Santa Cruz Post Acute

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of practice when Licensed Vocational Nurse A (LVN A) and LVN B did not follow their policy and procedures for administering medication when they did not document their initials and make entries in the Electronic Medication Administration Record (eMAR) after giving medications for 1 of 2 residents (Resident 1). This failure has the potential not to track when the medications were last given that may lead to double dosing or missed medications that may compromise Resident 1's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed serve food that accommodated allergies, intolerances, and preferences for one of three residents (Resident 1). This failure had the potential to affect the resident's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary treatment and services in accordance with professional standards of practice for one of three sampled residents (Resident 1)'s when:1. The Licensed Nurses (LN) did not consistently provide the treatment per physician's order to Resident 1's open wound on bilateral heels during the process of reclassification from a blister (is a painful skin condition where fluid fills a space between layers of skin) to deep tissue injury (DTI, is a type of subcutaneous tissue damage that results from an externally applied mechanical load (pressure)) then a diabetic ulcer (is an open sore or wound on the foot of a person with diabetes (high blood sugar)).2. [...]

Inspectors wroteBased on the interview and record review, the facility failed to follow Resident 1's physician order for collecting stool culture for one of three sampled residents (Resident 1) when Resident 1 had several days of diarrhea (loose stools). This failure had the potential to affect Resident 1's health and condition. During a review of Resident 1's medical record it indicated he was admitted to the facility on [DATE]. During a review of Resident 1's nursing progress notes, dated 3/11/25 at 3:23 p.m., it indicated, Patient has been having diarrhea on and off since he has been here. During a review of Resident 1's physician order, dated 2/13/25, it indicated, Collect stool to r/o (rule out) C-diff (Clostridioides difficile, is a bacterium that causes severe, watery diarrhea and intestinal inflammation (colitis)) and norovirus (is a very contagious virus that causes vomiting and diarrhea). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTIs) for one of three sampled residents (Resident 1) with foley catheter when: 1. Staff failed to follow a prescribed order dated 12/22/25 to collect a urine sample for culture and sensitivity (C&S, is a two-part diagnostic test used to detect urinary tract infections (UTIs) and determine the best antibiotic treatment) in timely manner. The nurses failure to collect urine culture sample had delayed the provision of appropriate treatment contributing to worsening in his condition resulting to transfer to acute hospital on 2/28/25 .2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services that met professional standards of quality when pre-operative instructions were not followed prior to a scheduled procedure for one of three residents (Resident 1). This failure resulted in Resident 1's procedure cancellation and had the potential to result in health complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident safety to prevent accidents resulting in a fall for one of three residents (Resident 1) when the facility van's wheelchair securement system (a safety device installed in accessible vehicles used to keep a wheelchair in place during transport and also secure the wheelchair user with safety straps) used to transport Resident 1 did not meet Code of Federal regulations, Title 49, Part 38 (49 CFR S 38.23(d)(7), Americans with Disabilities Act [ADA] Accessibility Specifications for Transportation Vehicles), and the facility used three staff members (maintenance supervisor [MS], central supply staff [CSS], and the maintenance assistant [MA]) that were not qualified and/or were not trained to transport residents using the facility van: [...]

Inspectors wroteThe facility failed to ensure the safety of one of three sampled residents (Resident 1) during in-bed care (a wide range of activities to ensure the health, comfort, and hygiene of someone who is bedridden), when:1. The facility failed to maintain Resident 1's safety during in-bed care.2. The facility failed to accurately complete Resident 1's fall risk assessment; and3. The facility failed to implement Resident 1's ADL (activities of daily living like bed bath, shower, transfer, positioning, etc.) care plan intervention to Ensure proper position. These failures resulted in Resident 1 sustaining comminuted fractures (a broken bone where the bone is shattered into more than two pieces) to the right tibia and fibula (the two bones in the right lower leg), requiring hospital transfer on August 17, 2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent for psychotropic medications from the responsible party (RP, a person empowered to make decisions for the resident) for one of three residents (Resident 1). This failure had the potential to result in the resident's RP not being fully informed regarding care and treatment in order to make health care decisions for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plans were developed and implemented for 11 of 40 sampled residents (Resident 10, 19, 38, 54, 67, 72, 93, 104, 111, 121, and 287 ). This failure placed the residents at risk of not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice for three of 40 sampled residents, (Residents 34, 124 and 5), when: 1. Resident 34, had no documentation that her weights were being monitored for the last 3 months; 2. Resident 124's STAT (is derived from the Latin word 'Statim, which translates to immediately, and it denotes that order should be prioritized first since it is required promptly) order for x-ray ( a type of radiation that produces images of the inside of the body to diagnose and treat some conditions like bone injuries, tumors, and infections) to left knee was not carried out in a timely manner; and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services for indwelling catheter (a catheter which is inserted into the bladder [a sac-shaped muscular organ that stores the urine secreted by the kidneys],via the urethra [the tube through which urine leaves the body] and remains in place to drain urine) for one of three residents (Resident 46) with indwelling catheters when there was no documented indwelling catheter care for Resident 46 in some days and shifts in December 2024, January 2025 and February 2025. This failure had the potential for the resident to develop catheter associated urinary tract infection (CAUTI, an infection caused by a bacteria [germs] that get into the bladder or kidneys [a pair of organs that are on either side of the spine, just below the rib cage of a person's back ] related to catheter use).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for 29 (Residents 21, 80, 302, 15, 40, 11, 68, 94, 23, 85, 106, 77, 27, 30, 12, 74, 4, 287, 29, 66, 91, 13, 299, 103, 75, 59, 53, 114, and 45) of 63 residents who used bed or side rails when: 1. There was no documentation of informed consents (a form in which residents are given important information, including possible risks and benefits, about a medical procedure or treatment) were obtained prior to bed/side rail use for four of 63 residents (Residents 91, 114, 45, and 59); 2. The Bed Rail Observation/Assessment was not updated in a timely manner for three of 63 residents (Residents 287, 29 and 53); 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing staff on a 24-hour basis based on the Staffing Data Report submitted to the Centers for Medicare & Medicaid Services (CMS). This failure could potentially affect resident's care, health, and psychosocial well-being.

Inspectors wrote2. During the medication pass observation on 2/24/25 at 9:17 a.m., Licensed Vocational Nurse C (LVN C), was observed giving medications to Resident 6. On 2/24/25 at 9:33 a.m., LVN C was also observed administering medications for Resident 47. Review of the facility's records of five nursing staffs' competency checks and medication pass trainings indicated, LVN C did not have a record that she was checked of her nursing care competencies and medication pass trainings. During an interview with the regional director of clinical services (RDCS) on 2/28/25 at 3:40 p.m., RDCS verified that the facility did not have a record that LVN C was checked of her nursing care competencies and medication pass trainings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision of pharmaceutical services that included availability of medication, accurate and safe administration of medications, and accurate accountability of controlled substance (that can be easily abused and are under strict government control) when: 1. A medication was not available to administer to Resident 296 for 10 days, and the nursing staff failed to follow up with the pharmacy or notify the physician of the missing medication. This had the potential for untreated and worsening of the resident's medical condition. 2. Two non-crushable medications for Resident 296 were crushed during administration. This had the potential for the resident to suffer from adverse effects of the medications due to too fast delivery of the medication. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for 7 out of 34 sampled residents (10, 38, 54, 104, 111, 121, and 287) and one non-sampled Resident 296. Also, the facility failed to respond to the CP's recommendation for Resident 296. This failures resulted in unnecessary medications for the residents including duplicate therapy and inappropriately monitored medication use for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 13 out of 40 sampled residents (Residents 10, 19, 38, 39, 47, 53, 60, 67, 72, 93, 104, 111, and 121) were free from unnecessary medications when there was inadequate monitoring and systemic failure in the management of antihypertensive (medication to manage high blood pressure) and antiarrhythmic (medication to manage arrhythmia [abnormal or irregular heartbeats]) medications, and lack of monitoring for signs and symptoms related to the use of anticoagulants (medication to prevent blood clots). They are as follows: 1. During a medication pass observation, Licensed Vocational Nurse C (LVN C) failed to measure Resident 47's blood pressure (BP) before administering an antihypertensive medication, losartan 50 milligrams (mg, unit of measurement), to Resident 47. 2a. For Resident 104: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of 28 sampled residents (Residents 45, 104, and 107) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 45 received as-needed (PRN) lorazepam (brand name: Ativan; medication to treat agitation and anxiety) beyond 14 days without the physician-documented clinical rationale and a specified duration for the extended period. 2. Resident 107 received Depakote (a medication to treat mood disorder) and quetiapine (brand name: [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 12.12% when four medication errors were observed out of 33 opportunities during medication administration for three out of six residents (Residents 6, 47, and 296). Resident 296 and Resident 6 received crushed medications when the manufacturer indicated not to crush; senna (a laxative) was missed for Resident 6; and Resident 47 received the wrong dose of vitamin C. This failure resulted in residents not receiving medications as prescribed and/or according to manufacturers' specifications, and had the potential to result in residents not receiving the full therapeutic benefit of their medications or experiencing negative health outcomes.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure medications were properly stored and labeled in three of three medication carts and in two of three medication rooms. Multiple opened inhalers, eye drops, and multi-dose vials were not labeled with open dates, or with an accurate expiration date, or being used past their discard dates. Also, one of three medication refrigerators was identified with incorrect setting and with temperature reading below freezing. These failures had the potential for residents to receive outdated and/or ineffective medications which could result in the residents not receiving the full benefit of the medications and negative health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure palatability and nutritive value of cooked foods were maintained when: 1. Three of 28 sampled residents complained that the food tasted bland (lacking taste or flavor); 2. Pureed foods (a puréed diet is an eating plan where all the foods have a soft, pudding-like consistency. It is a texture-modified diet that is often recommended for people who can't eat solid foods) were held in the heated oven for an extended time; and, 3. The recipe for making pureed food was not followed. These failures resulted in decreased food palatability that could lead to decrease in food consumed by residents, and the food held in the heated oven for extended time periods could lose nutritive value, leading to a decreased nutrient intake for the thirteen residents on puree diet order out of 139 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were stored and prepared in accordance with professional standards for food safety when: 1. The food items that were out of their original boxes and stored in the food containers, were not labeled with open dates and use by dates, and 2. The kitchen staff did not wear his face mask properly while preparing the desserts for the residents. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the 138 residents who received foods from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures when: 1. A dirty pair of gloves were found inside Resident 287's room floor; 2. Resident 72's used urinal (a plastic bottle for urination) was found on top of the overbed table; 3. Resident's used basins, bedpans (a container used to collect urine or feces), urinals and water pitcher were not labeled, cleaned/disinfected, and stored properly; 4. Certified nursing assistant P (CNA P) did not perform hand hygiene in between resident's meal set up; 5. Two nursing staff touched and opened two medication capsules without wearing gloves; 6. A nursing staff failed to perform hand hygiene between medication administration for residents; 7. One of three medication carts was observed with yellow and brown substances on the bottom drawer; 8. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain respect, and dignity to three of 28 sampled residents (Residents 46, 296, and 133) when: 1. Residents 46 and 296's indwelling catheter's (a catheter which is inserted into the bladder, thru the urethra and remains in place to drain urine) urinary bags were exposed and not covered with a privacy bag; and 2. Resident 133's personal information and care guide was posted in the room visible to roommate's visitors. These failures had the potential to negatively affect resident's emotional and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure on self-administration of medication (resident takes medication without staff assistance) when there were no documentation found in resident's records for self-administration of medication, and medications were left at bedside for two of 28 sampled residents (Residents 113 and 44). This failure had the potential for unsafe and improper administration of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure needs were accommodated for one of 28 sampled residents (Resident 296) when the call button (a red or white button used to call for assistance) was not within Resident 296's reach for use. This failure had the potential for a delayed response and not meeting the resident's needs timely.

Inspectors wroteBased on interview, and record review, the facility failed to complete a comprehensive minimum data set (MDS - a federally mandated resident assessment tool) admission assessment and a required discharge assessment in a timely manner for one of 10 residents (Resident 120). This failure resulted in Resident 120's admission and discharge assessment not completed within the time requirement and had a potential to result in inappropriate care planning and intervention.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comply with Federal and State laws and regulations when the approval letter for staffing waiver was not posted where visitors and residents could easily read. This failure had the potential to result in nurse staffing misinformation about residents' care.

Inspectors wroteBased on interview and record review, the facility failed to provide approriate and necessary services in accordance with professional standard of practice for three out of three residents (Residents 1, 2, & 3) when: 1. a) For Resident 1, the skin and wound assessment was incomplete and Nursing Care Plan (NCP a detailed document that outlines a patient's specific healthcare needs, identifying potential problems, setting goals, and detailing the nursing interventions required to address those needs) was not specific to wound status and b) Facilitys' Licensed Nurses (LNs) did not recheck and notify the physician for abnormal low blood pressures (the pressure of blood circulating against the walls of the blood vessels) measurements. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and/or communicate the appropriate information to the receiving facility for one of two residents (Resident 3) regarding the pending laboratory workup. This failure had the potential to negatively affect the continuity of care and may jeopardize Resident 3's health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Activities of Daily Living (ADL -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care was provided for one of two sampled residents (Resident 1) when there was no evidence of record by three certified nursing assistants that shower/bed bath was provided for three consecutive scheduled shower days for Resident 1. This failure may result in poor body hygiene and may affect the physical and psychological well-being of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 12 aides (Nursing Assistant A (NA A), Nursing Assistant B (NA B), and Nursing Assistant C (NA C)) completed their state certification program, including an examination to test the aides' knowledge and skills. This failure resulted in staff working as Certified Nurse Assistants (CNA) without proper certification and had the potential to put residents' safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to provide proper supervision for one of three residents (Resident 1) when a nurse aide (nursing assistant) did not have the required certification to work as a certified nursing assistant (CNA) and assisted Resident 1 out of the shower room by herself. This failure resulted in Resident 1's fall.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate care and services for an indwelling catheter (flexible tube inserted and left in the bladder to drain urine) for one of three residents when Resident 1 did not have a physician's order for an indwelling catheter, there was no care plan for an indwelling catheter, and there was no documentation of the assessment of urine output and whether catheter care was completed. Also, the facility staff did not document the number of times Resident 1 voided per physician's order. These failures had the potential to result in health complications for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure nurses documented the admission for one of three residents (Resident 1). This failure resulted in an incomplete medical record for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan (identifies residents' concerns and outlines the care and services needed to meet their needs) to address foley catheter for two of four sampled residents (Resident 1 and 2). This failure had the potential to result in the inability to identify the residents' individualized care issues and implement a person-centered care.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of two residents (Resident 2) when: 1. Discharge wound care order from acute hospital to skilled nursing facility was not transcribed, and 2. No physician order to insert foley catheter. This failure had the potential to negatively affect Resident 2's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor two of three residents' (Residents 2 and 3) requests for showers. This failure resulted in the resident's request and preference not being honored.

Inspectors wroteBased on interview, and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of two residents when it did not follow the physician's order to provide 1:1 monitoring for Resident 1. This failure had the potential to compromise residents' safety and health in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their bed rails (adjustable rigid bars attached to the side of a bed: side rails, safety rails, and grab/assist bars) policy for one of three residents (Resident 4). The facility failed to follow their bed rail policy when: 1. There was no documentation that alternatives were attempted prior to installing bed rails; 2. There was no documentation that the risks and benefits were explained to the residents or responsible parties (RP, individuals designated to make decisions on behalf of the residents) prior to installing bed rails; 3. There was no informed consent obtained prior to installing bed rails; 4. There was no documentation that the facility assessed for risk of entrapment (becoming trapped between the bed rail and mattress) prior to installing bed rails; and 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice for two of six residents (Resident 1 and 2) prior to a room change. Also, there was no documentation in the medical record regarding a room change for six of six residents (Resident 1, 2, 3, 4, 5 and 6). These failures had a potential to affect the residents' emotional and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure supervision and assistance were provided for one of three sampled residents (Resident 1), who was dependent on staff for transferring, when Resident1 was left sitting in her wheelchair in her room and fell on the floor on 2/19/2024 without staff watching and/or supervising her. This failure resulted in Resident 1 falling on the floor and sustaining a laceration (a deep cut or tear in skin) on her forehead that required hospital transfer on 2/19/2024 where she had 18 stitches (a way doctors can close certain types of cuts).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurses were trained and demonstrated competency in testing the functionality of the Wander Management Transmitters (wander guard, a device placed on a resident's wrist, ankle, or wheelchair that alarms to notify the staff if a resident tries to leave the facility) used for 9 of 9 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9). This failure had the potential to result in transmitter equipment failure or system failure and resident elopement (to leave a health facility without notification or permission).

Inspectors wroteBased on interview and record review the facility failed to ensure care and services were provided in accordance with professional standards of practice in performing accurate skin assessment to help prevent pressure ulcers (injury to skin and tissue below the skin caused from prolonged pressure on the skin) and provide necessary pressure treatment for one of three residents when staff failed to identify the presence of pressure ulcers for Resident 1. This failure resulted in Resident 1 not receiving pressure ulcer treatment and nursing interventions to aid in wound healing. When Resident 1 was transferred to a hospital's emergency department (ED) on 11/17/23, an unstageable pressure injury (unable to determine the stage; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for three of four sampled residents (Residents 1, 2, and 3) when: 1. Resident 1's Daily Skilled Charting documentation (documentation including symptoms review [head to toe review of any symptoms a person is experiencing] and assessment of the body systems [such as neurological (mental status and alertness), cardiovascular (examination of the heart), respiratory (examination of lungs and breathing), skin (examination of color, skin integrity), etc.]) from 11/7/23 to 11/16/23 was completed by a licensed vocational nurse working remotely, without physically seeing the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standard of practice when there were missing licensed nurse's signature entries in the treatment administration record (TAR) that indicated the treatment were done for one of two residents (Resident 1). This failure had the potential to compromise Resident 1's health.

Inspectors wroteBased on interview and record review, the facility failed to provide services which meet professional standards for one of three sampled residents (Resident 1) when there was no evidence of documentation that weekly nursing summaries are done consistently. This failure had the potential not to identify new healthcare needs and may compromised the continuity of plan of care that may affect the Resident 1's quality of care.

Inspectors wroteBased on interview and record review, the facility failed to provide safe discharge for one of three sampled residents (Resident 1) when: 1. The licensed nurse A (LN A) did not instruct accurately the dosing frequency of Methadone (medication used to treat moderate to severe pain when round the clock pain relief is needed for a long period of time) tablet to be taken at home as ordered by the physician for Resident 1, and 2. The inventory list of personal effects was not signed off by Resident 1 upon discharged from the facility. These failures had the potential to jeopardize Resident 1's health and safety for not taking the correct dosing frequency of Methadone tablet as prescribed by the physician and potential for missing and inaccurate accounting of personal belongings that may affect Resident1's safety when he got transfered to another facility or home.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan that reflect the specific care needs for one of three sampled residents (Resident 1) when there was no care plan developed specific to Resident 1's refusals of the weekly wound assessments. This failure had the potential to negatively affect the resident quality of care.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's responsible party (RP, a person responsible in making healthcare decision for the resident) and provide the Long-Term Care (LTC) Ombudsman (organization that routinely visits the facility and advocates on behalf of the residents) complete information regarding residents transfers and discharges from the facility when: 1. For Resident 1, there was no evidence of written notification of transfer to the Resident 1's RP when Resident 1 was transferred to the hospital, 'and 2. The information provided to the LTC Ombudsman for 17 of 17 residents who were transferred and discharged from the facility for the month of October 2023 were incomplete. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services were provided to meet professional standard of practice for one of two residents (Resident 1) when: 1. There was no documentation in Resident 1's medical record regarding the change of condition that led the resident to be transferred to the hospital. 2. There was no documentation in Resident 1's medical record regarding nursing intervention/action done for Resident 1's abnormal blood pressure and These failures had the potential to compromise the resident health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure quality of care was provided for two out of two residents (Resident 2 & 3) when the weekly wound evaluations were not completed. These failures had the potential for not meeting residents' care needs and affect residents ' quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure acceptable parameters of nutrition and hydration when the meal and fluid intake were not monitored and recorded consistently. This failure could potentially place Resident 1, who was already at risk for further decline and compromised in nutritional and hydrational status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the wound doctor write the progress notes at each visit for Resident 2. The wound doctor physician had no documented written notes in Resident 2 ' s progress notes of her visits from 7/26/23 to 11/25/23 regarding the Resident 2's wounds status/condition. This failure placed the resident at risk of poor continuity of care, poor follow- up, and unidentified resident's status for each wound evaluation visits. Review of Resident 2's medical record on 11/29/23 indicated Resident 2 was seen by wound doctor on 7/26/23, 11/15/23, 11/18/23, 11/22/23, and 11/25/23 for wound consultations for open wound on right calf and abrasions on right lower extremity and right lower abdominal quadrant. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident ' s medical records were complete and readily available for review by official authorized by law for Resident 2 when the wound consultation reports were not found in Resident 2's medical record. This failure had the potential to cause delay for the determination of the quality of care rendered to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of two residents when the facility did not follow the physician's order for diabetes (blood sugar higher than normal) management for Resident 1 when the attending doctor was not notifie dof blood sugar level greater than 400, and the insulin medicationw as not given with meals as ordered. This failure could compromise Resident 1's safety and health.

Inspectors wrote2. Review of Resident 523's Order Summary Report, indicated, Resident 523 was admitted on [DATE], with indwelling Foley catheter (FC, a thin, flexible catheter used especially to drain urine from the bladder by way of the urethra) care orders. During an observation on 5/8/2023 at 12:50 p.m., while inside Resident 523's room, Resident 523 was lying in bed. A FC urine collection bag was observed hanging on the left side of the bed, containing yellow urine. The FC urine collection bag was not covered with a dignity bag. During another observation on 5/9/2023, at 9:53 a.m., Resident 523's FC urine collection bag was still hanging on the left side of the bed, and remained uncovered with a dignity bag. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision for safe use of insulin (medication to lower blood glucose) pens; and controlled medications (those with high potential for abuse and addiction) were fully accounted, when: 1. The nursing staff failed to prime or accurately prime the Humalog Kwikpen (a pre-filled pen containing insulin lispro, a short-acting insulin) before administration for three out of three residents (Residents 78, 227, and 523). This had the potential for resident getting too much or too little insulin which would negatively affect the health of 15 residents receiving insulin pens; and 2. Random controlled medication use audit for three of six sampled residents (Residents 31, 223, and 225) did not reconcile. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist (CP) identify and report to the facility irregularities related to medication regimen for three of 25 sampled residents (Residents 62, 69, and 101) during the medication regimen review (MRR). The failure resulted in inadequate monitoring and had the potential for medications not being optimized for best possible health outcome.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 10.34% when three medication errors occurred out of 29 opportunities during the medication administration for three residents (Residents 78, 227, and 523): 1. For Resident 227, there was no priming of insulin (medication to lower blood glucose [BG]) pen before administration; 2. For Resident 78, the nursing staff did not correctly prime the insulin pen before administration; 3. For Resident 523, the nursing staff did not correctly prime the insulin pen before administration, and administered the insulin dose after a meal while the physician's order indicated before meal. The failure resulted in medications not given according to the manufacturer's instructions and/or physician's order, and had the potential for residents not receiving the full therapeutic effects of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food served to two of 25 sampled residents (Resident 63 and one anonymous resident) were maintained at the proper temperature, and food trays were delived late in one of five facility stations (Station 3). These failures had the potential for residents to consume less amount of food due to non-palatable temperature and delayed trays.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the proper disposal of garbage when two of the four receptacles were overfilled so the lids could not be closed. This failure had the potential for pests to harbor and breed on the garbage posing a hazardous environment for the residents and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the call light was within reach for one of 25 sampled residents (Resident 69). The failure could result to untimely delivery of resident's care.

Inspectors wroteBased on interview and record review, the facility failed to maintain the accuracy of the resident assessment of one of 25 sampled residents (Resident 113). The failure resulted in ineffective care planning of resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for one of two residents (Residents 69) who had a pacemaker (implanted device for a heart condition, a battery-powered device implanted inside the heart to restore a normal heartbeat) when: 1. The licensed nurses did not know the pacemaker location and no pacemaker information in the resident's medical record; 2. The licensed nurse did not check Resident 69's apical pulse (a pulse point on your chest that gives the most accurate reading of your heart rate) to monitor pacemaker malfunction; and 3. A cell phone was placed on the tray table at the bedside near Resident 69's chest. These failures had the potential to compromise residents' health. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an eye consultation and/or referral was arranged for one of 25 sampled residents (Resident 73) in a timely manner. This failure had the potential to negatively affect the resident's health, well-being, and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary podiatry services for one of 25 sampled residents (Resident 273) when: 1. The licensed nurses failed to assess the toenail issue, 2. The licensed nurses failed to develop a care plan for the toenail care, 3. The facility failed to refer Resident 273 to a podiatrist (foot doctor). These failures had the potential to affect the resident's foot health and contribute to resident's discomfort, injury and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of nine residents (Resident 273) who had the indwelling urinary catheters (a small, flexible tube that can be inserted through the bladder to drain urine into a urine collection bag) had appropriate urinary management when the Resident 273 wore the urine drainage leg bag on his bed higher than his bladder. This failure could potentially put the Resident at risk of urinary infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the central venous catheter (CVC, a thin, flexible tube that is placed into a large vein above the heart) care for one of three residents (Resident 69) with parenteral lines (one form of route of administration such as intravenous) were performed per professional standards of practice when: 1. The registered nurse (RN) failed to flush the CVC for two days, and no nursing notes indicated why not to flush, 2. The registered nurses failed to change the CVC dressing since admission, 3. The Registered nurse did not develop a person-centered, resident-specific CVC care plan and included CVC-related information such as insertion site/location, date of insertion, number of lumens (openings), type of catheter, etc. in the care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's medication regimen was free from unnecessary medication for two of 25 sampled residents (Residents 62 and 69). Resident 62 had been receiving magnesium oxide (an electrolyte to treat low magnesium level in the body) for two and a half years without magnesium level monitoring. Resident 69 had been receiving two types of insulin (medication to lower blood glucose [BG] in the body) without staff monitoring the signs and symptoms of hypo/hyperglycemia (too low/high BG). The failure had the potential for adverse effects to go undetected or recognized for timely intervention.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 25 sampled residents (Resident 69) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors). Resident 69 received trazodone (anti-depressant medication) and Depakote (a medication to treat mood disorder or seizures) without monitoring for hours of sleep related to trazodone use and the potential side effects of the medications. The failure resulted in inadequate monitoring for effectiveness and adverse effects of psychotropic medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to store food under sanitary condition when: 1. For Resident 105, there was an opened tube feeding (a way of giving medicines and liquids, including liquid foods, through a small tube placed through the nose or mouth into the stomach or small intestine) formula at the bedside; and 2. Two dented cans were not removed from the kitchen's dry storage area. These failures had the potential to expose residents to food borne illnesses in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure compliance with infection control practices when one Laundry Personnel I (LP I) was wearing gloves in the hallway. This deficient practice had the potential to affect the safety and well-being of residents, visitors, and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure peripherally inserted central catheter (PICC, a thin flexible tube was inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) line care for one of two residents (Resident 174) when licensed nurses did not measure the circumference and the length of the arm of Resident 174 as prescribed by the physician. This failure could compromise the health and safety of the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care in accordance with professional standards of practice for two of four sampled residents (Residents 63 and 6) when the licensed nurse failed to ensure oxygen was administered as specified in the physician's order for Resident 6 and facility staff administered oxygen without a physician's order and no No Smoking/oxygen in Use signs at the entrance door for Resident 63. These failures had the potential to compromise the residents' health and safety.

Inspectors wroteBased on interview and record review the facility failed to ensure: 1. The timely replacement of emergency kits (e-kit, a kit/box containing medications and supplies for immediate use during a medical emergency); 2. The accurate accountability of the controlled substance (CS, medications with high potential for abuse and addiction) medications for five of six residents (Residents 39, 55, 67, 75, and 114) 3. The availability of Resident 75's lantus (long-acting insulin). These failures had the potential to cause delay in treatment and compromise residents' medical health. 1. During an observation in medication room A on 1/21/2020 at 10:55 a.m. with licensed vocational nurse B (LVN B), revealed the emergency intravenous medication and supply kits were opened on 1/16/2020. During a concurrent interview, LVN B stated the e-kits should have been ordered the day it was opened. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents were free from unnecessary psychotropic (medication affecting the mind, emotions, and behavior) medications for 8 of 11 sampled residents (Residents 106, 94, 74, 45, 75, 25, 40, and 274) when: 1. For Residents 106, 94, 45, 75, 25, and 40, the facility failed to monitor the side effects of the medications; 2. For Resident 74, facility failed to monitor the specific target behavior and side effects of the medication; 3. For Resident 274, the facility failed to identify and monitor the specific target behavior for the use of the medication; 3. For Resident 25, the facility failed to implement the interdisciplinary team (IDT) recommendation to reduce Seroquel. These failures had the potential to negatively affect the residents' physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility had a 12% error rate when three medication errors out of 25 opportunities were observed during a medication pass. Resident 87 did not receive amlodipine besylate (medication for high blood pressure) and amantadine (medication used to treat Parkinson's disease [a movement disorder]) as scheduled. These failures resulted in medications not given in accordance with the prescriber's orders and may affect the resident's clinical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medication in accordance with professional standards when an Advair (medication that is inhaled and used to improve breathing) inhaler had no open date and was left unattended on the medication cart, latanoprost (eye drops used to lower pressure in the eye) bottle was not labeled with an open date, lorazepam (medication used to treat anxiety) container was not refrigerated, and expired insulin (medication used to lower blood sugar) vials were stored in the medication cart. These failures had the potential to allow residents and unauthorized staff to access medications and affect the integrity of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage practices when residents' food were not labeled and dated and when the temperature of two of two resident food refrigerators were not monitored. These failures had a potential for residents to contract food-borne illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff implemented proper infection control practices for 6 of 26 sampled residents (274, 175, 88, 87, 8, and 20) when: 1. For Resident 274, nebulizer face mask was not properly stored. 2. For Resident 175, indwelling catheter (a flexible plastic tube (a catheter) inserted into the bladder which provide for continuous urinary drainage) bag was not covered; 3. For Resident 88, contact precaution was not followed as prescribed by the physician; 4. For Resident 87, licensed vocational nurse A (LVN A) did not clean the top of the insulin vial with alcohol 5. For Resident 8, licensed vocational nurse J (LVN J) did not perform hand hygiene after touching a trash can and before administering medication 6. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate resident's needs for one of 26 residents (Resident 61) when staff did not attend to Resident 61's needs promptly. This failure resulted in Resident 61 waiting 22 minutes for her call light (a button pressed by a patient that turn on a light and/or sound alerting staff a patient needs their help) to be answered and had the potential for residents' to not receive assistance from staff in a timely manner and not meeting their needs.