Santa Anita Convalescent Hospital

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) received necessary monitoring, medical treatments, care and notification of change of condition (COC) to the doctor, in accordance with the resident's care plan, facility's policy and procedure (P&P) titled Care Planning, dated 10/24/2022 and facility's P&P titled Change of Condition Notification, dated 6/1/2017 by failing to ensure Resident 1 was being monitored and treated for pain and notify physician when Resident 1 complained pain on the left leg. These deficient practices has the potential to delay in the required medical services, treatments and care, to ensure Resident 1's health, wellbeing and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate clinical records as required by professional standard and practice, when Licensed Vocational Nurse 2 (LVN 2) added lorazepam (Ativan-a central nervous system depressant, a medication used to treat anxiety disorder [a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear, worry, or dread that interferes with daily life]) to the medication list for one (1) of two (2) sampled residents (Resident 1) without obtaining an order from Resident 1's physician. This deficient practice had the potential for Resident 1 to receive Ativan, resulting in medication error and lead to adverse reactions (any unexpected reactions to a drug) and the accidents that are associated with adverse reactions.

Inspectors wroteBased on interview and record review, the facility failed to report an unusual occurrence (events or situations that do not happen daily or that may have had an impact on the residents) for one of two sampled residents (Resident 1) to State Agency (SA) within 2 hours in accordance with the facility's policy and procedure titled Abuse Prevention and Prohibition Program. This deficient practice prevented SA from going to do thorough investigation and had potentially led to ongoing unusual occurrence for Resident 1 or other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized resident-centered care plan (a plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the resident's oxygen needs for one of two sampled residents (Resident 1). This deficient practice has the potential in delay the necessary care, services, recovery and wellbeing of Resident 1's Activities of Daily Living (ADLs - activities such as bathing, dressing and toileting a person performs daily) and result in injury and/or fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the facility staff had an accurate and complete progress note in the resident's medical record for one (1) of three sampled residents (Resident 1) per facility's policy and procedure. The progress notes dated 6/4/2026 did not include licensed nurse's post monitoring documentation regarding Resident 1's specific behavior after Ativan oral tablet (Lorazepam, is used to treat anxiety disorders) was given to the resident. This deficient practice had the potential to result in miscommunication and improper delivery of care and inaccurate information of the care provided to the residents which could negatively affect the overall wellbeing of Resident 1. FindingsDuring a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to fully inform the resident/ resident's responsible party (RP) in advance, of the risks and benefits of proposed care for two of five sampled residents (Residents 218 and a) reviewed for unnecessary medications in accordance with the facility policy by failing to ensure: 1. An informed consent was obtained from Resident 1 /RP for the use of Valproic Acid (a prescribed anticonvulsant used as a psychotropic medication [a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior]) to stabilize moods in bipolar disorder [a mental illness that causes unusual shifts in mood, energy, and concentration]).2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call lights (communication system in care facilities that allowed residents to instantly alert nursing staff when help was needed) were within reach and readily accessible for four of 35 residents (Resident 38, 77, 301, and Resident 386) by failing to: Provide an adaptive call light (customized version of a call light that allowed resident's with limited strength, mobility, or dexterity to easily call for help) when the resident was observed not being able to use the call light provided. Place Resident 77's call light within reach and provide an adaptive call light when the resident was observed not being able to use the call light provided. Place Resident 301's call light within reach and provide an adaptive call light when the resident was observed not being able to use the call light provided. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS, a federal mandated resident assessment tool) was accurate for six of seven sampled residents (Residents 55,126, 134, 233, 263 and 346) in accordance with the facility's policy and procedure. This failure had the potential for Residents 55,126, 134, 233, 263 and 346 resulted in inaccurate documentation in the resident's medical record which could impact continuity of care, facility reporting accuracy, and regulatory compliance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment for four of five residents (Residents 187, 228, 275, and 338) in the accidents care area when:1. The facility did not ensure both of Resident 187's siderails were (a bar attached to the bed that is used to prevent patients from accidentally rolling off or falling) padded for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions as indicated in the facility's policy and procedure (P&P) titled, Seizure Precautions.2. The facility did not post an Oxygen in Use sign on the door frame of Resident 228's room, who was actively using an oxygen machine, as indicated in the facility's P&P titled, Oxygen Administration.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for two (2) of three (3) sampled residents (Residents 2 and 202) observed for medication administration by failing to:Administer Resident 2's Lactulose oral solution (a medication used to treat chronic constipation)Administer Resident's 202's Rivaroxaban (to help prevent strokes or serious blood clots) oral tablet 20 milligrams (mg, units of measurement) and Venlafaxine Hydrochloride (a medication used to treat depression (a mood disorder characterized by persistent feelings of sadness, hopelessness, and a loss of interest in activities)) oral tablet 75 mg with foodThis deficient practice had resulted in Resident 2 and Resident 202 not receiving their medications as [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to:1. Discard an expired Bottle and Dressing Pack (a sterile, single-use kit used to safely drain fluid buildup from the chest or stomach) and eight (8) boxes of expired Arginaid Oral Powder (an oral supplement to support nutritional needs of wound patients) in Unit 900's Medication Storage Room.2. Store Resident 147's lorazepam (a scheduled IV controlled medication [a drug regulated by the government because it carries a risk of misuse, abuse, or physical and psychological dependence] that can create mental and physical addiction or dependency and used to treat anxiety [fear of the unknown]) in a locked container separate from the other non-scheduled medications (drugs that not regulated under federal schedules and they have a low potential for abuse or dependence). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two of seven sampled residents (Residents 380 and 2) in accordance with the facility's policy and procedure when:1. Resident 380's Peripheral Inserted Central Catheter (PICC, a long, thin, flexible tube inserted through a vein in the upper arm and guided into a large vein near the heart) line dressing was not changed every seven (7) days) in accordance with the physician's order.2. Licensed Vocational Nurse 12 (LVN 12) did not wear gloves during an intramuscular (IM) injection medication administration of Resident 2's Ceftriaxone (medication used to treat bacterial infections) on 5/27/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide privacy for one of one sampled resident (Resident 217) reviewed for dignity when Resident 217 was exposed from the waist down during activities of daily living on 5/27/2026. The deficient practice had the potential to result in Resident 217 not being able to enhance the resident's sense of well-being and feeling of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to complete the Minimum Data Set (MDS, a standardized assessment and care screening tool) within 14 calendar days of admission for one of seven sampled residents (Resident 336) reviewed for Resident Assessment. This failure had the potential to delay the development of a resident centered care plan which may result in Resident 336 not receiving timely care and services needed for overall wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to complete a Minimum Data Set (MDS-a resident assessment and care-screening tool) discharge tracking assessment (a type of assessment conducted when a resident leaves a nursing home, which includes clinical items for quality monitoring as well as discharge tracking and is transmitted to the Centers for Medicare and Medicaid Services [CMS, a United States government agency that administers healthcare programs]) for one (1) of seven (7) sampled residents (Resident 319) reviewed for Resident Assessment. This deficient practice had the potential to result in the facility's inaccurate quality monitoring data at transition points, such as when residents enter or leave the facility.

Inspectors wroteBased on interview and record review, the facility failed to create a measurable activities care plan for one of 35 sampled residents (Resident 336). This failure has the potential for Resident 336's activity needs not to be met which could result in negatively affecting the resident's psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to review and revise all care plans by the target date for one of one sampled resident (Resident 336) reviewed for care planning. This failure had the potential to negatively impact the timeliness and appropriateness of Resident 336's interventions and care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper maintenance and position of an indwelling urinary catheter (Foley catheter [FC]- a hollow tube inserted into the bladder to drain or collect urine) for one of two sampled residents (Resident 330) reviewed for catheter care area when staff did not maintain the FC tubing free of dependent loops (a U shaped sag in the drainage tubing that dips below the collection bag, allowing urine to pool and increasing the risk of infection). This deficient practice placed Resident 330 at risk for impaired urine drainage and increased the potential for urinary tract infection (UTI- an infection in the bladder/urinary tract).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care services for two (2) of five (5) sampled residents (Residents 16 and 57) reviewed for respiratory care by failing to: 1. Administer continuous oxygen at 2 liters per minute (L/min, Measurement units) to Resident 16 in accordance with the physician's order. This deficient practice had the potential for Resident 16 to experience respiratory distress. 2. Ensure Resident 57 received aerolized inhaled medications (breathing treatment) as indicated on the physician's order. This deficient practice resulted in Resident 57 not receiving breathing treatment as ordered, which increased the risk of shortness of breath, wheezing, and respiratory distress. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care in accordance with professional standards of practice (established guidelines and expectations that ensure a professional performs their duties safely, ethically, and competently) for one of one residents (Resident 21) reviewed for dialysis care area by failing to ensure Resident 21 who is on fluid restrictions and receiving dialysis was not left an pitcher of water at Resident 1's bedside in accordance with Resident 21's physician orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically related social service (services that assist residents in attaining or maintaining their mental [how a person thinks, feels, and behaves] and psychosocial health (the interaction between a person's psychological state [thoughts, feelings, and mental health] and their social environment [relationships, community, and cultural background]) in accordance with the facility's policy and procedure titled, Social Services Program for one of two sampled residents (Resident 361), who had loose upper teeth and had requested new dentures (removable oral appliances that replace missing teeth). The facility failed to follow up with the dental clinic and update the resident's responsible party (RP) 1 with his request for new dentures from 3/2/2026 to 5/26/2026 (approximately 3 months). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error, to yield an overall medication error rate of 8 % for one (1) of three (3) sampled residents (Resident 202) observed during medication administration (med pass). This deficient practice had the potential to result in adverse reactions (undesired effect of a drug or other type of treatment), ineffective treatment, worsening of Resident 202's condition, or potentially serious harm or injury.

Inspectors wroteBased on observations, interview and record review, the facility failed to serve lunch meal at the facility's scheduled delivery time in accordance with the facility's policy and procedure tilted, Meal Service Time, for one of 35 sampled resident (Resident 217). The deficient practice resulted in Resident 217 not receiving her lunch tray at regularly scheduled time, in which the resident verbalized dissatisfaction with late lunch and food did not taste good anymore. In addition, it placed the resident to be hungry and feel angry. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food brought to residents by family/visitors was not shared for one of 35 sampled residents (Resident 149) in accordance with the facility's policy. This failure had the potential to result in inadvertently causing Resident 149 severe allergic reaction, diet conflict, infection, and or aspiration (unintentional entry of substance such as food, into the airway or lungs instead of the esophagus [flexible, muscular tube that moves swallowed food and drink to the stomach]).

Inspectors wroteBased on interview and record review, the facility failed to maintain the complete and accurate medical records in accordance with the facility's policy and procedure (P&P) titled, Documentation-Nursing, for 2 of 35 sampled residents (Resident 380 and 273) as evidenced by:The nurse did not document in Resident 380's IV (intravenous, referring to delivering medicines or fluids through a needle or tube inserted into a vein) Administration Record after administering the residents meropenem (a medicine used to treat infections) IV which was scheduled at 10 PM on 5/24/2026. The nurse did not document in Resident 273's Controlled Drug (medications whose manufacture, possession, and distribution are strictly regulated by government authorities) Record after administering Endocet (a prescription medication used to relieve moderate to severe pain) on 5/27/2026 at 1:11 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled Residents (Resident 45) was informed and understood the concept of the proposed arbitration (solving disputes with a neutral third party instead of the court) and the Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes between them in respect of a defined legal relationship, whether contractual or not) Form before having the resident/ Resident Representative (RP) enter into a binding arbitration agreement. The deficient practice had the potential to result in Resident 45 unknowingly giving up their right to resolve any disputes with the facility through a court of law before a jury. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure to ensure an allegation of physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) was reported to state survey agency (CDPH, California Department of Public Health), local law enforcement (Police Department), and state ombudsman (advocates for residents of nursing homes) within two (2) hours for one (1) of five (5) sampled residents (Resident 1). This deficient practice had the potential to compromise the protection of Resident 1 from further abuse, which could affect the resident's physical, emotional and mental wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records for one (1) of two (2) sampled Residents (Resident 1), when Resident 1's arbitration agreement (a legally binding contract where parties agree to resolve disputes through a private arbitrator rather than a public court trial) indicated an electronic signature from Resident 1 on 2/10/2026 and from Resident 1's responsible party (RP 1) on 3/7/2026, when neither signed the arbitration agreement. This failure resulted in an inaccurate arbitration agreement for Resident 1, which could potentially lead staff to follow an agreement that RP 1 did not approve/consent to.

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent (is the act of agreeing to allow something to happen, or to do something, with a full understanding of all the relevant facts, including risks, and available alternatives) for the use of Zyprexa (antipsychotic medication primarily prescribed to treat schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder ) for bipolar disorder for one (1) of two (2) sampled residents (Resident 1), as indicated in the facility policy. This deficient practice had the potential for Resident 1 or Resident 1's Responsible Party (RP) not to be able to exercise their right to choose the resident's treatment plan.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) and/or Responsible Party 1 (RP 1) were given the right to choose an attending physician (the primary physician who is responsible for managing the resident's medical care) prior to or upon admission on [DATE], per facility policy. This failure resulted in Resident 1 being assigned to a different attending physician without RP 1's knowledge and consent.

Inspectors wroteBased on interview and record review, the facility failed to provide safety measures and supervision by not assisting, and/or monitoring to prevent falls and injury for one (1) of two (2) sampled residents (Resident 1) when Resident 1 was assessed to be at high risk for falls and fell on [DATE], hitting his head on the floor. This deficient practice has the potential to cause injury and/ or future falls to Resident 1.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a person-centered care plan for one (1) of two (2) sampled residents (Resident 1), to address Resident 1's need for supervision and assistant during the Activities of Daily Living (ADL's) as indicated on the facility's policy. This deficient practice had the potential of Resident 1 not receiving the necessary supervision and assistance during daily activities, which put Resident 1 at risk for falls and other accidents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure concise, and accurate documentation on Minimum Data Set (MDS, a resident assessment tool) for one (1) of two (2) sampled residents (Resident 1) that was completed on 7/28/2025 and 10/23/2025 respectively. 1. Resident 1's admission MDS dated [DATE] did not indicate the resident's mobility device included wheelchair only and not walker. 2. Resident 1's Quarterly MDS dated [DATE] did not indicate the resident's history of fall that occurred on 10/7/2025. This deficient practice had the potential to result in inaccurate care plans, inaccurate representation of a resident's acuity, which affects residents' treatment progress and plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise and ensure the safety of one (1) of 2 sampled residents (Resident 1) in accordance with the facility's Wandering and Elopement (leaving the facility without the staff's knowledge and/or supervision) Policy and Procedure (P&P). This failure resulted in Resident 1 eloping from the facility on 11/1/2025 around 4:15 PM which placed the resident at risk for exposure to extreme weather, medical complications, injury, serious harm, and/or death. Resident 1 was not found until approximately eight (8) hours later, on 11/2/2025, at 11:45 PM at the general acute care hospital (GACH).

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the use of a bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) for one (1) of four (4) sampled residents (Resident 1) as indicated on the care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) and facility fall policy. This failure had the potential for Resident 1 to have repeated falls which could cause injury and harm to the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of four (4) sampled residents (Resident 2 and 3), were treated with dignity and respect when: 1. Certified Nursing Assistant 3 (CNA 3) failed to speak respectfully to Resident 2 during incontinent (involuntary loss of urine or stool) care on 8/24/2025 during the night shift (11 PM through 7 AM). 2. CNA 3 failed to respect Resident 3's request not to receive incontinent care on 8/21/2025 during the night shift. These failures had the potential to negatively affect Residents 2 and 3's overall wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident 2), was assessed and monitored for 72 hours after an alleged incident episode of physical abuse (an intentional act causing injury or trauma to another person through bodily contact) as indicated in the facility's policy and procedure (P&P). This failure had the potential for Resident 2 not to be monitored for physical and/or psychosocial changes negatively affecting his overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures as indicated in the facility's policy and procedure by failing to ensure:1. Licensed Vocational Nurse 1 (LVN 1) doff (remove an item or clothing) Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and perform hand hygiene (the process of cleaning one's hands to remove dirt, germs, and other microorganisms. It involves washing hands with soap and water or using alcohol-based hand rubs) prior to exiting Room B.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was served at the proper serving temperature for one (1) of two (2) sampled residents (Resident 2) in accordance with the facility's policy and procedure titled Food Temperatures. This deficient practice had the potential to negatively affect Resident 2's meal intake. which could lead to health complications and weight loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two (2) dumpsters (a movable waste container) were closed and not overflowing, in accordance with the facility's Policy and Procedure (P&P) titled, Garbage and Trashcan Use and Cleaning. This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) and may cause disease and other health issues to residents, staff, and the community. During an observation on 8/12/2025 at 8:30 AM one dumpster located at the facility's back parking lot overflowing and its lid was not closed. It contained crushed eggshells in an open box and kitchen trash. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, clean, comfortable sanitary and home-like environment for two (2) of 3 three sampled residents (Resident 1 and 2) by failing to:1. Ensure toilet was free from brownish to reddish color dry substants on the toilet seat.2. Ensure that the floor was free of clutters and food stains.3. Ensure that the dirty white towel with brownish colored substance was not placed on top of the covered linen barrel.4. Ensure that the old food tray from dinner was picked up. These deficient practices caused an unsanitary and unsafe environment potentially put residents in contamination and at risk for serious illness and/ or injury. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs for one (1) of two (2) sampled residents (Resident 1) by ensuring the call light (initial communication between staff and residents) was within reach of Resident 1 when the resident needed to call for assistance for a brief change. This deficient practice has the potential to delay in the necessary care and services and/ or needs not being met for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to return the resident's personal belongings for two (2) of 2 sampled residents (Resident 1 and Resident 2) upon discharge from the facility as indicated in facility's policy and procedures (P&P) This deficient practice resulted in the violation of Resident 1 and Resident 2's right to have their personal belongings.1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate resident medical records for one (1) of two (2) sampled Residents (Resident 1) by failing to ensure Resident 1's inventory list (IL, a record of personal possessions brought into a healthcare facility upon admission) had the correct resident belongings and that the Il was signed and dated. This deficient practice had potential for all resident belongings not to be returned to Resident 1 upon discharge and potential for increased risk of loss or confusion. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from sexual abuse (non-consensual [without the person's permission] touching of one person for the sexual gratification of another) on 6/19/2025 by failing to: 1. Protect Resident 1 from Resident 2 by ensuring Resident 2 was provided a one-to-one sitter (1:1, an intervention when a nurse or healthcare professional provides constant observation and support to a resident who is at risk of harm, such as one with cognitive [mental action or process of acquiring knowledge and understanding] impairments, challenging behaviors, or one who may fall or cause harm to himself/herself or to others) in accordance with the physician's order on 6/19/2025 from 11 PM to 11:20 PM. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) who had episodes of wandering (moving aimlessly from place to place without a specific destination or purpose) was supervised by failing to provide a one to one sitter (1:1, an intervention when a nurse or healthcare professional provides constant observation and support to a resident who is at risk of harm, such as one with cognitive [mental action or process of acquiring knowledge and understanding] impairments, challenging behaviors, or one who may fall or cause harm to himself/herself or to others) in accordance with the physician's order on 6/19/2025. This deficient practice resulted in Resident 2 wandering into Resident 1's room on 6/19/2025 around 11:20 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that 524 out of 552 direct care staff (all facility staff who directly provide program and/or nursing services to residents) and indirect care staff (provide essential support services that do not involve direct, hands-on patient care like housekeeping, dietary, laundry, maintenance, and clerical staff) were in services/ trained on April 2025 on the rights of the residents and facility responsibilities when caring for the residents based on the facility's policy. This deficient practice can affect the staff's knowledge about their Resident's Rights when providing care for their residents.

Inspectors wroteBased on interview and record review, the facility failed to provide behavioral health training to the 452 out of 552 direct care staff (all facility staff who directly provide program and/or nursing services to residents) and indirect care staff (provide essential support services that do not involve direct, hands-on patient care like housekeeping, dietary, laundry, maintenance, and clerical staff) in the facility as required and determined by the facility assessment and facility policy. This deficient practice can affect the staff's knowledge when providing proper care for their 49 residents who have behavioral health issues and/ or concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plan for one of two residents (Resident 2) to address Resident 2's sexual inappropriate behavior of touching his private area noted on 6/12/2025. . This failure placed other residents in the facility at risk of being sexually abused (unwanted sexual activity perpetrated by another adult, often involving the use of force, threats, manipulation, or taking advantage of someone's vulnerability or incapacitation) by Resident 2 and vice versa.

Inspectors wroteBased on interview and record review, the facility failed to respect the resident's right to receive visitors of the resident's choice and the right to have a responsible party of the resident's choice for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1 being uncomfortable and feeling unsafe to be visited by Visitor 1, which had the potential to cause psychosocial (interplay between mental processes and the surrounding social environment, and how they affect a person's health, functioning, and development) and emotional distress.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide safety and supervision for two out of three sampled residents (Resident 3 and 4) to prevent fall. 1. On 2/17/2025, Certified Nurse Assistant (CNA) 1 provided bed mobility, dressing, and personal hygiene (bedside care) to Resident 3 without the assistance of another facility staff. 2. On 4/28/2025, the facility failed to provide documented evidence 1:1 sitter (a caregiver or facility staff who provides continuous, one- on- one supervisions t a resident who requires constant monitoring due to safety concerns) was provided to Resident 4 in accordance with the physician's order dated 1/22/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment to reflect the resident's weight loss on the Minimum Data Set (MDS, a resident assessment and tool) for one (1) of six (6) sampled residents (Resident 6) in accordance with the facility policy. This deficient practice had the potential for the facility not to develop and implement an individualized care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, and mental psychosocial needs) to prevent further weight loss and negatively affect Resident 6's overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nutritional care and services for one (1) of six (6) sampled residents (Resident 6) who had a significant weight loss in accordance with the facility's policy by failing to: a. Complete a Change of Condition (COC, tool used by health care professionals when communicating about critical changes in a resident's status) when Resident 6 had significant weight loss b. Follow the Registered Dietician recommendations when Resident 6 had a significant weight loss This deficient practice had the potential to place Resident 6 at risk for further weight loss and negatively affect the resident's overall wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer a medication as indicated on the physician's order for one of six sampled residents (Resident 5) by failing to administer Diphenhydramine HCl Cream 2% (a medication used to treat allergic reactions) to Resident 5 from 6/1/2025 to 6/10/2025 (total of ten days). This deficient practice had the potential to result in worsening of Resident 5's skin rashes.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of five sampled residents (Residents 124, 66, and 312) were free from chemical restraints (the use of medications such as psychotropic medications [drugs that affects brain activities associated with mental processes and behaviors, example is antipsychotics, antidepressants, anti-anxiety, hypnotics] not for therapeutic reasons, but to restrict a person's freedom of movement or control their behavior) when: 1. Resident 124 continued to receive Quetiapine (brand name: Seroquel; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist three of five sampled residents (Residents 40, 120, and 263) who were unable to carry out activities of daily living (ADL) to maintain good grooming, and personal and oral hygiene by failing to: 1. Provide oral care to Resident 40. This failure had the potential for Resident 40 to have dental carries, teeth and gum infections and mouth sores that could lead to hospitalization. 2. Provide Resident 120 with a communication board (a sheet of symbols, pictures or photos that residents will learn to point to, to communicate with those around them) for Resident 120 to effectively communicate his needs. This failure had the potential for Resident 120 to not be able to effectively communicate his needs and result in a decline in psychosocial being. 3. Keep Resident 263's fingernails clean. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and accurate provision of medication for four of four sampled residents (Resident 15, 32, 238, and 299) observed by failing to: 1. and 2. Identify Residents 299 and Resident 32 prior to administering medications. 3. and 4. Ensure physician orders which include parameter to determine when to administer blood pressure medication matched the prescription labels for Resident 238 and Resident 15. These deficient practices increased the potential for inaccurate and unsafe medication administration to meet the needs of each resident (Resident 15, 32, 238, and 299).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of medication error rate of five percent (5%) or greater, as evidenced by the identification of two medication errors out of 33 opportunities (observations during medication administration) for error, to yield a cumulative error rate of 6.06 % for two of four residents (Resident 32 and Resident 15) observed during the medication administration: 1. Facility failed to ensure the correct medication dose and form of docusate sodium was administered to Resident 32. 2. For Resident 15, facility licensed nurse did not check heart rate (HR, the number of times the heart beats per minute [bpm]) prior to administration of Amiodarone 200 mg as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of four (4) medication carts (med cart 1 - [Unit A medication cart ] a movable piece of equipment used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment) was kept locked when unattended to prevent unauthorized access in accordance with the facility's P&P titled Medication Storage in the Facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to ensure: 1. Two (2) can opener was clean and free of gunk (unpleasantly sticky or messy substance). 2. The apple bar from the cooling rack was properly covered. 3. Food trays were free of cracked and exposed metal that has rust (a reddish-brown substance that forms on the surface of iron and steel because of reacting with air and water). These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, which can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation interview and record review the facility failed to follow its own Policy and Procedures (P&P) titled, Food Brought in by Visitors by not labeling the food items brought by visitors to the facility with the resident's name and date they were brought to the facility. This failure had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for residents with stored food in the resident's refrigerator.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six (6) of 6 dumpsters (a movable waste container designed to be brought and taken away) were closed and not overflowing, in accordance with the facility's Policy and Procedure (P&P) titled, Garbage and Trashcan Use and Cleaning. This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) and may cause disease and other health issues to residents, staff, and the community.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures for seven of nine sampled Residents (Residents 270, 145, 183, 324, 149, 4, and 275) as indicated on the facility's policy and procedure (P&P) when the facility failed to: 1.2.3.4. Ensure facility staff donned (to put on) full personal protective equipment (PPE; clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before entering a contact (a type of transmission-based precaution [TBP; infection control measures used in healthcare settings to prevent the spread of pathogens] used for residents with diseases caused by microorganisms [bacteria and viruses] that are spread through direct and indirect contact) isolation room for Residents 270, 145, 183 and 324. 5. Ensure an enhanced barrier precaution (EBP; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to promote respect and dignity for two (2) of 2 sample residents (Resident 322, and 533) by failing to ensure: 1. Resident 233's privacy curtain (a cloth barrier used in health care settings to provide a private enclosure for residents) and/ or door was closed when staff provided incontinent care to the resident on 5/6/2025. 2. Resident 533's water pitcher was free of cracked, chipped parts and with sharp edges. These deficient practices had the potential for Resident 322 and 533 to experience loss of dignity, self-esteem and affect resident's psychosocial (pertaining to the influence of social factors on an individual's mind or behavior, and to the interrelation of behavioral and social factors) well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of 41 sampled residents (Residents 8 and 369) had call lights (one of the major communication technologies that link nursing home staff to the needs of residents) placed within the residents' reach. This deficient practice had the potential for the delay in Residents 8 and 369 receiving care, which could affect the residents' overall wellbeing and could put them at risk for injury in an event of a fall if the residents attempted to get out of bed to reach for the call light to call for help.

Inspectors wroteBased on observation and interview, the facility failed to ensure the side rail (vertical bars attached to the sides of a bed primarily designed to prevent falls and provide assistance with mobility) pads for one (1) of 41 sampled residents (Resident 139) were free of old food particles stains. This deficient practice caused an unsanitary environment and had a potential for Resident 139 to be placed at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right for one (1) of two (2) sampled residents (Resident 30) to be free from abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by another resident (Resident 312) in accordance with the facility's policies and procedures (P&P) titled Abuse Prevention and Prohibition Program. This deficient practice resulted in Resident 30 hitting her head on a doorway after Resident 312 tipped over the wheelchair that Resident 30 was sitting on.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment of the Minimum Data Set (MDS -resident assessment tool) for one of 41 sampled residents (Residents 275), by failing to reflect Resident 275's current oxygen therapy. This deficient practice had the potential for the facility to not develop and implement an individualized care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs), which could negatively affect Resident 275's care and overall well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop or revise a comprehensive care plan (a guide that healthcare workers used to ensure residents received tailored care to his/her individual needs and goals) for one of five sampled residents (Resident 124), when a care plan was not developed or revised for the use of Seroquel (an antipsychotic medication that helps treat several kinds of mental health conditions) for Resident 124. This failure placed Resident 124 at risk for not receiving specific and individualized care related to the use of strong antipsychotic medications (Seroquel).

Inspectors wroteBased on observation, interview, and record review, the facility failed to set the low air loss mattress (LALM, pressure relieving mattress that operates using a blower based pump that is designed to circulate a constant flow of air through the mattress, commonly used to heal pressure ulcers [wound that occurs as a result of prolonged pressure on a specific area of the body]) at the correct setting for one (1) of four (4) sampled resident's (Resident 112) in accordance with the facility's policy and procedure (P&P) titled, Pressure Ulcer Prevention and physician's order. This deficient practice had the potential to result in Resident 112 developing pressure ulcers.

Inspectors wroteBased on interviews and record reviews, the facility failed to lock the casters (wheels that are attached to the bottom of a furniture to make them easier to move) of the bed for one of seven sampled residents (Resident 190), who had a history of fall accidents. This deficient practice has the potential for Resident 190 to have a repeated fall and sustain serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper care and treatment for gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) was provided for two of five sampled residents (Resident 40 and 5) by failing to ensure: 1. Resident 40's head of bed (HOB) was elevated to an angle of 30 to 45 degrees while the resident was receiving G-tube feeding (a liquid food mixture provided through the G-tube). This deficient practice had the potential for Resident 40 to aspirate (when something swallowed enters the lungs) which could lead to pneumonia (infection that inflames air sacs in one or both lungs) and/or choke. 2. To maintain a clean [NAME] Valve (a stopcock-like device, which allows the health care worker to access enteral systems without breaking open the lines) for G-tube. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled resident (Resident 74), who was receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment was provided dialysis care and services by failing to assess the resident's right upper arm arteriovenous shunt (AV shunt, direct connection between an artery and a vein, bypassing the capillaries [tiny blood vessels that deliver nutrients and oxygen to cells throughout the body], which can be created surgically for various reasons including hemodialysis access) vascular (relating to vessels that carry blood or other liquids in a person's body) access in accordance with the facility policy. This deficient practice had the potential for Resident 74 to suffer from complications such as bleeding or infection and potential for unnoticed or missed excessive bleeding.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary behavioral health care and services by failing to implement the care plan to provide a one to one sitter on 5/6/2025 for one of two sampled residents (Resident 270) who was diagnosed with depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities), and with suicidal ideation (when you think about, consider or feel preoccupied with the idea of death and suicide [death caused by self-directed injurious behavior with the intent to die as a result of the behavior]). This deficient practice had the potential to cause harm/injury to Resident 270.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 134), preferred meal choices were implemented as requested by Resident 134. This failure resulted in a violation of Resident 134's right to have preferred meal choices, with the potential for decreased food intake and inadequate nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate medical records for one (1) of 8 sample residents (Resident 263) by not documenting oxygen therapy (the odorless gas that is present in the air and necessary to maintain life) administration accurately. This deficient practice had the potential not to have accurate evaluation of the residents' progression or regression of the delivery of treatment and/ or care services.

Inspectors wroteBased on interview and record review, facility failed to ensure the arbitration (a process of resolving dispute outside of a court system which involves a neutral third party [arbitrator] who makes legally binding decisions, resolving disagreement between nursing home and the reisdent or the resident's family) agreement signed by one of three samples residents (Resident 583), included information that provided for the use of a neutral arbitrator and the selection of a venue that is convenient to both parties [facility and residents] in accordance with the facility's policy titled Arbitration Agreement, . This failure resulted in an incomplete understanding of the facility's arbitration agreement for Resident 538.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, clean, comfortable sanitary and home-like environment for two (2) of 5 sampled residents (Residents 90 and 533) by failing to: 1. Ensure the bedside control (used to adjust the bed height, head of bed and/or foot of the bed) wires for Residents 90 were not exposed (occurs when the insulation around electrical cords and cables is frayed or damaged, revealing the wires within). 2. Ensure the call light (a call bell or nurse call button) wires for Residents 533 were not exposed 3. Facility failed to ensure the trash cans were not overflowing in Room A. These deficient practices caused an unsanitary and had potential for residents to be placed at risk for serious illness and/ or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two bedrooms measured at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms. Rooms A and C measured less than 80 sq. ft. per resident. This deficient practice had the potential of not providing the required space for residents' personal care, or the ability to permit the use of residents' care devices, room to visitors, and the use of personal furniture.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the appropriate care and services to for one (1) out of 1 sampled resident (Resident 1) who was admitted with Indwelling catheter (a tube that helps drain urine from the bladder [organ inside the body that stores urine] then your urine goes from your bladder and through a drainage tube [indwelling catheter tube] into a drainage collection bag) in accordance with the facility's policy and procedure title, Care of Catheter by failing to: 1. Monitor and document Resident 1 for signs and symptoms of urinary tract infection (UTI, an infection in the bladder/urinary tract): [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide laboratory services timely for one (1) out of 1 sampled resident (Resident 1) per physician's order dated on 4/3/2025. This deficient practice had the delay of providing the necessary care needed by Resident 1 and had resulted for Resident 1 to have critical laboratory results which needed for Resident 1 to be transferred to the General Acute Care Hospital (GACH) 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming services for one (1) of two (2) sampled residents (Resident 2) who was dependent with activities of daily living (ADLs- are activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), in accordance with the facility ' s policy. This deficient practice resulted in Resident 2 having oily matted hair(it has become a thick, untidy mass, often because it is wet or dirty), long and jagged (having rough, sharp points protruding) fingernails, potentially leading to skin injury, infection, and scarring.

Inspectors wroteBased on observation, interview, and record review, on 4/3/2025 facility failed to ensure post accurate updated Direct Care Service Hours Per Patient Day (DHPPD, refers to the actual hours of work performed per patient day by a direct caregiver) in accordance with the facility's policy and procedure titled Nursing Department- Staffing, Scheduling & Posting. This deficient practice resulted in residents and visitors not informed of the facility census, staffing and actual hours worked by staff.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician's orders to not change the wound vacuum assisted closure (VAC; a medical device that uses gentle suction to help wound heal faster by applying negative pressure [suction] around the wound effectively removing excess fluid and debris while promoting tissues growth) dressing for one (1) of two (2) sampled residents (Resident 1) when Treatment Nurse 2 (TXN 2) changed Resident 1's surgical wound VAC dressing on 2/15/2025. This failure had the potential to result in Resident 1's surgical wound not healing as intended by the orthopedic surgeon (MD; a medical doctor who specializes in diagnosing and treating injuries and diseases of the musculoskeletal system [the body's framework of bones and muscles and their interconnecting parts]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure by failing to: 1. Ensure three (3) basins, located in residents shared restrooms were labeled. 2. Ensure Resident 1 ' s indwelling catheter drainage bag (a collection device that holds urine that drains from a catheter inserted into the bladder) was not touching the floor. This deficient practice had the potential to increase the risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of three (3) residents (Resident 1), who had indwelling catheters (a tubing inserted through the urethra and into the bladder to drain urine), had a privacy bag to cover and maintain the resident dignity. This deficient practice had the potential for Resident 1 ' s dignity to not be maintained and negatively affecting Resident 1 ' s wellbeing (a person's physical, mental, emotional and social health factors.).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1) who had a diagnosis of diabetes mellitus [DM- a chronic disease where a person has high blood sugar level because the body does not produce insulin (a hormone made by the pancreas-an organ in the body)] received treatment and services, in accordance with professional standards of practice (guidelines and principles that define expected conduct, skills and responsibilities of professional in their roles) by failing to: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store and label medications for five (5) of 5 sampled residents (Residents 2, 3, 4, 5 and 6) in Medication Cart 2 by: 1. Failing to ensure a stored bottle of Vitamin D3 in the Central Supply room was not expired. 2. Failing to ensure Resident 2's open vial of insulin lispro (generic brand of a fast-acting insulin [a hormone that helps regulate blood sugar levels and metabolism]), Resident 3's open vial of Humulin R (brand name for insulin regular [a short acting insulin]) and Resident 4's opened bottle of Timolol (brand name for ophthalmic [referring to the eye] solution used to treat glaucoma [a group of eye conditions that damage the optic nerve which can lead to vision loss or blindness]) were labeled with an open date. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of resident's medical records upon written request for one of 13 sampled residents (Resident 11) in accordance with the facility's policy and procedure titled, Resident Access to PHI (Protected Health Information; information in the medical record that can be used to identify an individual) or Financial Records,. This deficient practice resulted in violation of Resident 11's Responsible Party 1 (RP 1) right to obtain a copy of the resident medical records per facility policy.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary treatment and services consistent with professional standards of practice for one (1) of two (2) sampled residents by failing to: a. Ensure Resident 1's physician orders for pressure ulcer (skin damage that occurs when constant pressure on a specific area of the body, often over a bony prominence, restricts blood flow and causes tissue breakdown leading to an open sore or wound if left untreated) treatments were transcribed when Resident 1 was admitted to the facility from Skilled Nursing Facility 1 (SNF 1- where reisdent was evacuated from) on 1/7/2025. b. Properly assess and document Resident 1's pressure ulcer/ skin condition and failed to provide treatment for the resident's pressure ulcer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent accidents for two (2) of 2 sampled residents (Resident 1 and 3) by: 1. Failing to ensure Resident 1 who had history of fall was free from falls and injury in accordance with the resident's care plan intervention to supervise Resident 1 while the resident is sitting in the wheelchair. On 1/3/2025, Certified Nursing Assistant 1 (CNA 1) left Resident 1 sitting in a wheelchair without staff supervision. This deficient practice resulted in Resident 1 being found outside of Building 1 on 1/3/2025 at around 1:45 PM. Resident 1 was found holding his left arm while lying on the ground with a laceration (a deep cut or tear in the skin) on the resident's left eyebrow measuring one (1) centimeter (cm- unit of measurement). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the Policy and Procedure on pressure ulcer prevention and wound management by: 1. Failing to ensure the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) was set at the correct settings in accordance with the resident's weight. 2. Failing to do assess and monitor, inform Reisdent 2's primary physician and provide treatment for the resident's open wound noted in the Documented Survey Report (Certified Nurse Assistant's [CNA's] documentation) from 1/1/2025 to 1/7/2025. These deficient practices had the potential for Resident 2's pressure ulcer to worsen and for the resident to develop new pressure ulcer.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain safe, clean, comfortable, sanitary, and home like environment for one of 51 sample rooms (room [ROOM NUMBER]) by failing to ensure trashcan is not overflowing, used and/ or dirty wash cloth were properly placed in the dirty bin and not on the floor or top of the white bin's (bin used to place residents' dirty clothes) lid. These deficient practices caused an unsanitary and had a potential for residents to be placed at risk for injury and/ or infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide treatment and care in accordance with the professional standards of practice (define diagnostic, intervention, and evaluation competencies) to one (1) of two (2) sampled residents (Resident 1) who had a change in condition (a sudden, clinically important deviation form a resident's baseline in physical, cognitive, behavioral, or functional domains). 1. On 9/2/2024 to 9/9/2024, Resident 1 had periods of being verbally aggressive towards facility staff. There was no documented evidence that the facility staff monitored and have interventions in place to address the resident's behavior. 2. There was no documented evidence that the facility staff monitored and have treatments/ interventions in place to address the Resident 1's small pink/ reddish raised bumps with dry flaky skin on the resident's arm. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures to prevent misappropriation of resident's property (the intentional, illegal use of the property or funds of another person for one's own use or other unauthorized purpose) for one (1) of two (2) sampled residents (Resident 1). Resident 1's inventory form (a data tool for recording all the items, supplies and commodities in an organization at a specific time) dated 1/12/2024 and 2/18/2024 were not signed by the resident/ resident representative when admitted at the facility on 1/8/2024. This deficient practice place Resident 1's items at risk for unauthorized use/ loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the follow call light was within reach for one of two sampled residents (Resident 1) as indicated on the facility policy. This deficient practice has the potential to delay in the provision of the necessary care and services Resident 1 needs which could result in injury and/harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free of physical restraint (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body) when the facility failed to: a. Conduct an assessment for the use of bed alarm (alerting device intended to monitor a resident's movement. The device emits an audible signal when the resident moves in certain ways). b. Obtain a physician's order for the use bed alarm. This deficient practice had the potential to result in limiting Resident 1's mobility which may cause Resident 1 not to feel treated with respect and dignity.

Inspectors wroteBased on interview and record review, the facility failed to follow its Care Planning policy for one of two sampled residents by not revising Resident 1's care plan after a fall on 8/11/2024 and 9/9/2024. This deficient practice had the potential for Resident 1 to have further falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the loss of personal property for one of two residents (Resident 1), when Resident 1 was transferred out of facility. This failure resulted in the misplacement and/or loss of Resident 1 ' s personal belongings/property.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled resident (Resident 2) was provided a communication board (pre-printed picture board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) with the language the resident was able to understand in accordance with the facility policy. This failure had the potential to result in Residents 2 experiencing a delay in receiving appropriate care and treatment due to the staff not being able to properly communicate with the resident and decreased quality of care and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to follow policies and procedures for significant weight loss significant weight loss (a loss of five [5] percent or more in one [1] month, 7.5% in three [3] months, or ten [10] percent in [6] months for one of two sampled residents (Resident 1) by failing to: 1. Notify the physician after a Resident 1 had a decrease in weight. 2. Document a change of condition assessment for Resident 1 ' s weight loss. 3. Revise Resident 1 ' s care plans for episodes of significant weight loss as indicated in the facility ' s policy and procedure (P&P). 4. Obtain readmission and weekly weights as order by the physician and indicated in the facility ' s policy and procedure. [...]

Inspectors wroteBased on observation and interview, the facility failed to prevent sexual abuse (sexual behavior or a sexual act [with the intent to arouse or gratify sexual desire a person touches the anus, breast, or the genitals of another] forced upon a woman, man, or child without their consent) for one (1) of three (3) sampled residents (Resident 1). 1. On 9/14/2024, Resident 2 touched and squeezed Resident 1's left breast while in the activity room and was witnessed by Activity Aide (AA). 2. On 9/17/2024 and 9/18/2024, the facility failed to provide one- to- one monitoring (a type of care that involves a staff member providing constant observation and support to a patient. [...]

Inspectors wroteBased on interview and record review the facility failed to assess, and implement facility's policies and procedure for a response to fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support) for one of three sampled residents (Resident 3) by failing to ensure that Resident 3 was assessed on [DATE] by a licensed nurse after Certified Nurse Assistant (CNA) 1 witnessed Resident 3 fall from the wheelchair. CNA 1 did not wait for licensed nurse to check Resident 3, and moved and placed Reisdent 3 back to the wheelchair. This deficient practice could have led to serious complications to Resident 1 due to the delay in care.

Inspectors wroteBased on observation, interview and record review, the facility did not follow infection control practices for three (3) of five (5) sampled residents (Residents 2, 3 and 4) by failing to: 1. Facility staff perform hand hygiene (the process of cleaning your hands to prevent the spread of infectious diseases. It can be through using a hand sanitizer [contains at least 60% alcohol (ethanol or isopropyl alcohol) when soap and water are not available] or hand washing with soap and water) and don (putting on Personal Protective Equipment [PPE; protective clothing, goggles, or other garments to prevent or minimize exposure to and spread of infection or illness]) PPE prior to entering Resident 3 and 4's isolation room (room that keeps patients separate from others to prevent the spread of germs or to protect patients who are more easily infected). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards (practices, skills, ethics, and/or qualifications set forth by a professional body representing the respective profession or discipline) of quality for one (1) of three (3) sampled residents (Resident 1) by failing to have a blood sugar check for Resident 1's physician's order of glucagon (medication used to treat severe low blood sugar) from 8/6/2024 to 8/15/2024. This deficient practice has the potential to put Resident 1 at risk for hypoglycemia (a condition in which the body's blood sugar level goes below the standard range).

Inspectors wroteBased on interview and record review, the facility failed to revise one of two sampled residents (Resident 1) care plan after identifying Resident 1 ' s increased behaviors of rising out of bed independently. This deficient practice had the potential for Resident 1 to sustain further injuries due to falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two (2) or three (3) sampled residents (Residents 2 and 3) in accordance with the facility policy by failing to ensure: 1. a. Resident 2's nebulizer (a drug delivery device used to deliver drugs in the form of inhalation into the lungs) face mask and tubing were changed weekly. b. Resident 2's nebulizer face mask and tubing bag was off the floor. 2. a. Resident 3's nasal cannula (NC, device used to deliver supplemental oxygen placed directly on a resident's nostril) tubing and humidifier (a device for supply moisture to the air to prevent dryness which could cause irritation) was changed weekly. b. Resident 3's nasal cannula was stored in a bag. c. Resident 3 had an order for oxygen administration by the physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to document records accurately and completely for two (2) of three (3) sampled residents (Residents 1 and 2) in accordance with the facility's policy and procedure by failing to: 1. Ensure Resident 1's two tablets of Sevelamer HCl (used to control phosphorus levels with chronic kidney disease who are on dialysis) was accurately documented on the Medication Administration Record (MAR, a medical record used by healthcare providers to document the administration of a medication or treatment) when found on her bedside table and documented as administered. 2. Ensure Resident 2's Ipratropium Bromide Inhalation Solution (administered by oral inhalation with the aid of a nebulizer to open the airways in lung diseases where spasm may cause breathing problems) was documented on the MAR when administered. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their employe handbook guidelines on Employee and Resident Relations for one (1) of two (2) sampled residents (Resident 1). As a result, Resident 1 felt uncomfortable when interacting with Activities Aid (AA) 1.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive resident-centered care plan for one of three sampled residents (Resident 2) in accordance with the facility policy. This deficient practice had the potential to result in a delay of nursing care and medical interventions.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to address care needs for one of three sampled residents (Resident 1) who had colostomy (surgery to create an opening for the colon [large intestine] through the belly [abdomen]) who required assistance with colostomy care. This deficient practice had the potential for Resident 1 to experience discomfort or excoriation (a place where skin is scraped or worn away) of the skin at the colostomy site.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmaceutical services procedures such as administering and disposing of drugs were followed in accordance with the facility's policy for one of three sampled residents (Resident 1) by failing to: a. Ensure Resident 1 was administered two tablets of Sevelamer HCl (used to control phosphorus levels with chronic kidney disease who are on dialysis) as ordered by the physician. b. Failing to dispose of Resident 1's Silvadene Cream (used to treat or prevent infections) in the appropriate container. These failures had the potential to result in medication errors and could lead to adverse reactions (any unexpected or dangerous reaction to a drug).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided a functioning call light. This deficient practice had the potential to result in staff delay in meeting Resident 1's care needs and services for activities of daily living (ADL: personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of two (2) sampled resident (Resident 4) was provided a communication board (pre-printed board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) for Resident 4 to understand and communicate care needs to facility staff. This failure had the potential to result in a delay of care services and needs for Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent injuries for one (1) of two (2) sampled residents (Resident 7) by not providing fall mats as indicated per physician ' s order. This deficient practice had the potential to result in injuries to Resident 7 in an event of another fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services in accordance with the facility's policy by failing to ensure: 1. Two (2) of two Emergency Kits (E-Kits) were replaced within 72 hours per facility's policy. 2. Facility's Pharmacy was notified of medication usage obtained from 2 of 2 E-Kits. 3. Pharmacist checked two of two E-Kits monthly. This had a potential for the residents to result in an insufficient inventory of medications in stock in case of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one of two sampled Residents (Resident 1) when Resident 2 grabbed and squeezed Resident 1's thigh and aggressively used derogatory (lack of respect) language towards Resident 1 on 7/10/24. This failure resulted in Resident 1 having a bruise on the left eye, a scratch on the forehead, and another abuse attempt from Resident 2 trying to hit Resident 1 the following day on 7/11/2024. This failure also had the potential to affect Resident 1's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its written abuse prevention policy for two (2) of 2 sampled residents (Residents 1 and 2) by failing to: 1. Report a resident to resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) to California Department of Public Health (CDPH) when Resident 2 grabbed and squeezed Resident 1's thigh and aggressively used derogatory (lack of respect) language towards Resident 1 on 7/10/24. 2. Protect Resident 1 from further abuse from Resident 2 by keeping both Residents 1 and 2 in the same room after the abuse incident on 7/10/24. This deficient practice had the potential to result in Resident 1 experiencing further abuse from Resident 2, which could lead to injury and harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for four (4) out of seven (7) residents (Resident 216, 217, 300, 179, and 277) by failing to: 1. Provide a 1:1 sitter for Resident 216, who was assessed as high risk for falls. 2. a. Ensure the licensed nurses developed a care plan with interventions to prevent Resident 300 from falls before the resident had a fall on 4/11/2024. b. Ensure the nursing staff developed a care plan for Resident 300's fall prevention after the resident's fall on 4/11/24 to prevent the resident from future falls including a fall on 5/1/2024. c. Ensure Resident 300 was provided with partial/moderate assistance (helper does less than half the effort) while walking on 5/1/2024 to prevent the resident from falling and sustaining an injury. d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident, who was complaining of having new onset of severe (that which is disabling, preventing performing normal activities during the day or night) pain to the right underarm area that was radiating to right shoulder had the pain under control for one of one sampled resident (Resident 88) by failing to: 1. Ensure Resident 88's pain was accurately assessed and re-assessed when the Tylenol (a pain reliever used to treat mild and moderate pain) was not effective in resolving Resident 88's pain. 2. [...]

Inspectors wrote3. A review of Residents 81's admission Record (Face sheet) indicated the facility admitted Resident 81 on 5/1/2024 with diagnoses that included unspecified dementia (the loss of cognitive functioning-thinking, remembering, and reasoning-to such an extent that it interfered with a person's daily life and activities) and unspecified psychosis. A review of Resident 81's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 5/8/2024 indicated the cognitive (the ability to think and process information) skills for daily decisions making was severely impaired. The MDS indicated Resident 81 had symptoms of feeling down, depressed (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), hopelessness and little interest or pleasure in doing things. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (a device used by patients to call for assistance from hospital staff) for nine (9) of 36 sampled residents were: 1-4. Within reach (an arm's length) for Residents 132, 143, 223 and 303. 5-6. Within reach for Residents 164 and 160. 7-9. Within reach for Residents 3, 272, and 180. This deficient practice had the potential to result in delayed provision of services, delay in care and not receiving assistance with activities of daily living (ADLs).

Inspectors wroteBased on interview and record review, the facility failed to ensure four of nine sampled residents (Resident 331, Resident 345, Resident 342, and Resident 151) medical records were updated to show documentation clarifying if a resident has an advance directive (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) or were provided an opportunity to complete the advance directive from. This deficient practice had the potential to result in confusion in the care and services for Resident 331, Resident 345, Resident 342, and Resident 151 and placed the residents at risk of receiving unwanted treatment and not receiving appropriate care based on the residents wishes.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the residents' needs for four of 36 sampled residents (Residents 306, 216, 300 and 36) by failing to: 1. Ensure Resident 306 did not have an individualized care plan for language barrier and interventions to address dementia (progressive brain disorder that slowly destroys memory and thinking skills). 2. Have a care plan for Resident 216 who had an indwelling foley catheter (a tube that drains urine from your bladder into a bag outside your body). 3. Resident 300 did not have a care plan created after an actual fall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Residents 291, 651, and 65) were provided necessary treatment and services to prevent formation of and promote healing of pressure injury (pressure ulcers-injury to the skin and underlying tissue resulting from prolonged pressure on the skin) in accordance with the facility's policy and procedure and physician's order by failing to: 1. Resident 291's low air loss mattress (LAL mattress, an air mattress designed to prevent and treat pressure wound/ulcer [sores that happen on areas of the skin that are under pressure]) was not set accordingly. 2. Ensure facility staff provided incontinent (involuntary or accidental leakage of urine or stool) care after Resident 651 had a bowel movement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 197 and 310) who had an indwelling urinary catheter (Foley Catheter, tube inserted into the bladder to drain urine into a drainage bag) received appropriate care and services as indicated in the physician's orders, by failing to appropriately assess and document signs and symptoms (s/sx) of urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder [organ that stores urine] or urethra [the tube through which urine leave the body]). These deficient practices resulted in delayed UTI identification, delayed treatment, and had the potential to lead to worsening infection.

Inspectors wrote2. A review Resident 336 's admission Record (Face Sheet), indicated the facility admitted Resident 336 on 4/11/2024, and was readmitted on [DATE] with diagnoses including chronic respiratory failure (a condition in which the blood does not have enough oxygen or has too much carbon dioxide [a colorless, odorless, incombustible gas, present in the atmosphere and formed during respiration]), muscle weakness, and left hemiplegia (paralysis of the left side of the body). A review of Resident 336's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 4/8/2024, indicated Resident 336 cognitive (the ability to think and process information) skills for daily decisions making was severely impaired. [...]

Inspectors wrote4. During a concurrent observation and interview on 5/23/2024 at 10:14 AM, Registered Nurse (RN) 1 threw into a regular trash can located inside Resident 36's room by the room entrance, the resident's intravenous (IV) medication bag (a piggyback or a small bag of solution attached to a primary infusion line to deliver medication over a specified period of time) and tubing (used for continuous infusion of fluids or medications. It was the one directly inserted end into the IV fluid bag or bottle. There were spikes at the top of IV tubing), after the resident completed the treatment. RN 1 stated the IV medication bag and tubing were disposed in the trash can in Resident 36's room. RN 1 stated she made a mistake. RN 1 stated used IV bag and tubing should be disposed in biohazard bin located in the biohazard room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three (3) of five (5) sampled residents (Residents 191, 302, and 306) were free from unnecessary use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure : 1. The indications of psychotherapeutic medications use for Resident 191 were consistent with the residents' psychiatric assessments and specific behaviors. There was no descriptive behavior documented for Resident 191. There were also no interdisciplinary team (IDT) meeting notes to evaluate the behavioral management of Residents 191. 2. The indications of psychotherapeutic medications use for Resident 302 were consistent with the residents' psychiatric assessments and specific behaviors. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 216) received the correct doses of lorazepam (or Ativan, a medication that treats anxiety) as per ordered for at least 4 doses. This deficient practice had a potential for adverse effect that may worsen Resident 216's conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure 1 of 2 injectable emergency drugs supplies (E-kits) stored at the medication refrigerator at the nursing unit 300 had a label on the outside of the container. 2. Ensure 2 of 8 medication carts were kept clean. 3. Ensure an outdated inhalation device for Resident 59 would not be available for use. These deficient practices had the potentials of delayed care, contaminations, and/or medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions by failing to ensure food items inside the kitchen produce refrigerator and dry storage were labeled, and expired food items were discarded and not mixed with other non-expired foods. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly dispose food waste products into a covered trash bin located under the food preparation (prep) table in accordance with the facility policy. This failure had the potential to attract and spread vermin (animals that are believed to be harmful or that carry disease, e.g., rodents, parasitic worms, or insects) that could potentially infiltrate the facility, affect the resident care areas, and pose a disease threat to the residents of the facility.

Inspectors wrote3. During a concurrent interview and record review on 5/24/2024 at 11:44 AM with the Maintenance Director (MD), the report titled, IWC Innovation, dated 4/15/2024 was reviewed. The report indicated water sample in nurses station collected on 4/2/2024 was positive for Legionella. MD stated the affected sink was in Nursing Unit 500. Per MD, he turned off the water on the affected sink on 4/15/2024 upon notification of the positive Legionella result, and he replaced the faucet of the affected sink on 5/20/2024. MD stated even though he turned off the water, staff could turn the water back on. Per MD, he informed a female staff (not identified) on 4/15/2024 about not to use the sink, but he did not put a sign. During an interview on 5/24/2024 at 1:46 PM with Licensed Vocational Nurse (LVN) 5, LVN 5 stated they (the nurses) barely stopped using the sink in Nursing Unit 500 since yesterday. [...]

Inspectors wrote3. A review of Resident 8's admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included hydronephrosis with renal and ureteral calculous obstruction (a condition where one or both kidneys swell due to a blockage in the tubes that drain urine from the kidneys), retention of urine, and pleural effusion (a buildup of fluid between the tissues that line that lungs and the chest). A review of Resident 8's History and Physical Examination (H&P), dated 11/13/2023, indicated Resident 8 did not possess the general capacity to make their own decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide privacy and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the individual's surrogate or representative) of the resident's medical records by not closing the computer screen for one of 36 sampled residents (Resident 20). This deficient practice violated Resident 20's right for privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to exercise reasonable care for the protection of one of one sampled resident's (Resident 66) personal property from theft or loss, when Resident 66 reported to staff her personal belongings were missing. This deficient practice resulted in the violation of the resident's right of having a safe environment and had the potential to cause emotional distress to the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) timely for one of three sampled residents (Resident 216). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 216.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to update and revised care plan for two of 36 sampled residents (Resident 216 and Resident 277) by failing to ensure: 1. Resident 216 care plan was not revised to addressed fall and behavior of physical aggression. 2. To update and revise care plan for falls after Resident 277 had an unwitnessed fall on 5/8/2024. Resident 277 sustained a right eyebrow laceration (a deep cut or tear in skin), fracture (broken bone) of the right zygomatic arch (a bone surrounding the eyeball is broken), and a fracture of the right orbital floor (surrounding the eyeball), anterior (in front of) wall and posterior (toward the back) wall of the maxillary sinus (located to the side of the nasal [relating to the nose] cavity, and below the orbit). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 36 sampled residents (Resident 306), with a hearing deficit and a language barrier was provided with a communication board/pencil and paper. This deficient practice had the potential for a delay in the necessary care and services for Resident 36.

Inspectors wroteCross Reference F686 Based on observation, interview, and record review, the facility failed to provide a shower and/ or bed bath according to the pre-determined schedule for one of two (2) sampled residents (Resident 1) who required assistance with activities of daily living (ADL). This deficient practice resulted in Resident 1 not receiving a shower and/ or bed bath from 3/29/24, for 12 days and had the potential to negatively impact Resident 1's quality of life and self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a doctor's appointment was completed for one of 36 sampled residents (Resident 18) when facility staff failed to provide a documented evidence that Resident 18 was able to have an orthopedic (ortho- a branch of medication dealing with the correction of deformities or the bones or muscles) appointment, as ordered. This deficient practice resulted in delay in Resident 18's intervention and resulted in incomplete assessment and treatment of Resident 18's left leg.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to change the PICC line (peripherally inserted central catheter- a long and flexible catheter that is inserted through a vein in the upper arm) dressing every 5-7 days and as needed (PRN) per facility policy for one of 36 sampled residents (Resident 651). This deficient practice had the potential to result in Resident 651 to develop an infection on the PICC line insertion site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 221) who received dialysis (hemodialysis, is a process of filtering the blood of a person whose kidneys are not working normally) had a dialysis emergency kit (kit that contains emergency supplies that will be needed in case dialysis site got dislodged and/or is bleeding) at the bedside. This deficient practice had the potential for Resident 221 to receive a delay in intervention during accidental bleeding from the resident's dialysis site.

Inspectors wroteBased on interview and record review, the facility failed to complete a Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) for one (1) of five sampled residents (Resident 216). This deficient practice had the potential for Resident 216 to experience adverse drug reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the tray card (a meal ticket with the resident's specific meal items and lists the resident's likes and dislikes and provides information about a resident for a specific meal) as written for one of four sampled residents (Resident 78). Resident 78's was served milk with the wrong milkfat (fatty portion of milk) percentage for lunch. This deficient practice had the potential to result in an elevated cholesterol (waxy substance found in the blood) level and placed Resident 78 at risk for complications from cardiovascular disease (a group of disorders of the heart and blood vessels) due to the excessive amount of milkfat in Resident 78's diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of thirty- six sampled residents (Resident 18) by failing to accurately document Resident 18's wound intervention on the Interdisciplinary Team (IDT, a group of healthcare professionals who work together to help residents receive the care they need) Wound Meeting/Wound Report. This deficient practice had the potential to result in a lack of or a delay in communication between the facility staff and can interrupt provision of care/intervention to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two bedrooms measured at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms. rooms [ROOM NUMBERS] measured less than 80 sq. ft. per resident. This deficient practice had the potential of not providing the required space for resident's personal care, or the ability to permit the use of residents' care devices, room for visitors, and the use of personal furniture.

Inspectors wroteBased on observation, interview and record review, the facility failed to prohibit and prevent retaliation (the act of hurting/ threatening and/ or harassing an individual due because they have reported an allegation of abuse or unlawful act) of Certified Nurse Assistant 1 (CNA 1) to one of two sampled residents (Resident 1) when CNA 1 went into the resident ' s room on 5/10/2024 and confronted Resident 1. This failure may result to psychosocial harm to Resident 1 such as experiencing fear (an unpleasant emotion or thought that you have when you are frightened or worried by something dangerous, painful, or bad that is happening) and/ or anxiety (a feeling of fear, dread, and uneasiness to get revenge).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a shower and/ or bed bath according to the pre-determined schedule for one of two (2) sampled residents (Resident 1) who required substantial/maximal (helper does more than half the effort, helper lifts or holds the trunk or limbs and provides more than half the effort) with activities of daily living (ADL, individual's self- care activities). This deficient practice resulted in Resident 1 not receiving a shower and/ or bed bath from 3/29/24 to 4/16/24 (18 days) and had the potential to negatively impact Resident 1's quality of life and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure the doctor was notified timely of a right femur [thigh bone] fracture (break in the bone) for one of three sampled residents (Resident 1). Resident 1 ' s medical doctor (MD) was made aware of the resident ' s abnormal Xray (an imaging study that takes pictures of bones and soft tissues) of the right leg result 18 hours from receipt of the Xray result, This failure had the delayed obtaining physician orders from the MD to treat and to provide necessary care for Resident 1 ' s femur fracture, which may lead to worsening of Resident 1 ' s femur fracture.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Xray (an imaging study that takes pictures of bones and soft tissues) result for one of three sampled residents (Resident 1), was charted accurately in Resident 1 ' s medical chart. This failure had the potential to not only delay appropriate care and treatment for Resident 1 ' s fracture, but the potential to cause worsening of Resident 1 ' s femur (thigh bone) fracture (break in the bone).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision and a safe environment to prevent accidents for three of five sampled residents (Residents 1, 3, and 6) by: 1. Failed to prevent Resident 1 who has history of illegal substance (illegal drugs [drugs forbidden by law]) abuse from possessing crystal methamphetamine (a colorless and odorless drug that is powerful, highly addictive, and lets people stay awake and do continuous activity with less need for sleep) and offer party drugs (main types of party drugs are depressants, stimulants, and hallucinogens. Party drugs can make a user feel euphoric or 'high', but they can also be dangerous. The effect of a party drug depends on the individual, and the drug dose) to other residents while residing in the facility. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to provide treatment and services to attain the highest practicable mental and psychosocial wellbeing for one of two sampled resident (Resident 1) who was diagnosed with depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) by facility staff failing to: 1. Monitor and acknowledge Resident 1's expressions of feeling depressed. Resident 1 verbalized his, ups and down with depression and continually expressing depressive symptoms due to external social and familial factors. 2. Review, revise, and implement care plan that can assist in the resident's existing needs and potential risks related to Resident 1's verbalization of being depressed. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent physical abuse (willful infliction of injury which includes, but is not limited to, hitting, slapping, punching, biting, and kicking) for two (2) of 2 sampled residents (Resident 4 and 5) This failure resulted to Resident 4 striking Resident 5 on the chest and in return, Resident 5 pushed a chair towards Resident 4, which hit Resident 4's shin causing a skin tear (a traumatic wound that is caused by direct contact between the skin and another object) on 4/3/2024.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for one (1) of three (3) sampled residents (Resident 1) in accordance with the facility ' s policy and procedure. This deficient practice had the potential to place Resident 1 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which could lead to irreversible damages of health and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Speech Therapy (ST, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) services to one of three sampled residents (Resident 1) who had swallowing and communication concerns. The facility failed to provide ST services when the facility discontinued Resident 1's ST services despite Resident 1 making progress in therapy and demonstrating skilled therapy (services that require specialized training and experience of a licensed therapist or therapy assistant) needs. This deficient practice prevented Resident 1 from receiving ST services to improve swallowing function, improve communication abilities, and maintain or achieve the highest practicable level of function.

Inspectors wroteBased on interview and record review, the facility failed to prevent sexual abuse (sexual behavior or a sexual act forced upon a woman, man, or child without their consent) for one (1) of four (4) sampled residents (Resident 2). This deficient practice resulted to Resident 1 went in Resident 2's room and squeezed Resident 2's breast.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident 1) had person centered care plan (taking a collaborative approach to assessing a person based on their needs, preferences, goals) to address resident's wandering a patient who goes beyond the view or control of staff without the intention of leaving the health care facility) behavior. This deficient practice resulted to Resident 1 went in Resident 2's room and squeezed Resident 2's breast.

Inspectors wroteBased on interview and record review, the facility failed to follow a physician's order to monitor vital signs (clinical measurements specifically heart rate, temperature, respiration rate and blood pressure, that indicate the state of a patient's essential body functions) every four hours for Coronavirus (COVID; a viral disease that is highly contagious and spreads quickly) monitoring for one of two sampled residents (Resident 1). This failure resulted in not being able to monitor and provide treatment to the resident for possible decline or change of condition and can lead to resident's death.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive resident centered care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) for one of three sampled residents (Resident 1) by not having fall mat (described as a cushioning pad designed with shock-absorbent properties to stay firm during normal transferring and walking activities but to soften under high impact to absorb the force of a patient falling)and call light (an alerting device for nurses or other nursing personnel to assist a patient when in need ) was out of the resident's reach. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement, to attempt to reduce/remove underlying risk factors to prevent worsening of a pressure ulcer/injury (localized skin injury and underlying tissue) for four of four sampled residents (Resident 1, 2, 3 and 4) by failing to: 1. Put the correct setting on the Low Air Loss Mattress (LAL Mattress; an air mattress designed to prevent and treat pressure wounds) for Resident 1 and 2 2. Ensure the physician's order of utilizing a Low Air Loss Mattress was followed when Resident 3 was observed to be laying on top of a regular mattress on the floor 3. Reposition Resident 4 every two (2) hours in accordance with the resident's care plan. This deficient practice has the potential for the residents' pressure ulcer to worsen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was served at the residents' preferred temperature for three out of eight sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for resident's poor meal intake and possibly lead to weight loss.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure on Abuse Prevention and Prohibition Program to investigate reports of injuries of unknown source timely for one (1) of two (2) sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 for further injuries.

Inspectors wroteBased on interview and record review, the facility failed to report immediately, not later than two (2) hours of the allegation of injuries of unknown source to the State Survey Agency for (1) of 2 sampled residents (Resident 1), in accordance with the policy and procedure. This deficient practice had the potential to place Resident 1 at risk for further injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the fall care plan for one (1) of two (2) sampled residents (Resident 1) in accordance with the facility policy. This deficient practice had the potential to result in repeated falls which could harm or cause injury to Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and sanitary environment as indicated in the facility policy by: 1. Failing to ensure Certified Nursing Assistant (CNA 2) and Housekeeping (HKP) doffed (remove) personal protective equipment (PPE- gowns, N95 masks [respiratory protective device designed to achieve a very close facial fit and very efficient filtration or airborne particles], and face shield worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) before leaving Residents 1, 2, 3, and 4's (who were on droplet isolation [residents known or suspected to be infected with bacteria transmitted by respiratory droplets that are generated by residents who are coughing, sneezing, or talking]) shared room. 2. Failing to ensure CNA 2 correctly donned (put on) an N95 mask. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of three (3) sampled Residents (Resident 4 and Resident 5) received care with elimination/toileting in accordance with the facility's policy and procedure. This deficient practice resulted in Resident 4 and Resident 5's diapers left wet for an extended period which could potentially result in skin irritation and had the potential for residents' toileting capability to decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside for three (3) of six (6) sampled residents (Resident 1, 2, and 3) in accordance with the facility policy and procedure. This deficient practice had the potential for an inaccurate administration of medications for Resident 2 and Resident 3 as indicated on the physician's order and potential for other residents to access the unattended medications, which can cause possible harm to Resident 2, Resident 3, and and other residents if ingested.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of six (6) sampled residents (Resident 1) received medication according to the facility ' s policy and procedure (P&P). Resident 1 did not receive Famotidine (used to treat gastroesophageal reflux disease [GERD]) (Pepcid AC) 20 milligrams (mg, units of measurement) 1 tablet by mouth (PO) timely as indicated in the physician ' s order. This failure resulted in Resident 1 receiving her medication over an hour late, which had the potential to result in Resident 1 not receiving the full efficacy of the medication, which could affect resident ' s overall wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 6) had a functioning call light in accordance with the facility's Policy and Procedure. This deficient practice had the potential for Resident 6 to not be able to call the facility staff for assistance, which could result to Resident 6's needs not being met.

Inspectors wroteBased on interview and record review the facility failed to develop a resident- centered care plan (plan of care; a form where a residents health condition, specific care needs, and current treatment are summarized) for one of two sampled residents (Resident 1) to address resident's use of bed rails (mobility restraints and enablers in long term care facilities; can assist to facilitate movement) and the resident's behavior of pulling herself up and moving around in bed using the bed rails. This deficient practice had the potential to result in Resident 1 injuring self with the bed rail.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent physical abuse (treating another person with violence, cruelty, hate, harm, or force) for one of three sampled residents (Resident 1) when Resident 2 struck Resident 1 on the head and punched the resident on the left eye after having a dispute with one another on 9/21/23. The facility also failed to prevent another possible abuse by Resident 2 when resident was observed going in and out of other resident ' s room on 10/6/23. These failures resulted to an actual abuse to Resident 1 leading to hospitalization and eight (8) inches with staples (used to close incisions or cuts) to the left side of head laceration with the potential for Resident 1 to feel powerless and unprotected by the facility. It also placed Resident 1 for further physical abuse and other residents in the facility by Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nurse Assistant 1 (CNA1) did not tie a sheet around the neck of one of three sampled Residents (Resident 1) and obtain a consent to place Resident 1 in a geriatric chair (gerichair) . These failures resulted in Resident 1 having difficulty breathing and coughing which had the potential to result in strangulation, entrapment, and injury, and resulted in Resident 1 not being treated with respect and dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical records were complete, pertinent, and accurate for two (2) of six (6) sampled residents (Resident 4 and 7) in accordance with the facility's policy and procedure. This deficient practice placed Residents 4 and 7 at risk for not receiving appropriate care and interventions. It can also have the potential to result in incomplete assessment of the residents needs and could lead to a lack of or delay in delivery of necessary care or services to Resident 4 and 7.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision and interventions for one of five sampled resident (Resident 1) who is at risk for elopement (instance of running off secretly and when a resident who is not capable of protecting or caring for themselves leaves the facility without authorization). Resident 1 did not have care plan and interventions in place to address Resident 1's low risk for elopement from 8/7/23 to 9/3/23. The facility also failed to reassess Resident 1 for elopement risk though Resident 1 had verbalize wanting to leave the facility multiple times from 8/7/23 to 9/3/23. This failure resulted to Resident 1 was able to exit the facility and eloped on 09/03/23. [...]