San Gabriel Conv Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two of three sampled residents (Resident 6 and 76) was free from unnecessary drugs as indicated in the facility's policy and procedure titled Medication Therapy. 1. For Resident 6 the facility failed to ensure: a. Journavx (a medication used for moderate to severe acute pain) was not administer ed for excessive periods of time from 3/29/2026 to 6/16/2026 while the pharmaceutical recommended to use for the drug for shortest duration, consistent with individual patient treatment goal. b. Journavx pharmaceutical recommendation indicated for moderate to severe acute pain, while Resident 6's was administered Journavx from 4/1/2026 to 6/15/2026 for pain level documented as zero (0) and administered for 148 times. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards of practice and the facility's policy and procedure titled, Sanitation and Infection Control and Dating and Labeling for food service safety and maintain sanitary food handling practices by failing to discard an expired food item dated 3/28/2026 and wash hands after performing a different task before returning to put away clean dishes. This deficient practice had the potential for contamination of food, clean food-contact items and for residents to be at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policies and procedures (P&P) titled Infection Control, unknown date, of maintaining an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection by failing to ensure: 1. Restorative Nursing Assistant (RNA) 1 assisting three of 13 sampled residents (Resident 57, Resident 91, and Resident 97) with their meals performed hand hygiene after leaving each resident and before assisting the next resident. These deficient practices had the potential to expose multiple residents to cross-contamination (transfer of disease-causing organism from one surface or food to another) and/or the transmission of infectious organisms/pathogens. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided assistance with dining in a manner that promoted and maintained resident dignity in accordance the facility's policy and procedure titled Dignity for one of three sampled residents (Resident 97) when Restorative Nursing Assistant (RNA) 1 who was assisting Resident 97 with eating placed her right index finger over her mouth and said Shush to Resident 97, who refused to eat more and pushed her plate to the side because she was already full. This deficient practice had the potential to affect Resident 97's psychosocial well-being and right to be treated with dignity in a manner that promoted and enhanced quality of life during dining.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Bed-Hold notice for one of two sampled residents (Resident 82) was signed by the resident and/or representative's indicating acknowledgement of receipt of the Bed-Hold notice on 4/21/2026 and 5/1/2026, when Resident 82 was transferred to General Acute Care Hospital (GACH). This deficient practice had the potential to affect resident's rights who required hospitalizations by limiting their awareness of bed-hold and readmission rights to the facility after hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive resident specific care plan for two out of two sampled residents (Resident 76 and 82) by failing to: 1. Develop a care plan for Resident 82, who had a change of condition and hospitalized for hypotension low blood pressure) and tachycardia (rapid heart rate) on 5/1/2026. This deficient practice had the potential to result in confusion of resident's care and negatively affect the resident's physical and psychosocial wellbeing. 2. Initiate and implement a care plan addressing the use, monitoring, and potential adverse effects of lorazepam (medication used to reduce anxiety and control seizures) use for Resident 76. This failure had the potential to result in ineffective monitoring of medication's effectiveness and inconsistent implementation of interventions for Resident 76.

Inspectors wroteBased on interview and record review, the facility failed to revise or update the care plan for one of one sampled resident (Resident 12) to address resident specific activities such as sensory stimulation, conversation, and music in accordance with the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered. This deficient practice had the potential to result in Resident 12 not receiving appropriate interventions and treatment and/or services for ---and negatively affect the resident's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled resident (Resident 6) with gastrostomy tube (as known as G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) was provided care and services to prevent skin irritation, breakdown, and infection as indicated in the resident's care plan and facility policy and procedure (P&P) titled Gastrostomy/Jejunostomy (a feeding tube placed directly into the small intestine) Site Care. This deficient practice had the potential to cause worsened skin breakdown on Resident 6's G-tube site and further lead to infection and complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 82) who was at risk for developing pressure injury (a skin breakdown due to prolonged unrelieved pressure, shear and friction on skin) the low air loss mattress (LAL, a specialized medical bed with air-filled tubes connect to a pump to relieve pressure points) was not set according to the manufacturer's Operational Manual. The LAL mattress was set at 160 that corresponded with the resident's assessed weight, it was set for 400 pounds resident. This deficient practice had the potential to compromise pressure redistribution and therapeutic support necessary for the prevention and healing of pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for one of three sample residents (Resident 76), who was considered a high fall risk, by failing to: 1. Immediately respond to the Pad alarm (a pad with sensors that will alarm on the chair or bed when a resident stands up unassisted to help prevent falls by alerting staff) when the alarm turns on to check Resident 76. 2. Ensure Resident 76 had frequent visual supervision as part of the Falling Star Program (a visual safety program used in long-term care facilities to prevent residents from falling). 3. Re-evaluate Resident 76's falls prevention interventions identified during the Interdisciplinary Team (IDT, group of healthcare professionals who collaborate to create a plan of care for residents) meeting on 2/11/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sample residents (Resident 8), who received hospice care (compassionate care for people who are near the end of life) and services was assessed and reassessed for the intensity of pain, characteristics, patterns, frequency, timing and duration and location of pain associated with the administration of Tramadol (a prescription pain medication to treat moderate to severe pain) in accordance with the resident's care plan and facility's policy and procedures (P&P) titled Pain Management. Resident 8 continued to receive Tramadol multiple times between May 2026 and June 2026 for a pain level of 0 - 4/10 on the numerical pain scale (a way to rate pain intensity, ranging from 0 - no pain to 10 - worst pain left) without pain assessment and reassessment documented in the clinical record. [...]

Inspectors wroteDuring an observation, interview, and record review, the facility failed to evaluate why the alternative interventions were ineffective prior to installing four bedrails for one of three sample residents (Resident 10). In addition, Resident 10 was not monitored for the use of side rails as indicated in the facility's policies and procedure (P&P) titled, 'Bed Safety and Bed Rails (adjustable metal or rigid plastic bars that attach to the head and foot of the bed), dated March 2023. These failures had the potential for Resident 10 to be at risk for entrapment (when a resident can get caught by the head, neck, chest, or other body part in the right spaces around the bedrail) and physical injuries such as bruising or fractures (broken bone), which may result in hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Pharmacist Consultant (PC) 1 identified and reported the medication irregularities to the attending physician and the facility's medical director and director of nursing during the medication regimen review for one of three sampled residents by failing to: 1. Administered Journavx (Suzetrigine a pain medication) tablet via G tube (a tube surgically inserted into the stomach for delivery of fluids and medications) without crushing from 3/29/2026 to 6/16/2026. A pharmaceutical recommendation indicated not to crush Journavx tablet. 2. Continuously administer Journavx tablet from 6/1/2026 to 6/15/2026 after effective administration of Acetaminophen ( a pain medication) was documented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify Physician 1 (On-Call Attending Physician) that one of three sample residents (Resident 90) the laboratory test result of positive urine culture (presence of bacteria in the urine) and sensitivity (laboratory test to determine the most effective medication to treat an infection) on 6/13/2026 at 10:27 PM. This failure resulted in Resident 90 receiving delayed treatment for infection and received first IV (intravenous, a method to deliver fluids or medication directly into the vein) antibiotic (medication used to treat infection) medication for her urinary tract infection (UTI, an infection in the bladder/urinary tract) on 6/15/2026 at 9:20 AM. This failure had the potential to result in worsening UTI, permanent kidney damage, hospitalization, and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure an informed consent for the use of lorazepam (medication used to reduce anxiety and control seizures) was signed by a physician for one of one sampled resident (Resident 76). This failure had the potential to result in no validation that Resident 76's representative received information on the purpose, risks/benefits, and potential side effects of the lorazepam.

Inspectors wroteBased on interview and record review, the facility failed to follow transfer/discharge procedure in accordance with the facility's policy and procedure (P&P) titled, Transfer or Discharge Notices, for one of four sampled residents (Resident 1) when Resident 1's Responsible Party (RP - an individual, often a family member who acts on the Resident's behalf) 1 was not notified of Resident 1's transfer to the hospital in writing. This failure had the potential to result in loss of continuity of care, confusion over bed hold (a resident's right to keep a bed vacant and available for seven days after their transfer to the hospital in anticipation of their return to the facility), and being unaware of plan of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a scheduled toileting care plan and incontinence (the loss of bladder control) care plan was developed for one of four sampled residents (Resident 1) in accordance with the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered. This failure had the potential to leave Resident 1's toileting and incontinence needs unaddressed, increasing Resident 1's risk of skin breakdown and urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide skin barrier cream (a topical medical cream intended to maintain the skin's physical barrier, seal in moisture, and protect fragile skin from external irritants, friction, and bodily fluids) per physician's order for one of four sampled residents (Resident 2) in accordance with the facility's policy and procedure titled, Prevention of Pressure Injuries. This failure had the potential to delay the healing and worsen Resident 2's moisture-associated skin damage (MASD - skin damage resulting from long-term exposure of the skin to moisture).

Inspectors wroteBased on interview and record review, the facility failed to ensure a scheduled toileting program was implemented for one of four sampled residents (Resident 1) in accordance with the facility's policy and procedure titled, Urinary Incontinence. This failure had the potential to worsen Resident 1's bladder incontinence (the loss of bladder control), increasing Resident 1's risk of skin breakdown and urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program in accordance with the facility's policy and procedure (P&P) titled, Infection Control, for one of four sampled residents (Resident 2) when Certified Nurse Assistant (CNA) 1 did not perform hand hygiene after handling Resident 2's soiled brief (a disposable, highly absorbant undergarment designed to manage bladder and bowel incontinence) during activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). This failure had the potential to increase risk for infections due to cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) and Resident 2 to develop infection.

Inspectors wroteBased on interview and record review, the facility failed to provide immediate, effective and uninterrupted basic life support (BLS - a set of emergency medical procedures designed to maintain life in individuals experiencing cardiac arrest, respiratory failure, or other life-threatening conditions) and cardiopulmonary resuscitation (CPR) on [DATE] for one of three closed record sampled residents (Resident 119), who was identified full code in the facility and found unresponsive and not breathing, in accordance with the facility ' s P&P, by failing to: 1. Implement Resident 119 ' s Physician Orders for Life Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner, or a physician assistant which specifies what a patient ' s lifesaving treatment wishes are) according to the resident ' s preferences for life sustaining treatment. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents' (Resident 81 and 99) Physician Orders for Life Sustaining Treatment (POLST forms that tell medical staff what to do if you have a medical emergency and are unable to speak for yourself) and Advance Directive (living will, 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) Acknowledgment Form correctly indicated Resident 81 ' s and 99 ' s Advance Directive. This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident ' s wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect three of three sampled residents' (Residents 29, 5, and 112) privacy to ensure the unauthorized personnels did not have the access to view and obtain the baby monitors for Residents 29, 5, and 112. The deficient practices had potential to violate the residents' right for privacy.

Inspectors wroteBased on observation, interview, and record review, the facility to failed to promote resident safety in administering oxygen for three (3) of 3 sampled residents (Resident 71, 119 who were receiving oxygen therapy, in accordance with the facility ' s policy and procedure by failing to: 1. Ensure the oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient ' s ears) was labeled with date opened and not touching the floor for Resident 71 2a. Ensure physician order for oxygen administration was followed for Resident 119 to titrate up to 4L per minute for oxygen saturation less than 90% every shift 2b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of five outdoor refuse containers (a waste container that a person controls that includes dumpsters, trash cans, garbage pails, and plastic trash bags) were closed with a tight-fitting lid and kept covered. This deficient practice had the potential to attract insects and harborage of pests in the refuse area that can cause a wide spread of diseases and affect the residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician for one of three sampled residents (Resident 371), who had developed edema (swelling caused by a collection of fluid in the spaces that surround the body's tissues) on the left elbow, in accordance with the facility ' s Policy and Procedure (P&P) for Change in Condition. This deficient practice had the potential to result in delayed care and treatment and could lead to tissue damage for Resident 371.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Identify and define specific problematic behaviors related to the use of quetiapine (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 16.) 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 86 was assessed using the standardized Quarterly Review assessment tool (Minimum Data Set [MDS], a resident assessment tool) no less than once every 3 months between comprehensive assessments and transmitted to Center of Medicare and Medicaid Services (CMS) in accordance with current federal and state submission timeframes for one of two sampled residents (Resident 86). This deficient practice failed to provide CMS specific resident information for quality care measure and tracking purposes.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of four sampled residents (Resident 67 and 9) by failing to: 1. Ensure Resident 67's primary language was indicated in the care plan. 2. Ensure Resident 9' s hard of hearing (HOH) and hearing aids (HA, a device worn in or behind the ear designed to amplify sound for individuals who have difficulty hearing) use were indicated in the care plan. These deficient practices had the potential to result in a delay of nursing care and medical interventions for Resident 67 due to language barrier and the potential for Resident 9's specific needs to not be met, and for facility staff to not monitor and evaluate the effectiveness for resident-centered care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 3), received restorative nursing treatment (nursing interventions that help people maintain or regain their ability to perform daily activities after an illness, injury, or surgery) that included application of left ankle-foot orthosis [AFO - a device worn on the foot and ankle to support and control movement, often used to help with walking, improve stability, or correct foot drop (a condition where it's difficult to lift the front part of the foot and toes, often causing them to drag during walking)] from 5/16/2025 to 5/22/2025 (total of 7 days) and application of left resting hand splint from 5/20/2025 to 5/22/2025 (total of 3 days) as ordered by Resident 3 ' s physician on 3/5/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free of hazard for one of four sampled residents (Resident 107), who was at risk for fall due to dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities] and had a history of recent fall on 3/14/2025, by failing to: 1. Ensure that CNA 1 placed a call light within Resident 107 ' s reach as indicated in the resident ' s care plan, when CNA 1 took Resident 107 back to the resident ' s room and left the resident alone in the wheelchair. 2. Ensure LVN 3 and LVN 4 placed a floor mat in accordance with Resident 107's physician's orders dated 3/11/2025 after the room was deep cleaned prior to the resident returned to bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services to one of three residents (Resident 76) with an indwelling catheter (a device that drains urine [pee] from urinary bladder into a collection bag outside of body) by failing to: 1. Follow the facility ' s Policy and Procedure (P&P) titled Fluid Intake& Output (I&O) to evaluate Resident 76 for the need of continue monitoring and documenting the resident ' s I&O at the completion of the 30-day period. 2. Monitor and document findings of Resident 76 ' s bladder distention (swelling or enlargement of the bladder due to an inability to empty it completely or a buildup of urine) as indicated in Resident 76 ' s physician ' s orders and care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically-related social service for one of three sampled residents (Resident 9), who was hard of hearing (HOH) and not satisfied with the hearing aids (HA, a device worn in or behind the ear designed to amplify sound for individuals who have difficulty hearing), by failing to follow up and make an appointment with the audiologist (a physician specialized in hearing loss). This deficient practice resulted in Resident 9 not utilizing the facility provided HA and leaving Resident 9 to remain hearing impaired and negatively impacting Resident 9 ' s quality of life and well-being.

Inspectors wroteBased on interview and record review, the facility failed to respond to the consultant pharmacist ' s (a medical professional responsible for a monthly review of all residents ' medication regimens) request for a gradual dosage reduction (GDR - a periodic attempt to lower the dosage of a medication or discontinue a medication to control a resident ' s symptoms with lower doses or fewer medications) related to the use of quetiapine (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 16.) The deficient practices of failing to respond to the consultant pharmacist ' s recommendation to perform a GDR related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) increased the risk that Resident 16 could have experienced adverse effects (unwanted or dangerous [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of nine sampled residents' (Resident 52) food preference was honored. This deficient practice had the potential for Resident 52 ' s to refuse meals and negatively affect Resident 52 ' s nutritional status.

Inspectors wroteBased on interview and record review, the facility failed to ensure to maintain a complete and accurate documentation of all services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychological condition, in accordance with the facility ' s policy and procedures (P&P) titled Change of Condition and Charting and Documentation. This deficient practice resulted in an inaccurate depiction of Resident 119 ' s care and health status and had placed Resident 119 at risk for having serious health complications. Cross referenced to F678, F695.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the enteral tube feeding (a feeding tube is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth) formula bag was labeled with the date and time for one of five sampled residents (Resident 80) in accordance to the facility's Policy and Procedure for Enteral Feeding Monitoring. This deficient practice had the potential to place Resident 80 at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident room measured at least 80 square feet (sq ft- a unit of measurement) per resident for 27 of 50 sampled resident rooms (Rooms 101, 102, 103, 104, 105, 106, 107, 108, 109,110, 201, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215, 216, 218, and 220). This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three Certified Nurse Assistant (CNA 1) demonstrate necessary competency skills necessary to care for residents assigned to CNA 1 as indicated in the residents plan of care. CNA 1 was assigned to work double shifts when the facility was aware that CNA1 ' s job performance demonstrated incompetency and received written warnings due to sleeping during work hours, taking long breaks than scheduled, leaves work without telling anyone in the facility and did not changed residents who found soiled or reposition in bed. This deficient practice had resulted in the residents not to received quality of care necessary to achieve their highest potential and result in a decline in the residents well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 3) were free from accident hazards as possible by failing to provide monitoring, supervision, identifying hazards and assistance for two of three sampled residents (Resident 1 and 3) who were at risk for fall in accordance with the facility's policy and procedure. In addition for Resident 3 the facility failed to ensure the bed alarm (an alarm that turns on to alert the staff when the resident attempts to get off the bed) was in functioning condition. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to promote the resident's right to receive services in the facility with reasonable accommodation of resident needs and preferences for three of three residents (Resident 88, 7 and 98) by failing to: 1. Accommodate Resident 88's needs by not providing a communication board (a sheet of symbols, pictures or photos that residents will learn to point to, to communicate with those around them) for the resident to effectively communcate her needs. 2. For Resident 98, who spoke and preferred to communicate in his native foreign language was not provided a communication board to be used to communicate with the facility staffs. This failure resulted in violation of the residents rights to communciate their needs, and cause confusion and miscommunication such as Resident 88 not receiving oral care. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were updated to indicate documentation that advance directives (AD-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and the written information were provided to the residents and/or responsible parties for four of the five sampled residents (Resident 7, 113, 107, and 39). These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives (AD) and had the potential to cause conflict with the residents' wishes regarding health care. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive Minimum Data Sets (MDS - a comprehensive standardized assessment and screening tool) were completed within the required time frame for four of four sampled residents (Resident 70, 54, 4, and 100). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 70, 54, 4, and 100.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS - a comprehensive standardized assessment and screening tool) were completed and submitted to the CMS (Center for Medicare and Medicaid) data base within the required time frame for four out of four sampled residents (Resident 70, 54, 4, and 100). This deficient practice had the potential for the residents not to receive or receive delayed necessary care and treatment, which could comprise residents' quality of care and safety, especially for the residents with major condition change that could result in a decline in Residents 70, 54, 4, and 100 wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist four of five sampled residents (Residents 19, 87, 98 and 17) who were unable to carry out activities of daily living (ADL) to maintain good grooming, and personal and oral hygiene by failing to 1. Assist Resident 19 and Resident 87 to trim the residents' fingernails during shower. These deficient practices had the potential to result in a negative impact on Resident 17 and Resident 87's quality of life and self-esteem. 2. Assist Resident 98 with oral care. This failure resulted in Resident 98's inconsistent oral care since 3/7/24 and which had a potential to result in dental carries, teeth and gum infections, lung infection, that could lead to hospitalization for higher level of care. Findings, 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation, preparation, and food handling practices, to prevent the outbreak of foodborne illness (an illness caused by contaminated food) in accordance with the facility's policy and procedure and professional standards for food service and safety by failing to: Replace a can opener that had rust (a reddish or yellowish-brown coating of iron oxide that is formed on iron or steel by oxidation (a process that occurs when atoms or groups of atoms lose electrons) especially in the presence of moisture), and chrome plating (a technique of electroplating a thin layer of chromium onto a metal object) that was peeling off from the kitchen device. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to meet professional standards of quality (care and services are provided according to accepted standards of clinical practice) for one of one sample residents (Resident 27) by failure to apply gentle pressure to the lacrimal duct (a small tube that drains tear from the eyes) to prevent systemic absorption of the medication (medications are absorbed into the whole of an organism, rather than applied to one area.) of Carboxymethylcellulose sodium (medication is used to relieve dry, irritated eyes) ophthalmic (eye). This deficient practice had the potential for the resident to have an adverse reaction (an undesired harmful effect resulting from a medication). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility ' s nurses were competent in ensuring their residents' low air loss mattress (LALM, a mattress that designed to distribute the body weight over a broad surface area and help prevent skin breakdown) were maintained with the correct setting based on residents weight. This failure had a potential to result in the resident's to develop pressure ulcer or worsened pressure ulcer (a skin injury due to prolonged unrelieved pressure or being in one position for a long time).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services when one (1) of seven (7) medication cart was left unlocked before entering a resident's room to administer medications. This deficient practice had the potential for non-authorized staff or residents to access the medication cart, which can result to diversion or if the medications were ingested, may cause serious injury/harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy and procedure for infection control and facility's protocol titled Enteral Feedings ( also known as Gastrostomy tube [GI] feeding, a tubing inserted into the stomach used to deliver fluids, liquid nutrition and medications into the stomach or small intestine) to one of three sampled residents (Resident 6), who was found with GT feeding on the floor on 5/22/24. This failure had a potential to result in a risk of contracting infections, which could lead to a decline in the resident's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and maintain a functioning call light for one of 21 sampled residents (Resident 103) This deficient practice had the potential to result in a delay in meeting the resident ' s needs for assistance and had the potential to lead to accidental falls/accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's bedroom measured at least 80 square feet (sq. ft.-a unit of measurement) per resident in multiple resident bedrooms for 27 out of 50 rooms. Rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 201, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215, 216, 218, and 220 that measured less than 80 sq. ft. per resident. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure on Resident lifting/Assisting Transfer Policy, regarding resident lifting for dependent residents (Resident 1). Certified Nurse Assistant (CNA) 1 and CNA 2 did not use the mechanical lift transfer to Resident 1, who was totally dependent with transfers, held Resident 1 ' s arm pits to stand up from the wheelchair. This deficient practice had result in Resident 1 ' s left shoulder fracture and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed toensure one of three sampled residents (Resident 1) was free from injury after sustaining a fall in the facility. 1. Certified nurse assistant (CNA)1 failed toreport to licensed nurses that Resident 1 was found on the floor in Resident 1 ' s room, by the foot of the bed on 3/24/24. 2. Registered Nurse 1 failed to immediately conduct an assessment onResident 1 after Resident 1 was found on the floor on 3/24/24. 3. CNA 1 failed to ensure Resident 1 was safely transferredto the bed after sustaining a fall. CNA1 transferred Resident 1 back to bed, alone, without licensed nurses assessing Resident 1 for any other injuries. 4. RN1 failed tonotify the physician and implement the facility ' s fall protocols immediately after Resident 1 ' s unwitnessed fall on 3/24/24. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow proper sanitation and safe food handling, in accordance with the facility's policy and procedures on Sanitation and Infection Control, by failing to ensure: 1. Main [NAME] 1 changed gloves while plating lunch, picked up paper from the floor, and proceeded to touch the parsley garnish with same plastic gloves. 2. Kitchen Assistant 1 and Kitchen Assistant 2 were observed not wearing hair net properly, exposing hair during breakfast preparation. These deficient practices had the potential to put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility ' s policy and procedure titled General Policies for IV (IV- is used to give medications and fluids directly to the vein) therapy, was implemented to infection control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) to prevent infection for one of two sampled residents (Resident 2). This deficient practice placed the residents at risk for potential infection or cross contamination of infections (the physical movement or transfer of harmful bacteria from one person, object, or place to another.