San Mateo Medical Center D/P SNF

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party of Resident 1 regarding changes in his clinical condition for one of four sample residents. This failure had the likelihood to prevent Resident 1's responsible party from being informed in a timely manner and from participating in care decisions related to Resident 1's change in clinical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of three sampled residents (Resident 1) when Phenobarbital (a prescription medication primarily used to control certain types of seizures), Olmesartan Medoxomil (a prescription medication used alone or with other drugs to treat high blood pressure), Metoprolol (a prescription medication primarily used to treat high blood pressure, prevent chest pain, and manage heart failure), and Hydroxyzine (a prescription medication primarily used to treat itching, anxiety, and allergic reactions) were not given according to the doctor's orders from February to April 2026. This failure was likely to result in Resident 1 being put at risk for not attaining or maintaining his highest practicable level of physical, mental, functional, and psychosocial well-being. [...]

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision to Resident 1 to prevent his elopement. This failure did not ensure Resident 1 was residing in a safe and supervised environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to thoroughly investigate an allegation of neglect for Resident 1, one of three sample residents. Resident 1 alleged she was calling out in pain for 4 hours and her call light was pulled out of the wall and was non-functional. The facility failed to: Interview other residents and/or responsible parties around Resident 1's room regarding call light response. Check to see if Resident 1's call light automatically triggers when pulled out of the wall socket. Ensure the Maintenance Director was knowledgeable regarding how a call light should function when unplugged from the wall. This failure may subject residents to delayed response to their request for assistant and may delay staff response to an emergent situation.

Inspectors wroteBased on interview and record review, facility staff failed to recognize and report an allegation of neglect for Resident 1, one of three sample residents: when Resident alleged she was in pain for four hours and staff failed to response to her call for assistance. This failure had the potential for residents to be subject to abuse/neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment free from potentially serious accident hazards for all residents when its policies and procedures were not implemented for the following practices:1. The facility failed to ensure hot water in 6 of 8 residents' bathroom sinks were at a comfortable and safe temperature level. This deficient practice placed the residents (Residents 165, 187, and 259) at increased risk for scalding. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker on a full-time basis that met the qualifications specified in the regulation for 267 of 267 residents residing in the facility. This failure had the potential to result in residents not receiving sufficient and appropriate coordination of medically related social services to meet their needs. Review of the facility's license to operate, it was indicated the facility had a bed capacity of 281, with an effective date of 2/1/25 and expiring date of 1/31/26. Review of the facility's census at the start of the survey, it was indicated 267 residents were admitted , with an additional two (2) residents on bedhold status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage in the kitchen when:1. Diced peaches sat in a partially opened container in the refrigerator.2. A large cut of beef was inside a sealed clear plastic package with no expiration date in the freezer.3. Chocolate puddings were prepared in not fully dried small wet bowls.4. There were an expired container of liquid smoked sauce and brisk coffee roasters in a small bin found in the dry storage.5. Food distribution to the residents were delivered in a timely manner. These failures had the potential to result in putting residents at risk for foodborne illness (a disease caused by consuming contaminated food or drink).1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program when:1. A live cockroach was observed on the floor in the kitchen.2. A pest control company report dated 5/27/25 indicated, confirmed cockroach activity in the downstairs kitchen and documented that service was performed. The company provided recommendations, made some recommendations; however, the facility has not implemented them.3. A pest control company report dated 6/30/25 indicated that service was performed to help control an ongoing cockroach problem. This indicates that, despite previous treatment on 5/27/25 cockroaches were still present in the kitchen.4. An interview with the pest control technician revealed that there was a small to moderate number of German cockroaches found in the kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately administer medications when one of 35 sampled residents (Resident 33) was self-administering prescribed oral medications without being appropriately assessed and approved for self-administration. This failure had the potential to place Resident 33 at risk for adverse health reactions like aspiration (choking, the accidental inhalation of food, liquid, or other material into the lungs) from improperly administered medication. Review of Resident 33's admission Record, indicated Resident 33 was readmitted to the facility on [DATE] with diagnoses including thrombosis (a blood clot, usually in the leg, which can cause swelling, pain, and redness), hypertension (high blood pressure) and dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 53) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when the order for Lorazepam (medication used to treat anxiety) PRN (as needed) did not have a stop date. This deficient practice had the potential for Resident 53 to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the annual Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment was completed within the required period of 14 calendar days from the Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) for one of 35 sampled residents (Resident 165). Failure to complete a comprehensive resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of Resident 165. Review of Resident 165's admission record indicated, was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA - a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of one sampled resident (Resident 53) when Resident 53 was admitted for hospice services. This failure could potentially delay the provision of appropriate treatment and services for Resident 53. Resident 53 was admitted on [DATE] with diagnoses that included cerebral infarction (also known as ischemic stroke, a medical condition where a part of the brain is damaged due to a lack of blood supply), hemiplegia (paralysis on one side of the body), and hemiparesis (condition characterized by weakness on one side of the body). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration for one of five residents (Resident 182) when Licensed Vocational Nurse (LVN) 1 did not observe Resident 182 take his medication after leaving one prescription medication on the overbed table with the presence of an ambulatory roommate. The deficient practice resulted in a medication error for Resident 182; and may result in medication error and/or adverse health reactions when taken by the roommate. During medication pass observation on 7/2/25 at 9:20 AM, LVN 1 prepared fifteen (15) medications for Resident 182 including ClearLax Polyethylene Glycol 3350 Powder for Solution (used to treat occasional constipation). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services were provided to one of three sampled residents (Resident 14) who had an indwelling urinary catheter, by failing to consistently monitor for catheter kinks. This deficient practice had the potential for Resident 14 to develop urinary tract infection. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist's (CP) recommendation for the use of psychotropic medication was acted upon for one of six sampled residents (Resident 53). This failure had the potential for Resident 53 to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being. Resident 53 was admitted on [DATE] with diagnoses that included cerebral infarction (also known as ischemic stroke, a medical condition where a part of the brain is damaged due to a lack of blood supply), hemiplegia (paralysis on one side of the body) and hemiparesis (condition characterized by weakness on one side of the body). Resident 53 was in hospice care. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal immunization (known as pneumococcal vaccination, refers to the process of administering vaccines to protect against pneumococcal disease, caused by the bacteria Streptococcus pneumoniae, also known as pneumococcus. These vaccines work by triggering the body's immune system to produce antibodies that fight off the bacteria, preventing or reducing the severity of these infections) for one of 5 sampled residents (Resident 650) when there was no evidence that the pneumococcal vaccine was given to Resident 650 even after a phone consent had been received from the responsible party on 2/26/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide COVID-19 immunization (also known as COVID-19 vaccine that helps our bodies develop immunity to the virus that causes COVID-19 without us having to get the illness. Different COVID-19 vaccines may work in our bodies differently, but all provide protection against the virus that causes COVID-19) for one of 5 sampled residents (Resident 650) when there was no evidence that the COVID-19 vaccine was given to Resident 650 even after a phone consent had been received from the responsible party on 2/26/25. This failure had the potential to result in putting Resident 650 at risk for acquiring (getting), transmitting (causing infections to pass on from one place or person to another), or experiencing complications from Coronavirus disease (COVID-19, an infectious disease caused by the SARS-CoV-2 virus. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation into an allegation of sexual abuse between Resident 116 and Resident 223, 2 of 8 sample residents with allegations of abuse. Failure to thoroughly investigate an allegation of abuse did not ensure other residents were protected from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of a preventable pressure ulcer ( PU) for one of three sampled residents (Residents 111) when staff did not perform an accurate body check that reflected and identified Resident 111's skin condition. This deficient practice resulted in the development of Stage III PU for Resident 111. Definition/Stages for Pressure Ulcer/Pressure Injury (also called a bed sore, is an injury to skin and underlying tissue resulting from prolonged pressure on the skin. Stage I: Intact skin with a localized area of non-blanchable redness (non-blanchable: redness persists and does not fade or turn white after removal of fingertip pressure). Stage II: Partial-thickness loss of skin with exposed upper skin layer. The wound bed is pink. May also present as an intact or ruptured blister. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to serve food and substitutes according to residents' preferences when: Residents with food preferences such as Jook and soups were not honored. This failure has the potential to deny the basic rights of 31 residents in a census of 264 residents to receive the services and care necessary to achieve or maintain their quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide meals according to the facility's serving hour schedule when: During mealtimes observation, the meal cart was observed arriving late on the second floor for breakfast and lunch. This failure to follow the 14-hour rule for mealtimes especially at breakfast time have the potential to deny the residents patient centered care that will affect their psychosocial well-being and health outcome.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety requirements in accordance with professional standards for food service when: 1. Serving plastic bowls, large plastic food containers and baking pans were not dried appropriately. 2. Plate warmers were not cleaned. 3. Serving trays were stacked and stored on a dusty cart outside of the kitchen door. 4. The kitchen staff still uses the hand sanitizer in the kitchen. 5. Bowls of cream of rice and bowls of oatmeal in the refrigerator were undated. 6. Two packs of grapes in the refrigerator were overripe, and some of them were mushy. The failure to store, serve, hand sanitize and distribute food in an unsafe and sanitary manner had the potential to put residents at risk for foodborne illness leading to severe illness and even death for 262 residents who consumed food by mouth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity and respect were maintained for one sampled (Resident 255) and two random residents (Residents 165 and 162) when: 1. Staff stood over Resident 255 and Resident 165 to assist with meals. 2. Facility failed to provide access to communication with staff in a language that is clear and understandable to the resident when a language translation service was not available for use by Resident 162. [...]

Inspectors wroteBased on observation, interviews and record reviews, facility did not ensure hospice services and interventions were addressed for three of five residents (Resident 155, Resident A, Resident B) when: 1. No coordination for plan of communication with facility and hospice agency regarding changes in Resident A's condition and death, and the staff were not trained on the protocol of who is the responsible provider for each specific function, to notify family,MD and Hospice. 2. The care plan did not include specific interventions of coordination of care between facility and hospice agency for Resident 155 and Resident B. These failure resulted in family not notified of change in condition and death of Resident A, and had the potential to result in not providing the needed treatment care and services for Resident 155 and Resident B.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents (Residents 66, 118, and 255) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when: 1. For Resident 66, consent was not obtained for the use of Mirtazapine (medication used to treat depression). 2. For Resident 118, consents were not obtained for the use of Aripiprazole (medication used to treat depression and Tourette syndrome [a nervous system disorder involving repetitive movements or unwanted sounds]), Haloperidol (medication used to control symptoms of Tourette syndrome), and Buspirone (medication used to treat anxiety [[a feeling of fear, dread, and uneasiness]). 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were not expired and stored properly when: 1. One out of six sampled medication carts had two prescription eye drops that were found to be expired or not labeled after opening, 2. Multiple medications were found to be stored in the garage without temperature control. This failure has the potential to result in medications being administered to residents that are expired, ineffective, or potentially hazardous to the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan (CP) for each resident that included measurable objectives and specific interventions for 2 of 38 sampled residents (Residents 111and 66) when: 1. No individualized person-centered CP was developed to address Resident 111's pressure ulcer (PU). 2. No individualized person-centered CP was developed for the use of Lorazepam (medication used to treat anxiety) for Resident 66. This failure had the potential for not meeting the residents' nursing needs and goals to attain their highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to post complete nurse staffing data daily from 3/11/24 to 3/15/24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep an accurate reconciliation (recordkeeping) for a controlled substance (a chemical or medication regulated by the federal government due to high risk for abuse or dependence) when one out of six sampled narcotic records (a logbook used to keep track of controlled substances used/discarded and still available in supply) had an inaccurate count of medication. This failure has the potential to result in medication diversion (the transfer of a controlled substance from lawful to unlawful use).

Inspectors wroteBased on interview, and record review, the facility failed to ensure the pharmacy consultant's recommendation for the use of psychotropic medication was acted upon for one of three sampled residents (Resident 255). This failure had the potential for Resident 255 to receive unnecessary psychotropic medications, be exposed to adverse health consequences from the medications, which could negatively impact the resident's mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's order of parameters regarding a pain medication for one of two sampled residents (Resident 233) when Resident 233 received an excessive dose of Hydromorphone (a potent pain medication). This failure has the potential to result in an adverse reaction (a harmful and unexpected effect of a medication) such as respiratory depression (slow breathing resulting in poor oxygen intake)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a refuse (solid waste not carried by water through the sewage system) container were disposed in a proper manner with the lid. This failure had the potential to promote development and spread of communicable diseases and infections that could jeopardize the health of the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control program and practices designed to help prevent the development and transmission of diseases and infections when: 1. There was unopened Biohazard Spill Kit (a cleaning supply to remove the biohazard and disinfect the area) with expiration date of [DATE] in the garage storage. 2. The facility did not implement the correct cleaning and disinfecting practices of a glucometer (a machine used to test a resident's blood sugar at the bedside) after obtaining a blood glucose (sugar) for one of two sampled residents (Resident 133). These failures had the potential for spread of infection or bloodborne pathogens (bacteria or viruses in blood that can spread disease) to residents and staff.

Inspectors wroteBased on observation, interviews and record review, the facility did not ensure staff were trained on infection control practices for oral suctioning, when eight residents have orders for suctioning PRN, nurses unable to tell protocol on change of tubes and cleaning the canister. This failure could result in break in infection control practice that could spread infection among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent abuse to one of one sample resident (Resident 35) when another resident threw a bottle of deodorant at her resulting to an injury. The facility's failure resulted to Resident 35 to sustain a bump (swelling) over the right eye, and bruising (when a part of the body is injured and the blood gets trapped under the skin) to the right orbital areas (skin area around the eye).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation for one of one sampled resident (Resident 122) when resident preference for a female Certified Nurse Assistant (CNA) as caregiver was not provided. This failure resulted to Resident 122 verbalized she felt disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their fall risk care plan for one of two sampled residents (Resident 209) when Resident 209 was transferred (moving a resident from one position to another) from the wheelchair to the bed with a two-person manual transfer (when two people physically lift someone to move them). This failure had the potential to result in a fall during transfers.

Inspectors wroteBased on interviews and record review, facility staff failed to provide pressure injury services for one of four sample residents, Resident 1. For Resident 1, the facility failed to: 1. accurately assess Resident 1's pressure injuries (wounds caused by prolonged pressure to a body part, see definition below). 2. turn/reposition Resident 1 to prevent development and/or worsening of Resident 1's pressure injuries. These failures resulted in worsening of Resident 1's right hip pressure injury, development of a new right elbow pressure injury, and development of a new pressure injury to the right side of Resident 1's back. Definition for pressure injuries Stage I: Intact skin with a localized area of non-blanchable redness (non-blanchable: redness persist and does not fade or turn white after removal of fingertip pressure). Stage II: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice when: 1. There was no evidence that the physician was notified of Resident 1's abnormal urinalysis (a medical test where the urine is examined to diagnose and monitor various illnesses). 2. There was no evidence Resident 1 was transferred to wheelchair daily as per the physician's order. These failures caused a delay in provision of treatment to Resident 1 and could have compromised Resident 1's ability to maintain her highest practicable physical, mental, and/or psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect three of 3 sampled residents (Resident 2 and Resident 3, and Resident 8) from sexual abuse (non-consensual sexual contact of any type with a resident) by Resident 1 when: 1. Facility did not identify, report, and initiate an investigation of Resident 1 touching Resident 3's breast in the dining room in July 2023. Additionally, the facility did not develop and implement interventions to address Resident 1's behavior of touching female resident's sensitive area. This resulted in delayed identification and implementation of interventions to address Resident 1's sexually inappropriate behavior towards a female resident. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide process oversight and ensure effective implementation of its abuse policies and procedures to protect three of three sampled residents (Resident 2, Resident 3, and Resident 8) when: 1. Facility did not ensure three allegations of sexual abuse (non-consensual sexual contact of any type with a resident) were reported to the State Survey Agency (SSA) within the required timeframe of two (2) hours for Resident 2 and Resident 3. Additionally, Certified Nursing Assistant (CNA) 2 and Licensed Vocational Nurse (LVN) 1 who witnessed and reported the sexual abuse allegations to the nurse-in-charge were placed on suspension. 2. Facility did not conduct a thorough investigation of the three allegations of sexual abuse for Resident 3 in July 2023 and two incidents for Resident 2 in August 2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a thorough investigation for six of 7 sampled residents (Resident 1, Resident 2, Resident 3, Resident 5, Resident 6, and Resident 7) when: 1. Three allegations of sexual abuse (non-consensual sexual contact of any type with a resident) were not thoroughly investigated for Resident 1, Resident 2, and Resident 3. In addition, there was no documented evidence Resident 1's sexually inappropriate behavior towards Resident 2 and Resident 3 was addressed and measures were not implemented to prevent further sexual abuse towards Resident 2. Furthermore, the facility failed to report the results of all investigations of three allegations of sexual abuse to the administrator or designee and State Survey Agency (SSA) within 5 working days of the alleged incidents. 1a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three allegations of sexual abuse (non-consensual sexual contact of any type with a resident) were reported to the State Survey Agency (SSA) within the required timeframe of two (2) hours for three of 3 sampled residents (Resident 1, Resident 2, and Resident 3). 1. Certified Nursing Assistant (CNA) 2 witnessed Resident 1 touched Resident 3's breast in July 2023, alleged incident was not reported to SSA until 8/31/23. 2. A month later, CNA 2 had witnessed same resident (Resident 1) attempted to touch inappropriately another female resident's (Resident 2) vagina in August 2023, the alleged incident was not reported to SSA. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision and assistance to prevent a fall to Resident 4; and prevent injuries to three residents (Resident 5, Resident 6, and Resident 7) . This facility failure resulted in Resident 4 sustaining fractures (broken) to the 4th, 5th, 6th, 7th, and 8th right ribs (part of the bony framework that protect the chest) and Resident 5, Resident 6, and Resident 7, who were totally dependent on staff with their activities of daily living (ADL, self-care activities) were found with fractures of the femur (thigh bone) of unknown cause.

Inspectors wroteBased on interview and record review, the facility failed to ensure a diagnostic procedure was provided for Resident 7 when a stat (medical term for rush) x-ray (a procedure to create images of the structure of the inside of the body, used to assess broken bones) was not completed as ordered by the physician. The failure resulted to the delay in identification and treatment of a femur (thigh bone) fracture (broken bone) for Resident 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 9), was free from misappropriation of resident's property when Former Director of Nursing (FDON) took Resident 9's Ozempic medication and kept it in his office. This failure resulted in Resident 9 not receiving his Ozempic medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate assessment was completed for one of 3 sampled residents (Resident 1) when Resident 1's physical behavioral symptom of abusing others sexually was not coded on the Minimum Data Set (MDS, a resident assessment tool) as of the Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process). This failure had the potential to result in delayed identification and implementation of interventions for Resident 1's sexually inappropriate behavior; and the potential to place residents in the facility at risk for sexual abuse by Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a person-centered care plan (CP, a road map for patient care) for two of two sampled residents (Resident 7 and Resident 9) when: a. Resident 7 did not have a CP to address osteopenia (bone loss). This failure puts Resident 7 at risk to not receive necessary care and services to manage the possible complication from osteopenia. b. There was no care plan developed to address alleged incident of missing medication and medication not being given timely for Resident 9. This failure had the potential to delay the identification and implementation of appropriate corrective actions for a possible misappropriation of property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services to two of two sampled residents (Resident 10 and Resident 9) according to standards of practice when: a. There was no evidence of documentation of progress or decline during the stay in the facility for Resident 10. b. There was no evidence of documentation of pain assessment and management for Resident 10. c. There was no evidence of documentation prescribed medication was administered as ordered by the physician for Resident 10 and Resident 9. The facility failure has the potential for the residents to not receive necessary care and services and experience adverse effects due to untreated medical conditions.

Inspectors wroteBased on observation, interview, and facility document review, the facility did not ensure safe and sanitation requirements were met when: 1. Handwashing sink faucet hot water was below the required temperature: 2. kitchen appliances, can opener, industrial mixer, plate warmer, ice machine, were found soiled during inspection. 3. food stuff found in open, unsealed, and undated packaging. These failures had the potential to place residents at risk for serious complications from food borne illness because of a compromised health status, in a susceptible population of 222 residents who received food from the kitchen out of a census of 231 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe medication storage and distribution practice when: 1) Twelve out of 13 eye drop bottles for seven residents, in nursing unit 2, were not labeled with residents names or with the date the medication was first open for use. 2) The facility did not provide any documented evidence that refrigerated medications were stored under appropriate temperature in one out of two medications room inspected. The refrigerator temperature for five days in May, May 1 to May 5, 2021 were not recorded. These failure had the potential for resident to receive wrong medications, contaminated medication, and/or ineffective medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Urinals (portable receptacles for urine) were found on the over bed table of three residents (Resident 99, Resident 150, and Resident 222); 2. The nebulizer set (a medical device used to administer medication directly and quickly to the lungs) placed at bedside of Resident 135 was uncovered and unlabeled; 3. A nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside the nostrils to deliver oxygen) for Resident 148 was found on the floor in his room; These failures could potentially lead to cross-contamination, placing the residents at risk for infections.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Physician's Orders for Life Sustaining Treatment [POLST- Patient indicated preferences regarding end-of-life care such as resuscitation measures and other life-sustaining treatment] was completed for one of eight sampled residents (Resident 102). This failure had the potential for the resident to receive incorrect or delayed treatment which is not compatible with the resident's or responsible party (RP)'s wishes during an emergency situation.

Inspectors wroteBased on interview and record review, the facility failed to provide notice of changes in Medicare coverage to the responsible party (RP) of one of three residents (Resident 59) when there was no evidence Resident 59's RP received the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN). This failure may result in Resident 59's RP of not being sufficiently informed of their right to appeal to end Medicare coverage of skilled services, and of the potential financial responsibility for services rendered no longer covered by Medicare. Definition of Terms: NOMNC - a notice that informs the resident or the resident RP when the skilled services the resident is receiving is ending, and provides information on how to make an appeal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan with specific interventions addressing fall prevention for one of 35 sampled residents (Resident 107) who had a history of repeated falls. This deficient practice placed Resident 107 at risk for further falls that could potentially result to harm and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment when there was no fire safety signage indicating the administration of oxygen in room [ROOM NUMBER]. This failure could potentially compromise the safety of the residents, staff, and visitors.