Inspectors wroteBased on interview and record review, the facility failed to update and implement a resident centered care plan for one of three residents (Resident 29) who was admitted to the facility with pressure developed a left upper buttock Stage 1 pressure injury (an intact skin with non-blanchable redness [meaning the area doesn't turn white when pressed] that developed due to prolonged unrelieved pressure and friction). This deficiency practice had the potential to result in the development of new and worsened pressure injury for Residents

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 11) care plan was revised and updated according to the residents current plan of care for the use of Febuxostat (an oral medication used to control gout [a disease that causes inflammation of the joints that causes pain and swelling]). This deficient practice had the potential for facility staff to not monitor the effectiveness or ineffectiveness of Resident 11's health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a communication tool or device that translate to a language the resident could understand for one of three residents (Resident 28) who does not speak the formal language in the facility. This deficient practice prevented Resident 28 from communicating with the staff the necessary needs that could delay in the resident receiving appropriate care/treatment the resident needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary care and services to residents who was dependent with the staff to carry out activities of daily living (ADL) for one of one sampled resident (Resident 10) who had communication problems related to slurred (speech are weak or are hard to control) and was at risk for fall by not ensuring Resident 10 ' s call light was within reach to be used to communicate needs with the staffs. This deficient practice had the potential for Resident 10 not to receive the necessary care and treatments timely especially in an event of emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 9 and Resident 29), received care to prevent the development of pressure injuries (PI, areas of skin and underlying tissue damage caused by prolonged pressure) in accordance with the facility's policy and procedure and care plans by failing to ensure: 1. Resident 9, who had a history of PI and was on a low air loss mattress (LAL- mattress designed to prevent and treat pressure sore [a skin breakdown due to unrelieved pressure and friction to the skin]), had the LAL correctly set at Resident 9's current weight as indicated in the manufacturer ' s guidelines to prevent and/or minimize skin pressure on the bony prominences of the body. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of four sampled residents (Residents 116 and 69) received oxygen treatment as defined in the facility ' s policy and procedures when: 1. Resident 116's nasal cannula (a thin plastic tube that is placed in the nostril) was observed on the floor, and not on the resident's nostril. 2. Resident 69 was administered oxygen without a physician's order. This deficient practice had the potential to place Resident 116 at risk for inadequate oxygenation that could lead to (a serious medical condition where the lungs are unable to adequately exchange oxygen and carbon dioxide in the blood) and for Resident 69 to receive excessive oxygen which could result in oxygen toxicity (develop toxins in the body and result in lung damage due breathing in too much oxygen).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure on Transmitting Medication Orders by failing to reorder a scheduled medication (Finasteride oral tablet, a drug to treat an enlarged prostate [a condition where the prostate gland grows larger than normal]) in a timely manner for one of three sampled residents (Resident 15). As a result, Resident 15 did not receive Finasteride 5 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) during a medication pass observation because the medicine was not available in the medication cart. This deficient practice had the potential to result in complications related to enlarged prostate such as difficulty with urination and worsen the health condition of the resident.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure on charting and documentation by failing to ensure that the resident has signed the POLST (Physician ' s Orders for Life-Sustaining Treatment, a portable medical order form that documents a patient's preferences for end-of-life care) for two of ten sampled residents (Resident 24 and Resident 179) before placing it in the resident ' s chart. This deficient practice can lead to misdiagnoses, inappropriate treatment, and gaps in patient care that could result to adverse health outcomes.

Inspectors wroteBased on observation and interview the facility failed to maintain a safe, sanitary and clean homelike environment by ensuring 2 of 2 bathrooms observed (Bathroom [ROOM NUMBER] and Bathroom [ROOM NUMBER]) did not have paint bubbling and peeling off the wall behind the sink and the bathroom sink had no light brown discoloration on grout sealer around sink and a white residue around faucet head. This deficient practice had the potential for the residents to be at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receives adequate supervision to prevent accidents for two of two sampled residents out of 16 smokers (Residents 104 and 79) in accordance with the acility ' s smoking policy and facility document titled smoking/vaping risk evaluation, who were observed with a cigarette lighter in their possession. This deficient practice had the potential to cause a fire or accidents especially in a facility that uses oxygen, which can negatively affect the life and safety of residents and staff.

Inspectors wroteBased on observation, Record review and interview, the facility failed to ensure 40 out of 54 residents' rooms meet the square footage requirement of 80 square feet per resident ' s room. The 40 resident's rooms consisted of 5 two bedrooms and 35 - three bedrooms. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for facility staff.

Inspectors wroteBased on interview and record review the facility failed to notify the resident ' s representative (RR) a change of condition for one (1) of three (3) sampled residents (Resident 1) by failing to notify the RR Resident 1 ' s diabetic ulcer by not implementing the facility ' s policy & procedure (P&P) titled, change in a Resident ' s Condition or Status, revised May 2017. The P&P statement indicated Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident ' s medical/mental condition and/or status (e.g. changes in level of care). [...]

Inspectors wroteBased on interview and record review the facility failed to develop a person-centered care plan (a treatment plan that focuses on the needs and preferences of a patient or individual) for one (1) of three (3) sampled residents (Resident 1). Resident 1 did not have a resident specific care plan for Prevalon boots (a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure), and the care plan did not include interventions on how to maintain the Prevalon boots. These deficient practices were lack of individualized focused quality care that provided to Resident 1 and had the potential to lead to worsening or irreversible of condition.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedures for one of four sampled residents (Resident 1), who is dependent on Dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly. It often involves diverting blood to a machine to be cleaned) by failing to: 1. Develop and implement a comprehensive person-centered care plan when Resident 1 repeatedly refused prescribed scheduled medications, vitamins, and supplements. 2. Ensure Resident 1 ' s responsible party (RP 1) was informed about Resident 1 repeatedly refusing prescribed medications, vitamins, and supplement; and communicate the resident ' s status to the Dialysis center. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve therapeutic pureed textured diet (food that have a soft, pudding-like consistency as prescribed by the physician) in accordance with resident's plan of care and preference for one of three sampled residents (Resident 1). Resident 1 had a tooth extraction of the lower gums 8/19/2024 that resulted in soreness of the gums verbalized to the staffs to be served a pureed textured diet (two days from the day of tooth extraction), but the facility continued to serve Resident 1 regular textured diet (food that does not require modification). This deficient practice resulted in Resident 1 ' s frustration of being served regular textured diet and refusal to eat meal due to discomfort which could result in weight loss and decline in overall health of the resident.

Inspectors wroteBased on observation, interview, and record review, the nursing staff did not revise the diabetes mellitus (a disease occurs when a person ' s blood sugar is too high) care plan for one of three sampled residents (Resident 1) by: 1. Not addressing Resident 1 ' s new order for longterm acting insulin- Lantus (medication to lower blood sugar) dated 6/11/24 in the current active care plan. These deficient practices had the potential for the residents to not receive appropriate care treatment and/or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality for one of three sample residents (Resident 1) by: 1. Not ensuring to notify the physician for a medication alert for Lantus (medication to lower blood sugar) daily dose was below the usual dose on 6/11/2024 for Resident 1. 2. Not ensuring Resident 1 endocrinology consult was ordered on 6/6/2024 for an elevated hemoglobin A1C (blood test that measures blood sugar levels that helps diagnose diabetes (a disease occurs when a person ' s blood sugar is too high)) on 6/5/2024. These deficient practices had the potential to result in Resident 1 having an unintended complication related to the management of high blood sugar such as diabetic ketoacidosis (complication from high blood sugar levels) which can lead to coma or death.

Inspectors wroteBased on interview and record review, the facility failed to provide social services for one out of three sampled residents (Resident 1) by failing to follow up on the physician's order for endocrinology consult for an elevated hemoglobin A1C (blood test that measures blood sugar levels that helps diagnose diabetes (a disease occurs when a person ' s blood sugar is too high) on 6/5/2024. This deficient practice had the potential for delay in the delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to respond to the grievance (an official statement of a complaint over something believed to be wrong or unfair) for one of three residents (Resident 2) when Resident 2 verbalized to facility staff of wanting to file a grievance. This failure resulted in Resident 2's grievance not being addressed.

Inspectors wroteBased on interview and record review, the facility failed to monitor the behavior for one of three residents (Resident 1) for the use of Trileptal (medication for convulsions) Oral Tablet 150 mg for Resident 1's behavior of hitting staff and throwing objects. As a result of the failure, Resident 1's behavior was not monitored for effectiveness of the prescribed medication, placing Resident 1 at risk for an unnecessary medication.

Inspectors wroteBased on interview, and record review, the facility failed to immediately contact and communicate with the attending physician/practitioner regarding any significant changes in the resident ' s status that may impact the dialysis portion of the care plan for one of two sampled residents (Resident 1), who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments. The facility ' s licensed nurse failed to notify Physician 1 on 4/13/2024 after Resident 1 missed his dialysis treatment due to transportation issues. In addition, the facility failed to promptly inform Physician 1 the second time, Resident 1 missed the second dialysis treatment rescheduled on 4/16/2024. Licensed Vocational Nurse (LVN) 1 notified Physician 1 on 4/17/2024 at 1 am. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident ' s needs related to dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments for one of two sampled residents (Resident 1), who was to receive scheduled dialysis treatments, as ordered by the physician. The facility failed to arrange services to transport Resident 1 to and from the off-site certified dialysis facility (an entity that provides outpatient maintenance dialysis services) for dialysis treatments on 4/13/2024 and 4/16/2024. As a result, Resident 1 missed two dialysis treatments scheduled on 4/13/24 and 4/16/2024. In addition, Resident 1 was transferred to the General Acute Care Hospital (GACH) Emergency Department (ED) for weakness and lethargy. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one of two residents (Resident 1) was free from physical restraint (any device attached or adjacent to the body that cannot be easily removed and restricts freedom of movement) when Certified Nursing Assistant 1 (CNA 1) tied the resident with a bed sheet to the waist and around the wheelchair on 4/11/24. According to CNA 1, she tied down the resident down in the wheelchair with a bed sheet to prevent the resident from getting up while she was attending to another resident (Resident 2) This deficient practice resulted in Resident 1's rights being violated, and held against her will. As a result of being tied down, Resident 1 expressed verbalization of feeling hopeless, humiliated, upset, cried, verbalized being treated like a kid, scared of CNA 1, and felt that day like a nightmare. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations of abuse are reported immediately but no later than two hours if the alleged violation involves abuse, to the local, state, and federal agencies, in accordance with the facility ' s policy and procedure on Abuse Investigation and Reporting for one of two sampled residents (Resident 1). Speech Therapist (ST) 1 found Resident 1 tied by a whitesheet around the wheelchair by Certified Nursing Assistant (CNA) 1 on 4/11/24 at 6 PM. The facility abuse coordinator was made aware of the incident on 4/12/24 at 9 AM and the facility reported to the California Department of Public Health (CDPH) on 4/12/24 at 11:41 AM (18 hours). This deficient practice put Resident 1 the potential to suffer further abuse, including other residents assigned to CNA 1.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure to ensure that only persons licensed or permitted by the state to prepare, administer, and document the administration of medications may administer medications for one of two sampled residents. Licensed Vocational Nurse (LVN) 2 delegated CNA 1 to administer medications (atorvastatin, melatonin, propranolol, senna, trazodone hydrochloride, and divalproex sodium) to Resident 1 on 4/11/2024. This deficient practice put Resident 1 at risk for harm due to lack of qualified staff ' s supervision of adverse reaction after medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from abuse for one of four sampled resident (Resident 2) when Resident 1 threw a cup of coffee at Resident 2 on 2/15/24 and the facility did not investigate the incident. Resident 1 and Resident 2 where then involved in another resident-to-resident altercation on 3/16/24 when Resident 1 punched Resident 2 on the right arm. This deficient practice had the potential for Resident 1 to suffer negative psychosocial outcome such as anger, fear, anxiety, or loss of self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident abuse for one of two sampled residents (Resident 1) to the California Department of Public Health (CDPH) Licensing and Certification, within two hours by telephone and written report, in accordance with the facility ' s policy and procedure titled Abuse - Reporting and Investigations. This failure had the potential for Resident 1 to be at risk for further abuse and resulted in the facility under reporting allegations of abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (2) of two (2) sampled residents (Residents 285 and 131), who had food intolerances (food sensitivity and inability to digest a certain food) and food allergies (a serious and potentially life-threatening medical condition to substances that are usually not harmful) were assessed for food restrictions, including food allergies and served with food substitutions (replaced food with allergens with food without allergens) as indicated in the facility ' s policies and procedures titled, Food Allergies and Intolerances, and Nutrition Assessment, by failing to: 1. Ensure [NAME] 1 did not serve fish and fish containing products to Resident 285 and Resident 131, who were allergic to fish on 2/18/2024. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents who are at risk for skin breakdown and pressure injuries receives treatment and services to prevent skin breakdown for two of_three___ (Resident 114 and Resident 16) sampled residents by failing to: 1. Use correct settings for Resident 114 ' s low air loss mattress (LALM; air filled mattress used to relieve pressure). 2. Reposition Resident 16 every two hours as indicated in the resident ' s care plan. These deficient practices had the potential to result in the decline in Resident 16 and 114 ' s skin integrity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards of food service safety for residents in the facility by failing to label and date food in the refrigerator. This deficient practice had the potential to place residents at risk for developing food borne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations for resident needs and preferences for one (1) of five (5) sampled residents (Residents 20) by failing to ensure the call light was withing reach. The deficient practice resulted in the resident delays in care and not receiving assistance with activities of daily living (ADLs). Findings, A review of Resident 20's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included complete traumatic amputation (surgically cut-off) of left hand at wrist level and history of malignant neoplasm of brain (a fast-growing cancer that spreads to other areas of the brain and spine). [...]

Inspectors wroteBased on interview and record review, the facility failed to make prompt efforts to file, resolve a resident ' s representative ' s (Family [FAM] 1) grievance and keep FAM 1 appropriately apprised of progress toward resolution for one of two sampled resident ' s missing personal belongings (Resident 29). This deficient practice violated the resident's right to have his representative ' s concern addressed.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident ' s rights to be free from misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident ' s consent) for one of two sampled residents (Resident 29) by disposing Resident 29 ' s television (TV) without the resident ' s or Resident 29 ' s family member ' s (FAM 1) consent, in accordance with the facility ' s policy and procedure on Personal Property and Investigating Incidents of Theft and/or Misappropriation of Resident Property. This deficient practice violated Resident 29 ' s rights to decide what to do to his personal belongings which included a TV brought to the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to report one of one sampled resident (Resident 97)allegation of abuse within 2 hours. This deficient practice resulted in the facility under reporting allegations of abuse and had the potential to result in the decline in Resident 97 ' s emotional and psychosocial status.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for one of two sampled residents (Resident 131) with food allergy. This deficient practice resulted in the facility served Resident 131 with food allergy on 2/18/2024, which placed Resident 131 at risk for allergic reactions that can cause death.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop a care plan for one of three sampled resident ' s (Resident 114) low air loss mattress (LALM; air filled mattress used to relieve pressure). This deficient practice had the potential to result in the decline of Resident 114 ' s skin integrity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) for the activities of daily living care area was provided care and services to maintain good grooming and personal hygiene. This deficient practice had the potential to result in a negative impact on Resident 1's quality of life and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide medically related social services (means services provided by the facility ' s staff to assist residents in attaining or maintaining their mental and psychosocial health) by failing to arrange for resident ' s communication needs through the resident ' s primary method of communication for one of twenty- nine sampled resident (Resident 74). This failure had the potential for Resident 74 feel frustrated (the feeling of irritability or anger because of the inability to achieve something) communicating with staff and visitors which could negatively affect Resident 74 ' s quality of life and quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to prevent consequences of medication-related adverse events for one (1) of seven (7) sampled residents (Resident 57) by failing to administer metformin (medication order to control blood sugar) with food per physician's order. This deficient practice had the potential to result in Resident 57 experiencing stomach or bowel side effects such as nausea, bloating, or diarrhea.

Inspectors wroteBased on observation and interview the facility failed to ensure safe provision of pharmaceutical services by failing to ensure the intramuscular injection (IM- medication administered into a muscle) emergency kit (E-Kit- secured container containing medications which are used for either immediate administration to residents or in an emergency situation.) located in Station 2 was replaced before the expiration date for one (1) of three (3) E-kit per facility's policy. This deficient practice had the potential for adverse reaction in the event that the expired medications were administered to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate oversight was provided by a qualified staff to carry out the facility ' s Food and Nutrition Services for two of two sampled residents (Residents 131 and 285) by failing to: 1. Ensure the Registered Dietitian (RD) and the Dietary Service Supervisor (DSS) correctly assess and verify food allergies and food intolerance to Resident 285. 2. Ensure the RD create a care plan that addressed fish allergy for Resident 131. 3. Ensure the RD and the DSS maintain records of residents ' food likes, dislikes and food allergies per facility ' s policy. 4. Ensure the RD conduct regular audits of the Food and Nutrition Services to ensure food safety and sanitation systems, practices and meal service requirements were in place and followed, as evidenced by no audit was done in January 2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the spread of infection for 2 of 6 sampled residents (Residents 27 and 92) by failing to ensure: Resident 27 ' s BiPAP (a type of ventilator device that helps with breathing) tubing and mask were left hanging on the resident's bed rail uncovered with moisture inside. There was no date and time of when it was last cleaned or changed. Resident 92 ' s handheld nebulizer (HHN) (a machine to compressed air to vaporize medication) tubing set up was not dated from when it was last changed. This failure had the potential to cause and/or spread disease which can negatively affect Residents 27 and 92 ' s quality of life.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure having a call system (allows patients to signal caregivers when they are urgently needed and allows caregivers to communicate with each other at a distance) accessible to residents while in bed, when the call light was observed on the floor for one of six sampled resident (Resident 89). This failure had the potential to result Resident 89 not getting assistance which can cause a decline in activities of daily living (ADL) and further skin breakdown.

Inspectors wroteBased on observation, Record review and interview, the facility failed to ensure 40 out of 54 residents ' rooms meet the square footage requirement of 80 square feet per resident ' s room. The 40 resident ' s rooms consisted of 6 two bedrooms and 34 - three bedrooms. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for facility staff.

Inspectors wroteBased on interview, and record review, the facility (SNF 1) failed to provide and document sufficient preparation to the resident to ensure a safe and orderly discharge from the facility (SNF1) to a transitional living facility (transitional housing refers to a supportive - yet temporary - type of accommodation that is meant to bridge the gap from homelessness to permanent housing) or one of one sampled resident (Resident 1), in accordance with the facility ' s policy and procedures, by failing to: 1. Provide an appropriate and safe discharge planning prior to discharge from the facility to a Transitional Living Facility on 2/1/2024. 2. Provide a Discharge Notice in advance to the Ombudsman (a person who investigates, reports on, and helps settle complaints) office, at least twenty-four (24) hours before the resident ' s discharge or transfer from the facility. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to exercise reasonable care to protect the resident from property loss or theft, by not having an accurate inventory of belongings for one of one sampled resident (Resident 1) that resulted in a missing wheelchair which had caused sadness and had the potential to negatively affect Resident 1s quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of her individuality for one (1) of three sampled residents (Resident 1). The facility staff was observed standing over Resident 1 while assisting the resident during a meal. This deficient practice had the potential to affect Resident 1's self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized and comprehensive care plan for one of three sampled residents (Resident 1). Who was receiving chemotherapy treatments and had Stage 1 pressure ulcer (skin intact erythema redness) discovered on 12/13/23. This deficient practice had the potential for facility staff to not meet and address Resident 1 ' s medical, physical, mental, and psychosocial needs according to the resident ' s assessed needs, physician orders, preferences, and desired outcomes.

Inspectors wroteBased on interview, and record review, the facility failed to assess a resident going to chemotherapy treatments outside of the facility, coordinate and address the medical and ADL (activities of daily living) needs of a resident who required moderate assistance to total dependence and was receiving chemotherapy (a drug treatment that uses powerful chemicals to kill fast-growing cells in the body, most often used to treat cancer) outside the facility, for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the resident ' s physical and psychosocial well-being and cause a delay in the delivery of care and services to Resident 1. In addition, Resident 1 had the potential to develop undesired complications while receiving chemotherapy treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide proper skin assessment and treatment intervention for a resident who was assessed at risk for developing pressure ulcer for one of three sampled resident (Resident 1). Resident 1 had a Stage 1 pressure ulcer (skin intact erythema redness) on12/13/23, and developed to a Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) on 12/27/23. In addition, the facility failed to address Resident 1 ' s incontinence needs while outside the facility during chemotherapy treatments for more than eight hours, including turning and repositioning which predisposes the resident for further skin breakdown. As a result of this deficient practice Resident 1 had the potential for further skin breakdown and worsening of the sacrococcyx pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), was provided care and services with grooming and personal hygiene that includes bathing, showering and kept clean. The deficient practice has the potential to result in Resident 1' s to develop skin breakdown, infection and a decline in the physical and mental wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to provided care and services with grooming and personal hygiene that included assistance with ADL (Activities of Daily Living) such as bathing, showering and kept clean and to ensure safety for one of three sampled residents (Resident 1). The deficient practice had resulted in Resident 1's not receiving ADL assistance timely that could result in skin breakdown or infection and a risk for resident to fall which could result in a decline in disease process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of two sampled residents with dignity and respect, in accordance with the facility's policy and procedure on Quality of Life - Dignity and Resident Rights, for one of two sampled residents (Resident 1) by failing to: 1. Ensure Resident 1's personal belongings were not packed by facility staff and placed outside the facility's parking lot without Resident 1s permission. The facility attempted to discharge Resident 1 from the facility on 11/21/23 after Resident 1 left the facility to go to an appointment in the morning. Resident 1 was readmitted back to the facility on [DATE] (same day) in the evening at around ____ PM. 2. Ensure another resident (Resident 2) was not transferred to Resident 1's room when Resident 1 attempted to discharge Resident 1 on 11/21/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had severely impaired cognition (thought process) was provided with adequate supervision, in accordance with the facility ' s policy on Safety and Supervision of Residents, and the resident ' s care plan for Impaired Cognitive Function/Dementia and Physical Limitation. This deficient practice resulted in Resident 1 eloping from the facility on 11/9/2023 from 11:20 AM to 7:20 PM (approximately 8 hours), when Placement Coordinator 1 (from Facility 2) did not accompany Resident 1 on 11/9/2023, to ensure the resident make it back physically, inside Facility 1, after a tour at Facility 2. The facility failed to inform Placement Coordinator 1 that Resident 1 had poor cognition and required redirection. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an environment that promotes dignity and respect for one of seven sampled residents (Resident 1) who observed a male resident (Resident 2) inappropriately touching his private region from across her room. Resident 1 stated she was not provided supervision when she requested to be supervised by the staff becaused she felt scared after she witnessed Resident 2 looking at her while he was touching his private region. This deficient practice had negatively affected Resident 1's psychosocial (having to do with the mental, emotional, social, and spiritual) wellbeing as evidenced by Resident 1 stated she was angry and scared. [...]