San Diego Post-Acute Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one resident (Resident 1) was free from sexual abuse when:Maintenance Personnel (MP) kissed Resident 1's forehead without consentMP made contact with Resident 1's upper extremities without consentMP pulled Resident 1's pants without consentMP sat on Resident 1's bed without consentAs a result, MP had continued access to Resident 1These failures to identify and report allegations of abuse did not protect Resident 1 Cross reference F600 F607 F609 F610Findings:On 5/11/2026 at 8 A.M. an unannounced onsite was conducted to investigate one facility reported incident of alleged abuse. On 5/19/2026 additional facility reported incident of alleged abuse for the same parties involved (MP to Resident 1). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when facility employees were made aware of allegations of abuse to one of one resident (Resident 1). As a result, facility failed to report in a timely manner and facility failed to protect Resident. Cross reference F600 F607 F609 F610Findings: According to the facility policy entitled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised date April 2012, indicated .Residents have the right to be free from abuse, neglect.freedom from.sexual.abuse.1.) Protect residents from abuse, neglect.from a facility staff.2.implement polices and protocols to prevent and identify.a. abuse.8. Identify and investigate all possible incidents of abuse.9. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when facility employees were made aware of allegations of abuse to one of one resident (Resident 1). As a result, facility failed to report in a timely manner and facility failed to protect Resident. Cross reference F600 F607 F609 F610Findings:On 5/11/2026 at 8 A.M. an onsite was conducted to investigate one facility reported incident of alleged abuse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly investigate two facility reported incidents of sexual abuse. As a result of this deficient practice, there was the potential for continued employee access to residents in the building. Cross reference F600 F607 F609 F610Findings:On 5/11/2026 at 8 A.M. an onsite was conducted to investigate one facility reported incident of alleged abuse. A review of the facility's Report of Suspected Dependent Adult/Elder Abuse (S0C 341, a report submitted to the State agency to report allegations of abuse) dated 4/29/26, indicated Resident 1 alleged MP inappropriately caressed her arm and sat on her bed in close proximity to her while she was seated in her wheelchair and reported type of abuse with check marked sexual. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 16 Registered Nurses (RNs 1, 11, 16) were trained and competent to administer an intravenous (IV-the administration of fluids, medications, or nutrients directly into the bloodstream through a needle or tube inserted into a vein) medication administration using a Medicine Ball infusion system (balloon-like reservoir filled with medication that relies on its own elastic walls to generate steady, continuous pressure, slowly pushing fluid into a patient's vein) to residents receiving an IV treatment. [...]

Inspectors wroteBased on observations, interviews, and document review, the facility failed to ensure infection prevention practices were followed by three of five staff members when:Staff did not perform hand hygiene before putting on their personal protective equipment (PPE - wearable gear to protect users from infectious hazards). A licensed nurse (LN) used a breathing treatment unit dose container (singe dose of measured dose of liquid medication) on a resident, after the container landed on the floor. These failures had the potential to spread infection to the residents, staff, and visitors. On 5/23/26 at 8:50 A.M., a medication administration observation was conducted on licensed nurse (LN) 25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication was administered according to the professional standards of practice for one of four sampled residents, (Resident 25), when the manufacturer's instructions and directions on the pharmacy label for Budesonide inhalation suspension (a medication to control symptoms of lung disease) were not followed during administration. This deficient practice had the potential for Resident 25 to not receive the full efficacy of the medication and to develop side-effects such as an oral thrush (a yeast infection on the mouth and throat with primary symptoms of white patches on tongue, cheeks, gums or tonsils with bleeding and pain).

Inspectors wroteBased on interviews and document review, the facility failed to ensure that their Facility Assessment included and addressed the nurse competencies related to administration of medication via intravenous (IV - into a vein) route, including the use of an IV bulb infusion system (a disposable, portable, and non-electric device used to deliver intravenous medication safely over a preset amount of time) . As a result, nurses who were not trained and whose competencies were not assessed on the IV bulb infusion system, were assigned to administer IV medication using the bulb infusion system. This may result in significant medication error and may cause harm to the resident. (cross reference F 726) A review of the facility's Facility Assessment, dated 4/1/26, indicated the facility provides IV medications and the number/average range of residents receiving IV medications was 3-4 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four licensed nurses (LN 1 and LN 2) reviewed for medication administration training and competency were trained and deemed competent to administer medications through a facility approved and documented validation evaluation. Licensed Nurse (LN) 1 prepared eight morning medications for Resident 6 including clozapine (used for schizophrenia, a distorted perception of reality), topiramate (used to treat seizures, abnormal and disruptive electrical activity in the brain), and levetiracetam (used to treat seizures) and gave the medications to LN 2 to administer. LN 2 then administered Resident 76's medications to Resident 187. In addition, four other LNs (LN 51, LN 52, LN 3, and LN) did not verify resident identification prior to administering their medications. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide meatal care (cleaning the area where a urinary catheter [a flexible tube inserted into the bladder to drain urine] enters the body [the meatus] daily using mild soap and water to prevent infections) for one (Resident 1) of 34 sampled residents. This failure had the potential for Resident 1's urinary catheter not to get assessed and/or cleaned appropriately and could lead to a nonfunctional catheter and/or a urinary tract infection.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were administered as ordered by the physician (MD), for one of three sampled residents (Resident 1) reviewed for medication administration. This deficient practice placed Resident 1 at risk for serious blood clots, stroke (loss of blood flow to a part of the brain), or pulmonary embolism (a blood clot that travels to the lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurse (LN) 2 completed medication administration for one resident (Resident 11) when two medications were left on the resident's bedside table. As a result of this deficient practice, Resident 11 was not administered his medications as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four residents (Resident 3, 4, 5, and 6) were free from physical abuse when:1. Resident 5's behavioral triggers (stimuli that may cause a specific action or response) were not identified, assessed, and care planned.2. Resident 6's wandering behavior into other residents' rooms was not identified, assessed, and care planned. As a result:1. Resident 5, when triggered, pushed Resident 4 down on 11/14/25, punched Resident 3 in the mouth on 12/25/25, and yelled at and grabbed Resident 6's arm on 12/30/25. Resident 3 sustained a laceration to the inner upper lip, experienced pain, and was distressed.2. Resident 6 entered Resident 5's room on 12/30/25 and put on his clothes. Resident 5 yelled and grabbed Resident 6 who then struck Resident 5 in the face causing him to fall to the floor. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of a room change to two of three residents (Resident 1 and 2). This deficient practice had the potential to cause psychosocial distress and limit the residents' and the responsible party's ability to participate in the decisions regarding having a room change. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (progressive brain disorder that affects memory, thinking and behavior) and unspecified dementia (loss of cognitive functioning). A review of Resident 1's History and Physical dated 5/19/25 indicated the resident, .does NOT have the capacity to understand and make decisions. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate two facility reported incidents of physical abuse and take appropriate corrective action. As a result of this deficient practice, there was the potential for further resident-to-resident altercations and abuse to occur. Cross reference F600. The First Reported Incident (12/25/25):A review of Resident 3's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses to include anxiety. A review of Resident 5's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include traumatic brain injury, post-traumatic stress disorder (PTSD, a mental health condition that develops after exposure to a traumatic event), bipolar disorder (a mood disorder that alternates between depression and mania), and Alzheimer's dementia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services for the behavioral health care of one of three residents (Resident 5) with a diagnosed mental disorder and post-traumatic stress disorder (PTSD, a mental health condition that develops after exposure to a traumatic event) when:1. Resident 5's behavioral triggers were not assessed and care planned.2. Resident 5's PTSD was not assessed and care planned with resident-specific interventions. As a result of these deficient practices, Resident 5 was involved in physical altercations with other residents when triggered. There was also the potential for Resident 5 to be retraumatized when staff were not knowledgeable of the resident's PTSD diagnosis and behavioral triggers. Cross reference F600. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personalized dementia care for one of two residents (Resident 6) when the resident's behavior of wandering into other residents' rooms was not identified, assessed, and care planned with individualized interventions. As a result, Resident 6 wandered into Resident 5's room, put on Resident 5's clothing which caused a physical altercation. This had the potential to negatively impact Resident 6's ability to achieve his highest level of functioning. Cross reference F600. A review of Resident 6's admission Record indicated the resident was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses to include unspecified dementia (loss of cognitive functioning) and schizophrenia (a mental disorder characterized by paranoia and delusions). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven residents' (Resident 5) medical record was accurately and completely documented when:1. Resident 5's provider documentation indicated staff reported the resident was being aggressive and having mood swings, but these behaviors were not documented by staff.2. Resident 5's behavioral monitoring on the medication administration record (MAR) was inaccurate. As a result, Resident 5's medical record did not correctly represent the resident's actual behavioral condition. A review of Resident 5's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include traumatic brain injury, post-traumatic stress disorder, bipolar disorder (a mood disorder that alternates between depression and mania), and Alzheimer's dementia. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a discharge care plan for one of three sampled residents (Resident 1). As a result, this deficient practice placed Resident 1 at risk for an unsafe or uncoordinated discharge, unmet care needs, and delays in services during any transition out of the facility.

Inspectors wroteBased on interview and record review, the facility failed to update and revise a person-centered discharge care plan for one of three sampled residents (Resident 3) that reflected their discharge needs, preferences, and goals. As a result, this deficient practice placed Resident 3 at risk for an unsafe or uncoordinated discharge, unmet needs during transition, and delays in needed services.

Inspectors wroteBased on observation, interview, and record request, the facility failed to secure medication carts when not in use by staff, for two of eight medication carts (Station 2 and Station 3), when reviewed for Pharmacy Services. This failure had the potential for residents, visitors, and staff, to obtain unauthorized medications that could cause harm.

Inspectors wroteBased on interview and record review, the facility failed to consistently provide a shower on scheduled shower days for one of three residents (Resident 1) reviewed for Activities of Daily Living (ADL). As a result, Resident 1 was not offered and provided a shower during his first week of admission to the facility. This failure had the potential to negatively affect the resident's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident's (Resident 2) Low Air Loss mattress (LAL, a mattress that uses a continuous flow of air through tiny laser made air holes in the top of the mattress surface so that the user floats on a soft cushion of air that helps to prevent pressure ulcers) was functioning properly when a plastic inflatable overlay mattress was placed on top of the LAL mattress. As a result, this had the potential for Resident 2 to experience skin breakdown and develop pressure ulcers.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff used the appropriate Personal Protective Equipment (PPE) when entering a room placed on Transmission Based Precautions (TBP - a sign outside of a resident's room which indicated that visitors had to wear PPE to avoid catching an infection from the resident) for two of three staff observed entering rooms on TBP. This failure placed the facility's residents at an increased risk of infection.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure sanitary practices in the kitchen were maintained for floor sink drains and the ice machine to prevent debris, slime, mold and other potentially contaminated substances to prevent exposure to unsafe and unsanitary practices that affect foods. These failures had the potential to place residents at risk of developing foodborne illnesses. The facility census was 238.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility's kitchen was free of pests when: 1) the pest control company recommendations were not carried out to prevent rodents, and 2) unsanitary practices with large uncovered openings and holes were found in the kitchen. This failure led to a kitchen closure by the local health department due to sightings of rodent droppings and had the potential to contaminate the residents' food prepared and stored in the kitchen and dining areas. The facility census was 238.

Inspectors wroteBased on observation, interview and record review the facility failed to take appropriate action to protect one (Resident 5) of three residents reviewed for abuse, from his alleged perpetrator (person who inflicts harm). This failure had the potential for Resident 5 for repeat abuse from the perpetrator and placing other residents at risk for a potential abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. The temperature was consistently monitored and documented for one of two medication (med/s) refrigerators, one of one utility room, and one of one utility refrigerator, 2. An opened multi dose flu vaccine was dated with an opened date and an opened inhaler was not labeled and dated, 3. discharged resident medications were kept after more than 30 days and commingled with active resident's medications, and, 4. Loose meds were found in the cycle drawer of the med cart. These failures had the potential to affect the efficacy of medications and effectiveness of treatment, to affect residents to receive expired medications, to affect discharge residents to not have available meds on discharge, and residents' safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that food served during lunch was at a palatable temperature for the residents. This failure had the potential to prevent the residents from eating their meals and not receive their daily nutrition.

Inspectors wroteBased on observation, interview, and record review the facility failed to store the following foods appropriately: 1. Grilled cheese 2. Soy sauce 3. Food thickener This failure had the potential for residents receiving spoiled or contaminated food.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment Performance improvement (QAPI- plan developed by the QAA (Quality Assessment and Assurance committee-committee that oversees facility conditons and trends) failed to identify deficient practices prior to their recertification survey which include; 1) Call light response time from staff and, 2) Identifying food concerns from resident interviews and during the resident council meeting. This failure had the potential for the facility to overlook trends in resident's health and quality of life. Cross reference : F804 A joint interview on 2/27/25 at 2:27 P.M., with the Administrator (ADM) and the Acting Director of Nursing (aDON) was conducted .The ADM stated they were not aware of the call light issues and food concerns. [...]

Inspectors wroteBased on interviews and facility documents review, the facility failed to ensure a safe discharge for one of four sampled residents, reviewed for closed record (Resident 80). This failure had the potential to compromise Resident 80's health, safety and well-being and, as a result, Resident 80 was admitted to an acute care hospital on 2/16/25.

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to nail care for two of four sampled residents (90 and 131). This failure had the potential to not meet the goals of treatment and needs of Resident 90 and Resident 131.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment in accordance with the facility's policy and procedure when a Licensed Nurse (LN) 12 did not use warm, purified water and completely diluted a resident's (Resident 141) medications during the administration of medications via a gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition or medications [med/s] directly to the stomach). This failure had the potential for not meeting Resident 141's therapeutic needs and had the potential of clogging the g-tube.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four residents (Resident 90 & Resident 131), who were unable to carry out activities of daily living (ADL-self- care activities such as personal hygiene), received assistance with nail care (cleaning, trimming and/or filing of nails). This failure resulted in Resident 98 and Resident 131 having long fingernails which had the potential to negatively impact the residents' hygiene, health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a smoking assessment was accurate on 1 out of 8 residents ( Resident 54) reviewed for accidents. This failure had the potential to place Resident 54 at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to monitor and document urine output (UO) per the facility's policy, for one of three sampled residents (Resident 141) with a urinary catheter (a tube inserted into the bladder to aid in urine flow). This failure had the potential for Resident 141 to have urinary retention and developed urinary tract infection (UTI).

Inspectors wroteBased on observation, interview, and record review the facility failed to restart Resident 39's (R39) continuous oxygen after transferring her from wheelchair to bed. This failure had the potential to affect the R39's respiratory health.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from unnecessary medication when a resident (Resident 93) was receiving heparin (blood thinner that prevents blood clotting, one side effect is bruising or bleeding) and was not monitored for signs and symptoms of bruising/ bleeding for one of two sampled residents reviewed for anticoagulant. This failure could result in medication related adverse events from inconsistent and poor management of medication therapy for Resident 93.

Inspectors wroteBased on observation, interview, and record review, the facility failed to indicate the appropriate and measurable target behavior of antidepressant (medication used to treat depression, sad mood and lack of interest) for one of five sampled residents reviewed for unnecessary psychotropic (mind-altering medications) medication use (Resident 45). This failure had the potential for unnecessary psychotropic medication use, its side effects, and a decline for residents psychological and mental well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent a medication error for 1 of 38 residents, (Resident 390). This failure had the potential for harm to Resident 390 (R390) from unnecessary medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control procedures were followed when a Licensed Nurse (LN) 12 did not perform hand hygiene (the practice of cleaning hands to remove germs, dirt, or other harmful substances) consistently after removing her gloves while passing medications (meds) during medication pass observation for 2 residents (Residents 141, 22). This failure had the potential for cross contamination and spread of infection between the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure water from the dishwashing sink drained appropriately onto the drain hole. This failure had the potential for accidents in the dishwashing area and a preventable flooding of the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure complete and accurate medical records were documented for two of seven residents (Resident 3 and 7) reviewed for resident records when: 1. Resident 3 and 7's inventory of personal items were not signed by the resident or the resident representative upon transfer to the hospital, 2. There was no documentation regarding following up with Resident 7's responsible party when the resident expired, 3. There was no physician's order to release Resident 7's body to the mortuary. This failure had the potential to result in inaccurate account of residents' belongings. In addition, the RP and md was not aware that Resident 7 expired and there was no physician's order to release Resident 7's body to the mortuary.

Inspectors wroteBased on interview and record review the facility failed to ensure a physician's order was followed when nursing staff did not do vital signs every four hours for one COVID-19 (a highly contagious respiratory disease) positive resident (1) who was transferred and later died at the hospital. This deficient practice delayed the gathering of vital information about Resident 1's condition and potentially impacted the transfer of care to the hospital.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement their policies related to accidents and supervision, elopements (leave without notice) and signing residents out, when staff did not: 1. Identified one of one resident (Resident 1) who left the facility and implement a search procedure (code green) when Resident 1 was not found in the facility. The facility did not announce a code green until the following day, approximately 12 hours since Resident 1 was last seen in the facility. 2. Consistently obtain a physician's order for an out on pass (OOP - out on pass, leave of absence), assess, and document in his clinical record the time he went out on pass and consistently sign the OOP form. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop a baseline care plan (detailed plan with information about a resident's treatment, goal, and interventions) for one of one sampled resident related to a resident's (Resident 1) multiple episodes of leaving the facility. As a result, the lack of a resident centered care plan with specific interventions had Resident 1 left the facility unnoticed by staff, got hit by a pickup truck and died on [DATE].

Inspectors wroteBased on observation, interview, and record review the facility failed to protect residents' privacy for two of 9 residents reviewed for privacy when male and female residents shared a shower and bathrooms in their room (Resident 5 and 6). As a result, Residents 5 and 6 felt uncomfortable using the bathroom.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure only authorized personnel had access to the medication storage cart (med cart)'s keys for one of two sampled med carts (1). This failure increased the risk of residents and unauthorized personnel accessing medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe supervision and assistance for one of three sampled residents (1) who was identified as high risk for choking and aspiration (happens when food, liquid, or other material enters a person's airway and eventually the lungs by accident). In addition, the Licensed Nurse (LN) 2 failed to clarify an out on pass order for one resident (4). These failures had the potential for Resident 1 to choke, if not safely assisted and supervised, and there was a potential for Resident 4 to go out on pass without a physician ' s order.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident to hospice as ordered for one of two sampled residents (1). As a result, Resident 1 expired without receiving hospice services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report to the California Department of Public Health (CDPH- the State Survey and Certification Agency) an alleged abuse violation regarding a resident-to-resident altercation. (Resident 7 and 14). This deficient practice had the potential for incidents of abuse to go unreported and for residents to be unprotected from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a thorough investigation of an alleged violation of abuse between two residents. (Resident 7 and 14) This deficient practice had the potential to not meet resident ' s needs for safety and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to update nutritional care plans for two residents reviewed for care planning. (Resident 5 and Resident 6). Failure to update a care plan related to nutrition had the potential for residents to not receive appropriate care, treatment, and interventions to provide nutrition and prevent further weight loss.

Inspectors wroteBased on interview, observation and record review, the facility failed to initiate and implement a shower refusal care plan for one of one sampled resident (Resident 1). This failure had the potential for Resident 1 to receive inadequate quality of care and miscommunication among health care providers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician orders were followed for two of two sampled residents (1,2) when, 1. Resident 1 was not transferred to the hospital after his condition started to worsen, and 2. Resident 2 ' s Methadone medication was not administered as ordered, and facility pharmacy was not notified. Failure to follow a physician ' s order had the potential for residents to suffer severe harm which could result to worsening of the resident ' s health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify and account for a physician ' s prescribed Methadone (an addictive narcotic medication used to treat severe pain) order to the facility ' s pharmacy for one of one sampled resident (1). As a result, Resident 1 did not receive a total of 11 scheduled medication doses of Methadone. Due to the missed doses of this medication, Resident 1 had the potential to have increased pain levels, increased use of unnecessary alternative narcotic medication and to suffer from opioid withdrawal (the unpleasant physical and mental effects that can result when you stop taking this class of medication).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices when urinary Foley (brand name) catheter bags were in contact with the floor for six of six of six residents, (Residents 24, 25, 59, 164, 411, 412), reviewed for urinary catheter care. As a result, there was the potential for Residents 24, 25, 59, 164, 411, 412 to be at risk for a facility acquired infection, which would negatively impact the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dignity of four of four residents (Resident 24,164, 411, 412) when foley catheter bags (collects urine from the bladder into a bag) did not have dignity cover. These failures had the potential for the resident(s) to not be treated with dignity and suffer emotional and psychosocial distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physicians Orders for Life Sustaining Treatment (POLST) forms were accurate and matched the facility's code status (the level of medical interventions a person wishes to have if their heart or breathing stops) for three of five residents reviewed for Advanced Directives (Residents 71, 77, and 177). This failure had the potential for Residents 71, 77 and 177 to receive the incorrect care in the event of a medical emergency.

Inspectors wroteBased on observation, interview, and record review, the facility did not conduct a physical assessment based on standards of care for one of 11 residents (Resident 201) with a gastrostomy tube (GT- a surgical opening into the stomach). As a result, there was potential for Resident 201 to have complications related to GT care including infection and/or occlusion (blockage).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure communication tools were provided to two of two non-English speaking residents (Residents 20 and 187). As a result, there was a potential the residents needs were not met.

Inspectors wrote3. A review of Resident 135's admission Record was conducted. Resident 135 was admitted to the facility on [DATE] with diagnoses which included end stage renal (kidney) disease, dependence on dialysis (machine used to remove waste from the blood when a person has kidney failure), and diabetes (inability to manger blood sugar in the body). On 6/15/22 at 11:45 A.M., a concurrent observation and interview was conducted with Resident 135. Resident 135 used a pad of paper and pen to communicate. While observing Resident 135, both hands were noted to have very long fingernails. Resident 135 stated he would like his fingernails cut because they were too long. Resident 135 stated the facility had not offered to cut his nails. Resident 135 stated he was going to ask his son to cut his nails next week when he comes to visit. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physical environment was free from hazards when unprescribed medications were left within reach of 2 of 2 residents reviewed for accidents and hazards (Resident 185, 164 ). This failure had the potential for accidental ingestion. and The facility also failed to ensure 1 of 1 sampled residents (415) was assessed as a fall risk, and interventions were in place to ensure thes resident's safety from falls. This failure had the potential to put Resident 415 at risk for injury due to unnecesay falls.

Inspectors wrote2. A review of Resident 201's admission Record was conducted. Resident 201 was admitted to the facility on [DATE] with diagnoses which included end stage renal (kidney) disease, dependence on dialysis (machine used to remove waste from the blood when a person has kidney failure), and encounter for gastrostomy (hole in the abdomen into the stomach wall to introduce feeding or fluids via a tube). A review of Resident 201's record was conducted. The record indicated a physician's order dated [DATE] to flush GT with 50 milliliters (ml) of water every shift and (if used for meds (medications) give 50 ml before meds and 50 ml after meds). On [DATE] 3:30 P.M., a concurrent record review and interview was conducted with LN 2. LN 2 stated there was a flush order for Resident 201's GT. LN 2 stated the physicians order for Resident 201's GT flush was to flush GT with 50 ml of water every shift. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen was administered per physician's order for one of two residents reviewed for oxygen use (Resident 185). This failure had the potential to affect the health and well-being of Resident 185.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 1 resident (Resident 59) was medicated for pain when requested by the resident. This failure had the potential for the resident to experience unnecessary pain.

Inspectors wroteBased on observation and interview, the facility did not properly care for a dialysis access site for one of three dialysis patients (Resident 135). As a result, this had the potential to increase Resident 135's risk for a dialysis access site infection and clotting of the access.

Inspectors wroteBased on observation, interview and record review, the Food and Nutrition Services department failed to provide nutritional supplements (NS, a shake or food product added to a diet, usually for additional calories or protein) as ordered by the physician, for two of six residents reviewed for nutrition (Residents 82, 168). This failure had the potential for the residents to not receive adequate nutrition, further compromising their medical status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe and sanitary environment that mitigated the risk for foodborne illness and cross contamination when: 1. a countertop-mounted can opener holder was not clean, and, 2. a wall in a food production area was not clean or repaired. These failures had the potential to place residents at risk for foodborne illness as well as bacterial, chemical and foreign object contamination of foods.

Inspectors wroteBased on interview and document review, the facility failed to conduct a COVID-19 (a type of infection) test for two of five sampled unvaccinated employees per the facility's policy. As a result, residents, employees, and visitors were at risk for contracting a COVID-19 infection.

Inspectors wroteBased on interview, record and document review, the facility failed to have a policy which included resident screening for COVID-19 vaccination (a preventative measure for an infection) status, offering the vaccination and vaccinating residents against COVID-19. As a result, residents, staff and visitors were at risk for COVID-19 infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently offer bedtime snacks to all residents. This failure had the potential to result in residents not having nourishment between evening meals and breakfast the following day.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure safe and sanitary practices were met in the Food and Nutrition Services Department when: 1. Hand hygiene was not correctly practiced during garbage disposal, 2. Food temperatures were not taken for food on the trayline steamtable, and 3. A plate warmer with clean plates had brown and black dirt inside. These failures had the potential to cause widespread foodborne illness in the residents who consume food from the facility's kitchen. The facility census was 215.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure communication aids (language boards with pictures and the resident's native language or translation service via phone) were available and utilized for two of two residents (492, 494) reviewed for language/communication who did not speak English. As a result, Residents 492 and 494 had the potential to not have their needs met.

Inspectors wroteBased on interview and record review, the facility did not ensure one of five residents (100) reviewed for advanced directives (a written document giving instructions for an individual's end of life wishes) had a completed Physician's Order for Life-Sustaining Treatment (POLST) form, when: 1. Resident 100's physician had not signed the POLST; and 2. Resident 100's POLST was signed by someone other then the listed Responsible Party (RP-a designated person responsible for making healthcare decision on behalf of the resident). As a result, there was a potential for end-of-life choices not being discussed by the physician with the RP, and Resident 100 could have received treatment not in accordance with the resident's wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment for three of 11 residents (100, 135, 82) reviewed for resident rights when: 1. Resident 100's window curtain was suspended from a curtain rod with zip ties, a cable wall plate was unattached and hanging from the wall, duct tape was unraveling from the edges of a mirror, and one wall was scuffed and dented with chipped paint. 2. Resident 135 did not have clear, easy access to his bathroom. 3. Resident 82 did not have any personal belongings kept at the bedside. These failures resulted in the residents or RP not being happy with their rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement care plans for two of five residents reviewed for care plans (82, 52). These failures had the potential to result in inconsistent treatment and care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly identify and intervene when a change in condition occurred for one of 35 residents reviewed for quality of care (96). This failure had the potential to result in a life-threatening allergic reaction for Resident 96.

Inspectors wroteBased on observation, interview, and record review, the facility failed to reposition one of eight residents reviewed for pressure ulcers (92). This failure had the potential for worsening of Resident 92's pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide RNA for one of five residents reviewed for limited range of motion (82). This failure had the potential to result in further decline of Resident 82's range of motion.

Inspectors wrote2. Per the Resident Face Sheet, Resident 52 was admitted to the facility on [DATE] with diagnoses to include chronic respiratory failure (long-term inability of the lungs to take in enough oxygen) and dysphagia (swallow difficulty). On 5/20/19, a record review of Resident 52's medical chart was conducted. Per a physician's order, dated 4/14/19, Peek-a-boo mittens Special instructions: on q 2hr (every two hours) and off for circulation and hygiene related to pulling out life sustaining devices . On 5/20/19 at 8:55 A.M., an observation of Resident 52 and an interview was conducted with a visitor. Resident 52's mittens were off. The visitor stated she was a family member, and she had taken the mittens off. On 5/20/19 at 2:55 P.M., an observation of Resident 52 alone in his room was conducted. Resident 52's mittens were not on his hands. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was adequate staff to provide the necessary care for 8 of 16 residents reviewed (75, 82, CR4, 6, 8, 10, 11, 14) for sufficient staffing when: 1. Call lights were not answered in a timely manner; or when answered, care was not provided, and; 2. RNA services were not provided as ordered. These failures had the potential to result in physical and emotional harm.

Inspectors wroteBased on observation, interview and record review, the IDT team (health care team managing resident care) did not fully assess the psychotropic medication regime (medications affecting the nervous system and mental state of an individual) for one of three sampled residents reviewed for psychotropic medications (220). This failure had the potential for a decrease in function for Resident 220.

Inspectors wroteBased on observation, interview and record review, the facility failed to secure one of six medication carts reviewed for medication storage. This failure had the potential for residents, visitors, and staff to have access to unauthorized medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the Food & Nutrition Services staff effectively carried out the functions of the department for sanitizer testing of dish machine equipment and red buckets. This failure in staff competency had the potential to cause foodborne illness in the residents who consumed food from the facility's kitchen. The facility census was 215.

Inspectors wroteBased on interview and record review, the facility failed to ensure the staff had the knowledge of proper food storage and heating time of foods brought into the facility by visitors for resident consumption. These failures had the potential for foodborne illness.

Inspectors wroteBased on interview and record review, the facility did not ensure a hospice agency's written documentation of visits were present in the health record for one of five sampled hospice residents (104). As a result, there was the potential to put Resident 104 at risk for delayed or uncoordinated care between the facility's healthcare team and the hospice agency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light system was working properly for one of 35 sampled residents (64). As a result, there was the potential Resident 64 would be unable to communicate his needs to the staff.