Santa Clarita Post-Acute Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat with dignity and respect one of three sampled residents (Resident 1). This failure had the potential to negatively impact the psychosocial well-being (is the state of mental, emotional, and social health) of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within residents` reach for five (5) of ten sampled residents (Residents 39, 44, 81, 73, and 117) investigated under environment facility task. These deficient practices had the potential to result in the residents` inability to call for assistance when needed, placing the residents at risk for unmet needs, delayed care, accidents, injury, and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents` environment was free of accident hazards for two (2) of two (2) sampled residents (Resident 93 and Resident 116) reviewed for accidents by failing to: 1. Ensure that no medications were left unattended at Resident 93`s bedside. This deficient practice had the risk of accidental ingestion or unsafe medication administration. 2. Promptly identify and remove a puddle of water observed on the floor at the foot of Resident 116`s bed. This deficient practice had the potential to result in slips, falls, fractures, head injuries, pain, hospitalization, and other avoidable injuries to residents, staff, and visitors.

Inspectors wroteBased on observation, and interview, the facility failed to ensure: Residents with a n indwelling catheter (a thin, flexible hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for one of one sampled resident (Resident 93) reviewed for urinary catheter or UTI care area, by failing to ensure the indwelling catheter tubing and bag was not on the floor. The deficient practice had the potential for Resident 93 to develop UTI. Medications were administered in a manner that prevented contamination and maintained infection control standards for one of one sampled resident (Resident 14). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the resident's right to be treated with dignity and respect for personal privacy for one randomly observed resident (Resident 39) by failing to ensure the resident's buttocks was not exposed to other residents, staff, and visitors while being transported down the hallway to the shower room. This deficient practice violated the resident's right to be treated with respect and dignity potentially resulting in a decline in the psychosocial well-being of the resident.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of staff-to-resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) or mistreatment (inappropriate treatment or exploitation of a resident) immediately, but no later than two (2) hours after the allegation was made to the State Survey Agency (CDPH, California Department of Public Health), the Ombudsman (a resident advocate), and local law enforcement (LLE) in accordance with federal and state law for one of three sampled residents (Resident 25) reviewed under the Abuse care area. This deficient practice had the potential to result in unidentified abuse and mistreatment in the facility and failure to protect Resident 25 and other residents from harm.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) by failing to thoroughly investigate an allegation of staff-to-resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) or mistreatment (inappropriate treatment or exploitation of a resident) and report the results of the investigation to in accordance with State law, including to the State Survey Agency (CDPH, California Department of Public Health), the Ombudsman (a resident advocate) for one of three sampled residents (Resident 25) reviewed under the Abuse care area. This deficient practice had the potential to result in unidentified abuse and mistreatment in the facility, retaliation from staff, and failure to protect Resident 25 and other residents from harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 3) had a preadmission screening and annual resident review (PASARR a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level II care plan to personalize the special needs of the resident. This deficient practice placed the residents at risk of not receiving necessary care and/or delay of services that residents need.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who had a positive Level 1 Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) received the required Level II PASARR evaluation and determination for one of two sampled residents (Resident 11) investigated under the PASARR care area by failing to resubmit a Level 1 Screening after Resident 11's case was closed due to the facility staff were unresponsive to two or more separate attempts of communication within 48 hours of a Level I Screening. This deficient practice had the potential to result in a delay of specialized care and services for Resident 11.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the comprehensive care plan (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was revised for one of two sampled residents (Resident 9) reviewed during the Respiratory care area and one of one sampled residents (Resident 2) reviewed during the Comm-Sensory care area by failing to: 1. Ensure the CP for Resident 9's use of supplemental oxygen (O2) reflected the physician's order for continuous O2 at four (4) liters per minute (LPM, a measurement of flow rate). 2. Ensure that Resident 2's CP reflected the resident`s correct Primary language. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure residents who were incontinent of bladder received services and assistance for one of one sampled resident (Resident 113) by failing to ensure Resident 113's urinal bottle (a portable, handheld container designed to collect urine) was labeled with the name of the resident. This deficient practice had the potential for Resident 113's urinal bottle to be contaminated (making a substance, surface, or place dirty, impure, or hazardous by introducing a harmful, unwanted, or foreign material) which may lead to development of urinary tract infection (UTI, a common infection that occurs when bacteria enter and multiplies in the urinary system, which includes the kidneys, bladder, and urethra).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the water flush bag was labeled with the correct information for one of one sampled resident (Resident 47). This failure had the potential to cause fluid overload (body holds onto more water than it can manage) or dehydration (body loses or uses more fluids than it takes in) to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who need respiratory care are provided care consistent with professional standards of practice for two of two sampled residents (Resident 9 and 114) reviewed under the Respiratory care area by failing to: 1. Ensure oxygen (O2) was administered per physician orders at four (4) liters per minute (LPM, a measurement of flow rate) to Resident 9 on 6/1/2026 and 6/2/2026. 2. Ensure O2 was administered per facility policy and procedure (P&P) with a physician's order and monitored while in use for Resident 114. These deficient practices had the potential to place residents at risk for respiratory distress with a delay in necessary care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two food scoopers (used to scoop dry goods food) were clean. This failure had the potential to for the food scooper to carry harmful germs, bacteria, or chemical residues which can contaminate the residents' meals and increase the rise of foodborne illness to the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all parts of the call light system (CL, an alerting device for nurses or other personnel to assist a patient when in need) were functional for one of eight sampled residents (Resident 67) investigated under the Environment task. This deficient practice had the potential to result in the delay of care and services and falls with injury in residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices by failing to ensure [NAME] 1 verified the internal temperature of grilled chicken prior to service on 2/11/2026 for four of four sampled residents (Resident 4, Resident 5, Resident 6, and Resident 7). This deficient practice had the potential to result in unsafe food temperatures, allowing harmful bacterial growth and increasing the risk of foodborne illness in a medically compromised resident population who received meals prepared in the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for two of three sampled residents (Resident 1 and Resident 3) by failing to: 1. Ensure licensed nurses monitored Resident 1's medical status after the resident's changes of condition (COC) on 11/15/2025 and 11/29/2025. 2. Ensure Resident 1's physician order for oxygen therapy (O2 therapy - a treatment that provides a person with supplemental or extra oxygen) at two liters per minute was followed. On 1/30/2025, Resident 1's oxygen therapy was at three liters per minute (lpm - unit of measurement). 3. Ensure licensed nurses monitored Resident 3's gastrointestinal (stomach and intestines) status after the resident's COC on 12/4/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for two of eight sampled facility staff (Licensed Vocational Nurse [LVN] 1 and Certified Nursing Assistant [CNA] 1) by failing to:1. Ensure CNA 1's N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) was worn while inside a COVID-19 isolation room (a set of precautions used to prevent the spread of COVID-19).2. Ensure LVN 1 wore the N95 mask properly while inside the facility. LVN 1's N95 mask was not covering the nose and mouth while at a resident care area. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received services with reasonable accommodation for one of three sampled residents (Resident 4), who was at risk for falls, had the call light (an alerting device for residents to call for assistance) within Resident 4's reach. This deficient practice had the potential for not meeting Resident 4's needs for assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1) was created and implemented. The facility failed to develop and implement an individualized care plan with interventions addressing Resident 1's food preferences as indicated in the resident's medical records. This deficient practice resulted to Resident 1 being served food identified as the resident's food dislike.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from significant medication errors by failing to ensure the physician orders were followed. The facility failed to ensure Resident 2's midodrine hydrochloride (HCl) oral tablet (a medication, taken by mouth, used to treat low blood pressure that causes severe dizziness or fainting) 10 milligrams (mg - unit of measurement) was administered and documented at the scheduled time. This deficient practice placed Resident 2 at risk for inadequate blood pressure management which can cause hypotension (low blood pressure) and irregular heartbeat.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's food preference was followed for one of three sampled residents (Resident 1). The facility served Resident 1 with fish that Resident 1 disliked. This deficient practice had the potential to result in decreased meal satisfaction and affect Resident 1's nutritional status.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) concerns were investigated and documented in the grievance form as indicated on the facility's policy and procedures (PnP). This deficient practice had the potential to violate residents' rights to have grievances addressed.

Inspectors wroteBased on record review and interview, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and care in a manner that promotes maintenance or enhancement of their quality of life by failing to ensure Resident 1's right to refuse care was respected. This deficient practice had the potential to negatively affect Resident 1 psychosocially (involving mental, emotional, social, and spiritual aspects of a person's life).

Inspectors wrote2. During a review of Resident 248's admission Record, the admission Record indicated the facility admitted the resident on 1/24/2025 with diagnoses including fracture (a crack or break in a bone) of shaft of right tibia (also known as shin bone the large bone located between the knee and ankle), unsteadiness on feet, and generalized muscle weakness. During a review of Resident 248's H&P dated 1/25/2025, the H&P indicated the resident can make her needs but cannot make medical decisions. During a review of Resident 248's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for four of four sampled residents (Residents 37, 63, 78, and 248) reviewed for physical restraints care area by failing to ensure: 1. Residents 37 and 63 had a physician's order, an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), a restraint assessment, and a care plan for restraint bed placed against the wall. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for four (4) of six (6) residents reviewed for unnecessary medications (Resident 7, 37, 53 and 55) by failing to: 1. Develop and implement a care plan for methenamine hippurate (an antibiotic) for Resident 37. 2. Implement the Care Plan (a document outlining a detailed approach to care customized to an individual resident's need) for providing non-pharmacological (not involving medications or drugs) interventions for the use of trazodone (a psychotropic [any medication capable of affecting the mind, emotions, and behavior] used for insomnia [difficulty sleeping]) for Resident 7. As a result, Resident 7 did not have non-pharmacological interventions provided as outlined in the Care Plan between 2/1/2025 and 2/11/2025. 3. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) the insulin administration site (subcutaneous (beneath the skin) for one (1) out of one sampled resident (Resident 73) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood). 2. Rotate subcutaneous insulin medication administration sites for one of five (5) sampled residents (Resident 63) investigated under unnecessary medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure five (5) of six (6) sampled residents (Resident 5, 7, 53, 55 and 71) drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) in accordance with the facility policy and procedure by failing to: 1. Limit the use of lorazepam (generic name for Ativan) as needed order to fourteen days or specify a duration or provide a stop date for Resident 71. 2. Limit the use of Ativan (a psychotropic medication used for anxiety [a feeling of fear, dread, and uneasiness]) as needed order to fourteen days or specify a duration or provide a stop date for Resident 5. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 29 total opportunities contributed to an overall medication error rate of 6.9% affecting one (1) of three (3) residents observed for medication administration (Resident 196.) The medication errors were as follows: 1. Resident 196 received metoprolol (a medication used to for hypertension [HTN - a condition in which the blood vessels have persistently raised pressure]) and aspirin (a medication used to prevent cerebrovascular accident [CVA] - stroke] from having atrial fibrillation [irregular, fast heart rate]), at a different time than ordered by Resident 196's physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards): 1. For one (1) out of one sampled resident (Resident 73) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area by failing to rotate (a method to ensure repeated injections are not administered in the same area) the subcutaneous (beneath the skin) insulin administration sites. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen reviewed during the kitchen facility task by failing to: 1. Ensure food items in the walk-in refrigerator were labeled according to facility policy. 2. Ensure used cloths and towels were stored per facility policy. 3. Ensure the walk-in freezer temperature was maintained per facility policy and procedure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly reviewed during the kitchen facility task by failing to ensure the surrounding area of the dumpster (large trash container designed to be emptied into a truck) did not have three tied clear bags of trash and one open trash bag containing items including disposable gloves, dirty rags, a Styrofoam (brand of plastic) cup, and a food wrapper. This failure had a potential to attract birds, flies, insects, and rodents resulting in the transmission and spread of infection to 89 of 93 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for one (1) of 1 sampled resident (Resident 249) reviewed under the dignity care area by failing to ensure the resident's urinary drainage bag (a container connected to a hollow tube inserted into the bladder to drain or collect urine) was provided with a privacy cover. This deficient practice had the potential to affect Resident 249's self-esteem, self-worth, and sense of independence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one (1) of 1 sampled resident (Resident 248) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to call for assistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain resident's privacy by failing to pull/close the privacy curtains during medication administration affecting two (2) of three (3) sampled residents (Resident 5 and 196) observed during medication administration. This deficient practice had the potential to result in unauthorized exposure of the resident's treatment and care potentially resulting in psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse reporting policy and procedure (P&P) by failing to report an allegation of injury of unknown origin to the State Survey Agency (Department of Public Health) within two hours for one of one sampled resident (Resident 93) reviewed under the Abuse care area. This deficient practice had the potential to place the resident at risk for elder abuse.

Inspectors wroteBased on interview and record review, the facility failed to revise one of two sampled residents (Resident 6) care plans to reflect the updated interventions provided to Resident 6 reviewed for Nutrition care area. This deficient practice had the potential to place the resident at risk for a delay in necessary interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers/injury (the breakdown of skin integrity due to pressure) for one (1) of 1 sampled resident (Resident 12) reviewed for pressure injury by failing to ensure: 1. The resident was turned every two (2) hours. 2. The staff documented the position the resident was placed every time they turned the resident. 3. Licensed Vocational Nurse (LVN) 1 and Certified Nursing Assistant (CNA) 6 documented the reason when the resident refused to turn on 2/12/2025. These deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for two of four (4) sampled residents (Resident 19 and 66)) reviewed for accidents by failing to ensure: 1. Resident 19's bilateral fall mat (a cushioned mat that reduces the risk of injury from a fall) did not have furniture or equipment on top of them. 2. To accurately complete Resident 66's risk for falls after a fall incident on 10/11/2024. 3. Conduct an interdisciplinary team (IDT - a collaboration of healthcare professionals who work together to plan and coordinate patient care) meeting after Resident 66 fell on [DATE] and 11/13/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for one (1) out of 1 sampled resident (Resident 249) reviewed for urinary catheter or UTI care area when the facility failed to ensure Residents 249's urinary catheter tubing did not have a loop while hanging on the side the bed. This deficient practice had the potential for the resident's urine not to flow freely which may lead to development of UTI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff providing care and services to the resident who has a feeding tube (are soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) are aware of, competent in, and utilize facility protocols regarding feeding tube nutrition and care for one of one sampled resident (Resident 22) reviewed for tube feeding by failing to ensure the water flush bag was labeled with the name, room number, and the rate of the water flush. This deficient practice had the potential to result in altered nutritional status that can lead to over or under hydration, gastrointestinal infection to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents were consistent with professional standards of practice for two of two sampled residents (Residents 22 and 346) reviewed for respiratory care by failing to ensure: 1. Resident 22's suction canister (a temporary storage container for secretions or fluids removed from the body) was labeled with the date it was last changed. 2. Resident 346's oxygen tubing (a flexible, clear tube used to deliver oxygen from a source like a tank or concentrator to a patient's nose or mouth) was labeled with the date it was last changed and was off the floor. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) one medication emergency kit ([ekit] - storage container for emergency use medications) containing controlled substances ([CS] -drugs which have a potential for abuse and may also lead to physical or psychological dependence,) in one (1) of one (1) inspected medication carts (Medication Cart Station 1). 2. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Medication Count Sheet accountability logs for four (4) of four (4) sampled CS records awaiting disposal (removal, destroying) stored inside a locked cabinet. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed pharmacist during drug regimen review provided a recommendation on the use of an antibiotic as a prophylaxis for UTI to one of two sampled residents (Resident 37) reviewed for antibiotic use by failing to: 1. Ensure the use of methenamine hippurate as a prophylaxis (an attempt to prevent disease) for urinary tract infection (UTI, a bacterial infection in the urinary system, which includes the kidneys, ureters, bladder, and urethra), an antibiotic (medicines that fight bacterial infections in people and animals) had an order for monitoring for signs and symptoms of UTI to evaluate its effectiveness. 2. Follow-up with the attending physician the reason for prolonged use of methenamine hippurate as a prophylaxis for UTI, as it was ordered since 9/2/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's drug regimen was free from unnecessary drugs to one of two sampled residents (Resident 37) reviewed for antibiotic (medicines that fight bacterial infections in people and animals) use by failing to ensure Resident 37's methenamine hippurate used as a prophylaxis (an attempt to prevent disease) for urinary tract infection (UTI, a bacterial infection in the urinary system, which includes the kidneys, ureters, bladder, and urethra) was not used for excessive duration and without adequate monitoring for signs and symptoms of UTI. This deficient practice had the potential to cause adverse effects (an undesired effect of a drug or other type of treatment, such as surgery) from the continued use of this medication.

Inspectors wroteBased on interview, and record review, the facility failed to ensure necessary care was provided consistently for a resident who was receiving hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) for one of one sampled residents (Resident 30) reviewed for Hospice and End of Life care area by, failing to ensure the hospice aide (HA) visited according to the hospice plan of care for Resident 30. This deficient practice had the potential to negatively affect the resident's physical comfort, psychosocial well-being, and had the potential to result in a delay or a lack of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure: 1. Resident 20's urinal bottle (a container for collecting urine that is used by people who are unable to use a bathroom toilet) was labeled with the name and room number for one of 24 sampled residents (Resident 20) during an initial pool screening. 2. Clean linens, clean clothing, and clean curtains were not placed on the ground in the Clean Linen Folding area during a review of the Infection Control task The deficient practices had a potential to spread infections and illnesses among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the residents' right to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to post the most recent survey results in a place that is prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents, family members, and legal representatives of residents for four of five resident council attendees (Resident 5, 13, 41, and 16). This deficient practice resulted in the residents' and their representatives not having access to examine the most recent survey results.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required room size of 80 square feet (sq ft-a unit of measurement) per resident in multiple bedrooms for 35 out of 38 resident rooms (rooms 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 36, 37, 38, and 39). This deficient practice had the potential to result in inadequate space for resident care and mobility.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) for reporting all allegations of abuse immediately within two hours of being made aware for one of three sampled residents (Resident 1). This deficient practice resulted in a delay of notifying the necessary agencies, delay in conducting the facility's investigation and may have placed Resident 1 at risk for further abuse.

Inspectors wroteBased on interview, and record review, the facility failed to thoroughly investigate a sexual abuse (when someone touches another person in a sexual manner without consent) allegation for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect Resident 1 from abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for one of three sampled residents (Residents 1) by failing to ensure Resident 1 had a care plan regarding change of condition. This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay or lack of delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to monitor one of three sampled residents (Resident 1) after having a change of condition. This deficient practice could result to Resident 1 encountering serious health issues that may go undetected, leading to complications and potentially life-threatening situations.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent developing a pressure ulcer (PU - a localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure, or a pressure in combination with shear [occur when forces are applied to body tissues or parts that cause these tissues to move in opposite directions]) for one of three sampled residents (Resident 1) by: 1. Failing to inform the Physician on 6/23/2024 of Resident 1 ' s PU. 2. Failing to inform Family Member 1 (FM 1) of Resident 1 ' s PU on 6/23/2024. These deficient practices resulted in delay of obtaining appropriate instructions from the physician for proper management and violated FM 1 ' s right to be informed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent developing a pressure ulcer (PU - a localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure, or a pressure in combination with shear [occur when forces are applied to body tissues or parts that cause these tissues to move in opposite directions]) for one of three sampled residents (Resident 1) by: 1. Failing to inform the Physician on 6/23/2024 of Resident 1 ' s PU. 2. Failing to provide treatment to Resident 1 ' s PU from 6/23/2024 to 7/3/2024. 3. Failing to inform Family Member 1 (FM 1) of Resident 1 ' s PU on 6/23/2024. 4. Failing to develop a care plan to address Resident 1 ' s PU on 6/23/2024. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to remove intravenous catheter (IV-a thin, flexible tube inserted into a vein, usually in the back of the hand, the lower part of the arm, or the foot to draw blood or give fluids) for one of three sampled residents (Resident 1) when Resident 1 completed the IV fluids hydration on 6/29/2024. This deficient practice had the potential to cause infection and discomfort.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident). On 6/24/2024 and 7/1/2024 Resident 1 ' s Situation Background Assessment and Recommendation (SBAR) Communication Form (form that provides communication between members of the health care team) nurses did not accurately document date and time the physician and the family were called. This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1 ' s medical record.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received care consistent with professional standards of practice to prevent from development of a Stage 3 pressure ulcers ([PU] a localized injury to the skin and/or underlying tissue usually over a bony prominence because of pressure) by failing to: 1. Ensure Resident 1 ' s right heel was elevated ([offloaded] minimizing or removing weight placed on the foot and heel to help prevent development and assisted in pressure ulcers healing) off the mattress and was not continuously laying directly on the mattress thus contributing to the development of Resident 1 ' s right heel pressure ulcer. 2. Provide Resident 1 with a Low Air Loss Mattress ([LALM] a mattress designed to distribute a resident's body weight over a broad surface area and help prevent skin breakdown. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident with a urinary indwelling catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services that included to anchor (secure) the urinary catheter tubing to the resident ' s thigh for one of four sampled residents (Resident 4). This deficient practice had the potential to result in urinary catheter dislodgement (forcefully pulled out of a secure position) causing urethral (the tube through which urine leaves the body) tearing that may result in pain, bleeding, and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for five of seven sampled staff (Medical Records Assistant [MRA], Licensed Vocational Nurse 1 [LVN 1], LVN2, LVN 3 and Director of Staff Development Assistant [DSDA]) while the facility had a Coronavirus Disease 2019- (COVID-19, highly contagious viral respiratory infection that spreads from person to person through droplets releases when an infected person coughs, sneezes or talks) outbreak (more cases of a disease than expected in a specific location over a specific time period) when: 1. Medical Records Assistant (MRA) was walking in the hallway by the front lobby with no protective mask. 2. Licensed Vocational Nurse 1 (LVN 1) standing outside Resident 1's room preparing medications beside a medication cart with N95 hanging on her neck with nose and mouth visible. 3. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to involve the resident's Power of Attorney (POA-a person legally or non-legally appointed to make decisions on behalf of a patient who lacks capacity) of one of three sampled residents (Resident 1) regarding the decision to cancel Resident 1's health insurance. This deficient caused the POA to not receive needed medical information that Resident 1 had canceled his health insurance for 1/2024 and to make an informed decision regarding Resident 1's care.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical supervision of the care for one of three sampled residents (Resident 399), who was newly admitted to the facility and had diagnosis of diabetes mellitus (DM - is a disorder in which the body does not produce enough or respond normally to insulin [a hormone that controls the amount of sugar in the blood], causing blood sugar (glucose) levels to be abnormally high). Attending Physician 1 (MD 1), who was a new doctor for Resident 399 at the facility, did not perform a thorough review of Resident 399's discharge documents from General Acute Care Hospital 1 (GACH 1) including diagnoses and medications to meet the resident's diabetic care upon Resident 399's admission to the facility on [DATE]. Resident 399 did not receive the needed insulin for a total of 11 consecutive days (12/26/2023 to 1/6/20224). [...]

Inspectors wroteB. A review of Resident 70's admission Record indicated the facility admitted the resident on 9/28/2023 and readmitted the resident on 12/22/2023, with diagnoses including, type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high) with diabetic neuropathy (nerve damage caused by diabetes) and type 2 diabetes mellitus with foot ulcer (an open sore on the foot). A review of Resident 70's History and Physical (H&P), dated 12/15/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 70's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/31/2023, indicated the resident had the ability to make self-understood and understand others. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhance a resident's dignity and respect in full recognition of their individuality by failing to ensure Certified Nursing Assistant 3 (CNA 3) knocked and asked permission before entering a resident's room for one of one random observations (Resident 76). This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Assess a resident for self-administration of medication of insulin via an insulin pump (provides non-stop insulin [a hormone that lowers the level of sugar in the blood] delivery through a tubeless, waterproof insulin pump with no multiple daily injections) for one of two sampled residents (Resident 70) investigated during review of insulin care area. 2. Assess if a resident was capable and trained to perform self-administration of medication safely before leaving the medications at bedside for one of 13 random observations conducted during resident screening. These deficient practices had the potential to violate the resident's right to be assessed for capacity and be informed of their ability to self-administer medications and had the potential to result in unsafe medication administration.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (contains relevant information about a resident's conditions, goals of treatment, specific actions that must be performed, and a plan for evaluation): 1. For two out of two sampled residents (Residents 70 and 85) investigated during review of insulin use by failing to ensure Resident 70 and Resident 85 had a care plan on insulin (a hormone that lowers the sugar in the blood) use addressing rotation (a method to ensure repeated injections are not administered in the same area) of subcutaneous (beneath the skin) administration sites. This deficient practice had the potential for ineffective treatment to normalize blood glucose (also called blood sugar) levels and placed the residents at increased complications of insulin use on residents. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility: 1. Failed to update the resident's care plans (contains relevant information about a resident's conditions, goals of treatment, specific actions that must be performed, and a plan for evaluation) for two of two sampled residents (Resident 57 and Resident 67) investigated during review of pressure injury care area by failing to: a. Ensure Resident 67's care plan was updated to reflect the intervention for Z-flex heel boot (a protective boot designed to prevent pressure and pressure sores on the heel area) on for skin maintenance. b. Ensure Resident 57's care plan was updated to reflect the intervention for low air loss mattress (LALM - a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) for skin maintenance. 2. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to one out of five sampled residents (Resident 70) investigated under unnecessary medications. 2. Rotate subcutaneous administration sites of insulin to one out of one sampled resident (Resident 85) investigated under insulin. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) for four (4) out of five random observations (Residents 57, 67, 85, and 27) investigated under pressure ulcer care area, by failing to: 1. Ensure Resident 57's low air loss mattress (LALM - a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was set according to the physician's order. 2. Ensure Resident 67's Z-flex heel boot (a protective boot designed to prevent pressure and pressure sores on the heel area) was applied according to the physicians' order. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor hemodialysis (dialysis, a procedure to remove waste products and excess fluid from blood when the kidneys are no longer healthy enough to do this work adequately) treatment complications by not performing post dialysis assessment for three days as ordered, for one of two sampled resident (Resident 63) investigated addressing dialysis care area. This deficient practice placed Resident 63 at risk for complications of dialysis such as redness at the catheter site, edema (too much fluid trapped in the body's tissues), and excessive bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Various items of food were not discarded after passing their use by date (date when a product may no longer be safe to eat). 2. The red bucket (container used to hold sanitizing product) in the three-compartment sink did not maintain the recommended sanitizer strength according to manufacturer's guidelines. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for two out of five sampled residents (Resident 6 and Resident 64) investigated during review of environment facility task. This deficient practice had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the resident's comfort and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three randomly sampled residents (Resident 304) reviewed for changes in Medicare coverage were provided with the Notice of Medicare Non-Coverage (NOMNC) appeal process in a timely manner. This deficient practice had the potential to result in the resident and or their representative not being able to exercise their right to file an appeal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the window of the resident was free from draft due to deteriorating window seal to one of five sampled residents observed during review of environment facility task (Resident 70). The deficient practice violated the resident's rights to a safe, clean, sanitary, and homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to provide notice of transfer before transfers and discharges for two of three sampled residents reviewed under hospitalization (Resident 63 and 82) by failing to: 1. Provide Resident 63 the notification of transfer or discharge on [DATE] and send a copy of the notification to the long-term care ombudsman (resident advocate). 2. Provide Resident 82's responsible party the notification of transfer or discharge on [DATE] and send a copy of the notification to the long-term care ombudsman. These deficient practices had the potential for Resident 63 and 82 to have an unsafe discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold notice to a resident before transfer to the general acute care hospital (GACH) for two of three sampled residents reviewed under hospitalization (Resident 63 and 82). This deficient practice had the potential for Resident 63 and 82 to not know if they had a place to return to after hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) for two of two sampled residents (Resident 300 and 7) being investigated under urinary catheters (a tube that is inserted into the bladder, allowing urine to drain) by failing to: 1. Place a leg strap (an elasticized thigh strap to anchor catheters in place) to secure Resident 300's suprapubic catheter (urinary catheter that is inserted into the bladder). 2. Ensure Resident 7's suprapubic catheter tubing was free from coils. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered into the digestive system as a liquid) for one of one sampled resident (Resident 67) investigated under the tube feeding care area by failing to ensure the EF bottle was labelled properly per facility's policy. This deficient practice had the potential to place Resident 67 at risk for complications of enteral feeding such as diarrhea or vomiting which may lead to dehydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an infection control program by failing to replace the humidifier bottle (medical device that increase the humidity while using supplemental oxygen) when it ran out of fluid for one of three residents (Resident 34) during a random observation being investigated under the respiratory facility task. This deficient practice had the potential to cause irritation to Resident 34's nasal (referring to the nose) passages.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary drugs for one of five sampled residents (Resident 60) being investigated under unnecessary medication facility task by failing to monitor and document Resident 60's postural/orthostatic hypotension- (a drop in blood pressure [hypotension] due to a change in body position when a person moves to a more vertical position: from sitting to standing or from lying down to sitting or standing postural/orthostatic hypotension and can lead to falls and injuries of the residents) readings while taking Latuda (an antipsychotic medication-used to treat disordered thinking associated with severe mental illness) per physician's order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the meal plan calendar on 2/7/2024, during breakfast by failing to prepare the breakfast at an appetizing temperature to one of eight sampled residents (Resident 70) being investigated under dining observation facility task. This deficient practice had the potential for Resident 70 to have a decrease in food intake and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition for one of five sampled residents (Resident 82) investigated under Environment when Resident 82's bed controller (device used to change the height and angle of the bed) cable was open with exposed wires. This deficient practice had the potential to place Resident 82 at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post daily staffing information that included the actual hours worked by registered nurses (RN), licensed vocational nurses (LVN), and certified nursing assistants (CNA) for all three shifts (7 a.m. to 3 p.m., 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m.) on three of three sampled days (2/6/2024, 2/7/2024, and 2/8/2024). This deficient practice resulted in residents, visitors, and facility staff not knowing how many staff were available to provide care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for three of nine facility staff (Certified Nursing Assistant 1 [CNA 1], CNA 2, and Housekeeping 2 [HKP 2]) by failing to ensure CNA 1, CNA 2, and HKP 2 wore the N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly. CNA 2 was providing care to Resident 3 while CNA 2 ' s N95 mask was not worn properly. The facility also failed to ensure that COVID-19 screening was done on all visitors entering the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignity to three of six sampled residents (Resident 1, 3, and 4) by, failing to ensure staff were not standing over the residents while assisting the residents to eat. This deficient practice had the potential to affect the residents' self-worth.

Inspectors wroteBased on interview and record review, the facility failed to implement infection prevention and control program by: 1. Failing to conduct coronavirus disease 2019 (COVID-19, a highly contagious viral illness that can lead to mild respiratory issues to severe pneumonia [a lung infection causing symptoms like cough, fever, and difficulty breathing]) response testing according to the facility's COVID-19, Prevention and Control policy and procedure for six out of 10 sampled staff (Licensed Vocational Nurse [LVN] 1, LVN 2, LVN 3, LVN 4, Certified Nursing Assistant [CNA] 2, and Dietary Aide [DA] 1). 2. Failing to develop staff COVID-19 testing policy and procedure regarding the appropriate timing, documentation, and submission of the staff's COVID-19 test results. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 6) with her preferred method of showering, when staff was observed only offering Resident 6 a bed bath. This deficient practice had the potential negative effect on Resident 6's quality of life.