San Rafael Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for four of 27 residents (Resident #1, Resident #3, Resident #47, and Resident #123) reviewed for medication errors. The facility failed to hold Resident #1's midodrine (blood pressure medication) when Resident #1's blood pressure was outside of physician's parameters on May 6th, 13th, 14th, and 21st of 2026. The facility failed to hold Resident #3's Midodrine when Resident #3's blood pressure was outside of the physician's parameters on May 5th, May 6th, May 7th, May 8th, May 10th, May 13th, May 18th, May 20th, May 21st, May 22nd, May 23rd, May 24th, May 26th, May 27th, and May 28th. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 8 medication carts (Nurse Cart 1 and Nurse Cart 2) and 2 of 2 supply rooms (nurses' supply room and general supply room) reviewed for storage. The facility failed to keep medication carts free from expired supplies and unnecessary food/drink items. Nurse Cart 2 contained LVN C's personal items, drinks, and snacks at 3:25 PM on 05/27/26. Nurse Cart 1 contained expired COVID tests at 3:53 PM on 05/27/26. The facility failed to keep the nurses' supply room and the general supply room free from expired supplies. The failure could place residents in the facility at risk of receiving treatment from expired supplies and contamination of medications.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 1 nutrition rooms for storage, preparation, and sanitation. 1. The facility failed to ensure the kitchen followed their cleaning schedules and the floor was slick. 2. The facility failed to ensure the ice cream freezer was clean and defrosted. 3. The facility failed to ensure the ice machine was clean and the door closed properly. 4. The facility failed to ensure the oven doors and the area behind the oven were clean. 5. The facility failed to ensure there were no personal items in refrigerator B. 6. The facility failed to ensure the handwashing sink and paper towels functioned properly. 7. The facility failed to ensure the steam table wells were clean. 8. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #47) reviewed for documentation. The facility failed to ensure Resident #47's blood pressures were documented on 13 separate occasions for May 2026. This failure could place residents at risk for errors in care and treatment and not receiving the services needed to attain or maintain their highest practicable physical well-being.

Inspectors wroteBased observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 dining rooms reviewed, and 1 of 5 residents (Resident #127) reviewed for infection control practices. The facility failed to ensure CNA-F performed proper or adequate hand hygiene while assisting with dining on 05/26/2026. The facility failed to ensure CNA-F did not wipe her nose on her hand while assisting with dining on 05/26/2026. The facility failed to ensure CNA-F correctly passed cups while assisting with dining on 05/26/2026. The facility failed to ensure the CNA-G performed proper or adequate hand hygiene during wound care on 05/27/2026. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program so the facility is free of pests and rodents for 1 of 1 kitchen, 1 of 3 medication storage rooms (100 hall), and 2 of 20 resident rooms (Resident #4 and Resident #92) reviewed for pests. The facility failed to have pest control effectively treat the kitchen for roaches. The facility failed to ensure effective pest control for the medication room on the 100-hallThe facility failed to ensure pest control effectively treated the rooms of Resident #4 and #92 from roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was developed and implemented for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified for 2 (Resident #2 and Resident #75) out of 5 residents reviewed for care plans. The facility failed to review or revise Resident #2's care plan to include all smoking related privileges, restrictions, and concerns. The facility failed to review or revise Resident #75's care plan to include all smoking related privileges, restrictions, and concerns. These failures could place residents at risk for receiving inadequate care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was developed and implemented within a timely manner for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 2 residents (Resident #17 and Resident #9) of 5 residents whose care plans were reviewed. The facility failed to ensure Resident #17's comprehensive care plan was developed and implemented after starting anticoagulant (blood thinner) medication on 05/29/25. The facility failed to ensure Resident #9's care plan was revised to accurately reflect the most current anti-anxiety medication status. [...]

Inspectors wroteBased on Interviews and record reviews, the facility failed to ensure the director of nursing did not serve as a charge nurse when the facility had an average daily occupancy of 60 or higher for 4 days (08/03/25, 08/11/25, 09/08/25, and 09/14/25) reviewed for DON staffing in the last 2 months. The facility failed to ensure the DON did not work as a charge nurse for 4 different shifts in August and September 2025 while the average census was above 60. This failure could lead to dividing the DON's attention, preventing them from performing duties assigned to the DON leading to possible harm to a resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for 2 of 5 residents (Resident #2 and Resident #16) reviewed for pharmacy services. 1. The facility failed to administer Resident #2's Clonidine (a medication used to treat high blood pressure) per the prescribed order and blood pressure parameters in June of 2025. 2. The facility failed to administer Resident #16's Clonidine (a medication used to treat high blood pressure) per the prescribed order and blood pressure parameters in September of 2025. These failures could place residents at risk for complications and jeopardize their health and safety. Findings Included: 1. Record review of Resident #2's face sheet, dated 09/25/2025, revealed a [AGE] year-old female with an original admission date of 04/22/2025, and a current admission date of 09/05/2025. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records that were accurately documented for 3 (Resident #1, Resident #2,and Resident #16) of 5 residents reviewed for medical records. 1. The facility failed to ensure Resident #1's vital signs were accurately documented in the MAR on 08/15/25.2. The facility failed to ensure Resident #2's blood pressure was accurately documented in the MAR during the month of September 2025.3. The facility failed to ensure Resident #16's blood pressure was accurately documented for the month of September 2025. These failures could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure menus met the needs of residents in accordance with established national guidelines for 1 (R#1) of 4 residents reviewed for pureed diets. The facility provided R#1 with a whole hot dog when R#1 required a puree diet, leading to a choking incident on 10/16/25 that required the use of the Heimlich maneuver and resulted in anoxic brain injury. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 10/16/25 and ended on 10/17/25. The facility corrected the non-compliance before the investigation began. This failure could place residents that require specialized diets at risk of choking, hospitalization, and death. Record review of the Resident #1's admission Record dated 10/22/25 revealed Resident #1 was a 66year old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for one resident (Resident #5) of three residents reviewed for skin irregularities. When Resident #5 was readmitted into the facility on [DATE], LVN E failed to complete a thorough and accurate head-to-toe assessment that included assessing what was under Resident #5's right arm dressing/bandage. This failure could compromise a resident's skin integrity, which could increase the risk for progressive skin complications. Record review of the Resident #5's admission Record dated 10/24/2025 revealed Resident # 5 was a [AGE] year-old male who was initially admitted on [DATE] and readmitted on [DATE]. Resident #5 was admitted with multiple diagnoses which included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access for 1 of 2 wound treatment carts on hall 100 reviewed for storage. The 100 hall wound care treatment cart was found unlocked. This failure could place residents at risk of access and ingestion of medications or supplies not intended for them and/or misappropriation.

Inspectors wroteBased on record review and interview, the facility failed to maintain clinical records in accordance with accepted professional standards of practice, that were complete and accurately documented, for one resident (Resident #5) of three residents reviewed for total body skin assessment documentation. 1. When Resident #5 was readmitted into the facility on [DATE], LVN E failed to document a bandage on Resident #5's forearm/elbow area. 2. When Resident #5's skin irregularity was assessed on 09/25/2025, LVN F failed to document and detail the right arm skin impairment. These failures could affect residents who require care and monitoring and place them at risk of not receiving the care and services to meet their needs. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure residents received adequate supervision to prevent accidents and/or hazards as possible for 1 of 5 residents (Resident #1) reviewed for supervision, accidents, and hazards. The facility failed to keep Resident #1 free from accident and/or hazards when she fell on [DATE] which caused her to sustain a left hip fracture by not providing the necessary monitoring and supervision for Resident #1 with known history of behaviors of wandering into other resident rooms. The three staff assigned to supervise the secure unit were at the nurse's station distracted and engaged in personal conversation when Resident #1 wandered out of her room and into another resident's room. An IJ was identified on 08/20/25. The IJ template was provided to the facility on [DATE] at 3:22 PM. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to enforce the post-fall assessment policy leading to Resident #1 being moved from the floor to her wheelchair, and from her wheelchair to her bed after a fall while having severe pain and an obvious hip and leg deformity. The failure could affect residents currently residing in the facility, resulting in them not receiving the needed care to maintain optimal health and placing them at risk for injury or deterioration in their condition.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the appropriate State Agency, but no later than 2 hours after the allegation was made, for 1 of 5 Residents (Resident #1) reviewed for reporting allegations of abuse and/or neglect. The facility failed to report Resident #1's fall with a major injury on 06/01/25 in which Resident #1 sustained a left hip fracture. State Agency was not notified of the fall with injury. This failure could result in placing residents at increased risk for not receiving a proper or thorough investigation.

Inspectors wroteBased on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and measures were taken to prevent further potential abuse, neglect, exploitation or mistreatment in accordance with State law, and if the alleged violation was verified appropriate, corrective action must have been taken for 1 (Resident #1) of 5 residents reviewed for abuse, neglect, and/or misappropriation. The facility failed to do a thorough investigation to include interviewing Resident #1, as well as other residents or staff which may have been involved in or witnessed the incident. This failure placed residents at risk of not having their allegations investigated thoroughly or timely.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed and 2 of 2 nutrition rooms for storage, preparation, and sanitation. The facility failed to use internal thermometers in 2 freezers. The facility failed to maintain cleanliness of shelves, the ice machine, coffee cups, and microwave oven throughout the kitchen. The facility failed to follow a proper cleaning schedule. The facility failed to ensure kitchen utensils were in good working order. The facility failed to ensure dented holding pans were not in use and on the clean rack. The facility failed to ensure the dumpster side doors were kept closed. The facility failed to ensure all containers of food in the refrigerator was labeled. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain effective pest control for 1 of 1 kitchen reviewed for pests. The facility failed to have pest control effectively treat the kitchen for roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 8 (Resident #75 and Resident #110) residents reviewed for accurate procedures for medication administration. 1a. The facility failed to ensure LVN C checked and/or documented an accurate blood pressure for Resident #75 before administering Resident #75's blood pressure decreasing medication that had physician ordered hold parameters on 5 of 12 opportunities from 02/01/25 to 03/04/25. 1b. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 5 (Resident #16, Resident #34, Resident #75, Resident #83, Resident #88) of 8 residents reviewed for infection control. 1. The facility failed to ensure LVN C sanitized the blood pressure cuff between use on Resident #83, Resident #88, Resident #34, Resident #75, and Resident #16 on 03/06/25. These failures could place the residents at risk of cross-contamination and development or spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the notice of transfer or discharge, and the reasons for the transfer or discharge, in writing to the resident, resident representative, or the Office of the State Long-Term Care Ombudsman as soon as practicable before transfer or discharge when an immediate transfer or discharge was required for urgent medical needs for 2 of 5 residents (Resident #24 and Resident #66) reviewed for transfer and/or discharge. The facility failed to send written notice of transfer or discharge of Resident #24 ' s transfer on 01/28/25, and Resident #66 ' s transfer on 01/25/25. This failure could affect residents by placing them at risk of being discharged and not having access to available resources, advocacy services, discharge/transfer options, and the appeal processes.

Inspectors wroteBased on interview, observation and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #43) of 5 residents reviewed for comprehensive person-centered care plans. The facility failed to develop and implement Resident #43 ' s care plan to include oxygen therapy. This failure could affect the resident by placing them at risk for not receiving care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received assistance devices to prevent accidents for one of five residents (Resident #103) reviewed for accidents and hazards. The facility failed to ensure floor mats were in place beside Resident #103 ' s right side of the bed. This failure could place residents at risk for an injury or a major injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (Resident #7) residents reviewed for respiratory care. The facility failed to ensure Resident #7's oxygen concentrator administered oxygen at the correct setting of 2 liters per minute. Resident #7's oxygen concentrator was set at 3 liters per minute on 03/04/2025 at 8:33 AM and at 4:55 PM. This failure places residents who receive respiratory care at an increased risk of developing respiratory complications, and a decreased quality of care.

Inspectors wroteBased on observation, and interview, the facility failed to dispose of expired biologicals in 2 of 2 medication rooms reviewed for storage. The facility failed to discard 19 expired swab kits in the 100-hall medication room. The facility failed to discard an expired enteral feeding tube de-clogger device in the 200-hall medication room. These failures could place residents at risk of infection and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 5 (RD) qualified dietary staff reviewed. The facility failed to ensure the registered dietician (RD) attended weekly weight meetings. This failure could affect residents who ate food from the kitchen and could result in the dietary needs of residents not being met.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 8 residents (R #75) reviewed for accuracy of records. -The facility failed to ensure LVN C checked and/or documented an accurate blood pressure for Resident #75 before administering Resident #75's blood pressure decreasing medication that had physician ordered hold parameters on 5 of 12 opportunities from 02/01/25 to 03/04/25. -The facility failed to ensure LVN I checked and/or documented an accurate blood pressure for Resident #75 before administering Resident #75's blood pressure decreasing medication that had physician ordered hold parameters on 10 of 11 opportunities from 02/01/25 to 03/04/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and sanitary environment for 1 of 1 kitchen. The facility failed to maintain an electrical outlet, lighting fixture, and two AC ducts from dripping water and water damage in the kitchen. These failures could place residents at risk for exposure to an unclean, unsanitary environment, risk of falls and other injuries due to an unsafe environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 3 of 5 residents (Resident #3, Resident #4, and Resident #5) reviewed for accuracy and completeness of clinical records. 1. The facility failed to ensure administration of narcotic medication was accurately documented in the electronic medication administration record when Resident #3 received Lorazepam (a controlled medication [benzodiazepine] used to relieve symptoms of anxiety) 9 times between 01/10/25 and 01/13/25. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of five residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse. On 09/28/24, Resident #2 pushed Resident #1 backward. Resident #1 tripped, then fell and hit the back of her head on the floor which resulted in a hematoma (swelling) to the back of her head. This failure could place residents at risk for abuse and physical, mental, and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation for 1 of 6 residents (Resident #3) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #3's lorazepam (a controlled medication [benzodiazepine] used to relieve symptoms of anxiety) and Tramadol (a schedule IV controlled opioid medication used to treat pain) tablets. This failure could place residents at risk for not receiving prescribed medications which could lead to physical, mental, or psychosocial harm.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 5 resident's (Residents #1) reviewed for accidents/supervision in that: CNA B failed to have a second staff assist her with care for Resident #1 and Resident was left unattended and rolled off her bed during incontinent care on 06/12/24. This failure could place residents at risk for injuries related to falls.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that drugs and biologicals were stored behind a closed and locked door in a secured unit (Hall 300) in one of 3 medication rooms. The medication door was left open on hall 300. This failure could place residents at risk of access and ingestion of medication in the medication room.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one of one residents reviewed for call lights. The facility did not ensure Resident #1's call light was with in reach. This failure could place residents at risk for illness due to cross contamination in the kitchen and left a resident without access to staff and at risk for falling.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one kitchens reviewed for safety. The kitchen vent was drpiping condensation from the ceiling to the surface beneath the area creating slipping hazards and possible contamination during food prepartation. This failure could place residents at risk for illness due to cross contamination in the kitchen and left a resident without access to staff and at risk for falling.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 Residents (Resident #1) reviewed for medical records accuracy, in that: Resident #1's clinical record was incomplete. Staff did not document Residents #1's fall that occurred on 06/21/24 in the shower room. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one facility reviewed for environment. 1. The facility failed to ensure resident rooms were safe and in good repair 2. The facility failed to ensure the smoking area had self-closing lids for discarded cigarette butts 3. The facility failed to ensure the maintenance log work orders were fulfilled before signing off 4. The facility failed to ensure resident closet ceilings and hallways were safe and in good repair These failures could place residents at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one resident (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 eloped from the facility at night. This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm. The noncompliance was identified as Past Non-Compliance. The IJ began on 12/18/23 and ended on 12/18/2023. Verifcation of corrections ended on 12/22/2023. The facility had corrected the noncompliance before the investigation began.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 1 residents (Resident #1) of 1 resident reviewed for abuse/neglect. The facility did not report the allegation of resident neglect to the State Survey Agency within the allotted time frame for Resident #1 who had eloped from the facility on 12/18/2023. This failure could place all residents at risk for injuries, abuse, and/or neglect due to not reporting or completing investigations of elopements.

Inspectors wroteBased on observation , interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to ensure dishes were clean and sanitized 2. The facility failed to ensure equipment was clean and sanitized 3. The facility failed to ensure food in the freezer was properly contained 4. The facility failed to ensure dry storage items and spices were sealed properly 5. The facility failed to maintain cleanliness of the floor in the kitchen 6. The facility failed to properly label and date items in the refrigerator These failures could place residents at risk of foodborne illnesses.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain all equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment: 1. Bowls, cups, and glasses had whitish residue in them 2. The vent hood manifolds were rusted 3. Two freezers were inoperable These failures could place residents and staff at risk of foodborne illnesses and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 4 residents Resident # 83 (R#83), Resident #35 (R#35), Resident #414 (R#414 ), Resident #49 (R#49) of 10 residents reviewed for accommodation of needs. The facility staff did not provide R#83, R#35, R#414, R#49 with a call light that was within reach. This failure could place residents who utilized call lights at risk for not having their needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 33 residents (Residents 57 (room [ROOM NUMBER]), 109 (room [ROOM NUMBER]), 24 (room [ROOM NUMBER]), 88 (room [ROOM NUMBER]), 15 (room [ROOM NUMBER]), 64 (room [ROOM NUMBER]), 103 (room [ROOM NUMBER]), 6 (room [ROOM NUMBER]), 19 (room [ROOM NUMBER]), 26 (room [ROOM NUMBER]), 16 (room [ROOM NUMBER]), 25 (room [ROOM NUMBER]), 106(room [ROOM NUMBER]), 56 (room [ROOM NUMBER]), 41 (room [ROOM NUMBER]), 27 (room [ROOM NUMBER]), 52 (room [ROOM NUMBER]), 21 (room [ROOM NUMBER]), 230 (room [ROOM NUMBER]), 40 (room [ROOM NUMBER]), 60 (room [ROOM NUMBER]), 73 (room [ROOM NUMBER]), 82 (room [ROOM NUMBER]), 37 (room [ROOM NUMBER]), 34 (room [ROOM NUMBER]), 8 (room [ROOM NUMBER]), 32 (room [ROOM NUMBER]), 55 (room [ROOM NUMBER]), 39 (room [ROOM NUMBER]), 51 [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the resident environment was as free of accident hazards as is possible, on the 100 hall, for 1 of 3 shower rooms observed for hazards. The facility failed to secure the shower room door and securely store chemicals to keep out of reach from any resident that resided within the first-floor unit. These failures could place residents at risk for accidental poisonous hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 25 opportunities which resulted in an 8 percent error rate involving Resident #1. 1. LVN A administered another resident's IV Vancomycin 1gram/250mL normal saline to Resident #1. The name on the Vancomycin IV medication bulb label had another person's name the label which was not Resident #1's name. 2. CMA A did not follow the physician's order to hold medication if the blood pressure was less than 110/60 mmHg. Resident #1's blood pressure was 107/77 mmHg, and CMA A administered Resident #1's Metoprolol Tartrate 25mg tablet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 1 (Resident #1) of 7 residents reviewed for significant medication errors, was administered his medication as per his physician's order. The facility did not carry out Physician's Orders to hold Resident#1's Metoprolol Tartrate 25mg tablet for blood pressure less than 110/60mmHg. This failure could affect multiple residents who reside in the facility who are taking blood pressure medication by causing a decline in their quality of care and quality of life due to not only the lack of competent blood pressure monitoring but also the lack of adherence to physician's orders.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the wound care nurse (LVN B) had the specific competencies and skills sets necessary to care for 1 of 5 residents (Resident #101) that required wound care. 1. LVN B did not provide wound care for Resident #101 for 2 days but documented wound was provided. Resident #101's physician orders stated wound care be performed every day and as needed. This deficient practice could place residents requiring wound care at risk for adverse effects and have the potential to result in the development of infection, sepsis, and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for one Resident (R #1) of six residents reviewed for care plans, in that: The facility failed to update R #1's care plan to include history of fabricating stories, as well as failed to update R#1's care plan to reflect actual event that transpired on 11/12/2023. This failure could place residents at risk for not having their needs met and psychosocial complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one resident with an indwelling urinary catheter received appropriate treatment and services for one (Resident #1) of three residents reviewed for urinary catheters, in that: CNA A did not ensure Resident #1's indwelling catheter tubing was allowed to flow freely via gravity drainage. Resident #1's catheter bag was incorrectly positioned on top of the resident's bed, which was situated above the resident's bladder for an undetermined amount of time, during the entire duration of cleaning care. These failures could place residents with indwelling urinary catheters at risk of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate supervision and services were provided to prevent accident hazards for 1 of 5 resident reviewed for accidents, Resident #1 (R #1) in that: The facility failed to recognize a trapeze bar hanging above resident's bed installed by a family member without consent from facility. The device was attached to the resident's bed overnight from 6/23/23 until morning of 6/24/23. The trapeze equipment fell onto R #1 when he was adjusting himself in bed which resulted in R #1 sustaining a serious injury of a left tibia and fibula fracture and concussion. This failure of identifying and preventing the installment and use of unapproved medical equipment could lead serious injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all essential equipment is maintained in safe operating condition for 1 (Resident #1/R #1) of 5 residents reviewed for maintenance of medical equipment, in that: The facility failed to recognize a trapeze bar hanging above resident's bed installed by family member without consent from facility. The device was attached to the resident's bed overnight from 6/23/23 until morning of 6/24/23. The trapeze equipment fell onto R #1 when he was adjusting himself in bed which resulted in R #1 sustaining a serious injury of a left tibia and fibula fracture and concussion. This failure of identifying and preventing the installment and maintenance of unapproved medical equipment could lead serious injury for residents requiring medical equipment.