Santa Fe Heights Healthcare Center, LLC

Inspectors wroteBased on interview and record review, the facility failed to ensure interventions were implemented to prevent worsening malnutrition (a physical condition where a person's body does not get the proper balance or required amount of nutrients, vitamins, and calories necessary to maintain healthy tissues and organ function) for one of two sampled residents (Resident 1) when: 1. Registered Nurse (RN) 1 did not notify the resident's physician or the facility's Registered Dietician (RD) after Resident 1 was identified as malnourished during a Mini Nutritional Assessment conducted on 6/24/2026.2. The RD failed to conduct a comprehensive nutritional assessment for Resident 1 within seven days, following admission to the facility. These deficient practices resulted in delayed interventions to assist Resident 1 in achieving gradual weight gain and prevent continued weight loss and malnutrition.

Inspectors wroteBased on interview and record review, the facility failed to obtain an order for routine blood glucose monitoring (measuring the amount of sugar in the blood, normal level is 70 to 140 milligrams per deciliter [mg/dL- a unit of measurement)] and hemoglobin A1C (HbA1c- measures the average blood sugar level over the past two to three months) for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 being admitted to the general acute care hospital (GACH) with an initial blood glucose level of 591 mm/dL requiring intravenous (IV, through the vein) insulin therapy (the administration of medication used to lower blood glucose levels).

Inspectors wroteBased on interview and record review, the facility failed to manage two of three sampled residents' (Residents 1 and 3) pain when pain medication, ordered for moderate pain (pain rated four to six on a 10-point scale), was given for severe pain (pain rated seven to ten on a 10-point scale). This deficient practice had the potential to result in the mismanagement of Residents 1 and 3's pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2) medical records were accurately documented when:1. License Vocational Nurse (LVN) 1 intentionally fabricated (something that is fake) Resident 1's vital signs (e.g., temperature, heart rate, blood pressure, respiratory rate, oxygen saturation [amount of oxygen in the blood]).2. The Treatment Nurse (TN) did not document Resident 2's wound treatments on the Treatment Administration Record (TAR). This deficient practice resulted in Residents 1 and 2 having an inaccurate medical record that did not reflect the assessments and care provided.

Inspectors wroteBased on interview and record review, the facility failed to verify informed consent for the administration and re ordering of the psychoactive (a medication that affects mood, thoughts, behavior, or perception) medication, Ativan (an anti-anxiety medication), for one of three sampled residents (Resident 10), despite documented evidence that the resident lacked decision making capacity. This deficient practice resulted in Resident 10 receiving psychoactive medication on multiple occasions without confirmation that the resident's responsible party (RP 1) had been informed of the risks, benefits, and alternatives, as required by facility policy.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely responsible party (RP) notification for one of three sampled residents (Resident 10) when Resident 10 exhibited increased anxiety (an overwhelming feeling of uneasiness) on 5/15/2026 and required an administration of Ativan (a psychotropic medication, a medication that affects mood, thoughts, behavior, or perception) intramuscular injection (medication administered in the muscle). This deficient practice led to RP 1 being unaware of Resident 10's emergency administration of Ativan and episode of increased anxiety on 5/15/2026.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from sexual abuse for one of four sampled residents (Resident 2), when Resident 4 and Resident 2 were found in bed unclothed. This deficient practice resulted in Resident 2 being sexually abused by Resident 4 and had the potential for Resident 2 to experience physical harm, emotional trauma, fear, humiliation, and psychological distress.

Inspectors wroteBased on interview and record review, the facility failed to report a sexual abuse allegation to the State Agency (California Department of Public Health [CDPH]), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement for two of four sampled residents (Residents 2 and 4), after Resident 4 was observed unclothed in Resident 2's bed, who was also unclothed. This deficient practice resulted in a delay of an onsite investigation by CDPH and had the potential to place all residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) and Restorative Nurse Aide (RNA) services were provided and performed as ordered for four out of four sampled residents (Resident 16, Resident 28, Resident 11, and Resident 69) when the facility did not ensure:1. Resident 11 received appropriate services to maintain functional ability and comfort related to activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).2. RNA orders were carried out as ordered for Resident 28.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the restorative nursing aides (RNA) accurately documented care provided, and failed to ensure repositioning and bathing was performed and documented four of four sampled residents (Resident16, Resident 8, Resident 65, and Resident 11). These deficient practices resulted in clinical records that did not reliably reflect restorative nursing care provided to Residents 16, 28, and 65, which had the potential to impede the facility's ability to monitor implementation of restorative nursing services and timely re-evaluate resident treatment needs. These deficient practices also impeded in the facility's ability to verify implementation of pressure injury prevention and hygiene care for a resident at increased risk for skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to timely submit a referral to the Office of the Long-Term Care Patient Representative (OLTCPR- office that provides a trained public representative for specified long-term care residents who may need medical treatment but lack decision-making capacity and have no legally authorized decision-maker) for one of one sampled residents (Resident 25). This deficient practice resulted in a delay in obtaining a representative for Resident 25, which resulted in the bio-ethics committee (a multidisciplinary team designed to address, guide, and resolve resident-care issues) overseeing Resident 25's care.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from one of five sampled residents' (Resident 10) responsible party (decision maker when an individual does not have the mental capacity to do so) prior to the administration of psychotropic medication (medications that affect the mind, emotions, and behavior). This deficient practice resulted in Resident 10, who did not have the capacity to consent, making uninformed decisions about her care and unable to understand the use, side effects, and risks of taking psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device that residents use to request assistance from staff) was within reach for three of 18 sampled residents (Residents 28, 91, and 48). This deficient practice had the potential to negatively impact Residents 28, 91, and 48's psychosocial well-being and result in delayed provision of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of ten sampled residents' (Residents 11 and 10) Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) and advanced directive rights were reviewed, completed and accurately reflected the residents' wishes. This failure has the potential to result in Resident 11 receiving life-sustaining treatment that did not align with his preferences during a change in condition or medical emergency and Resident 10, who did not have the capacity to make medical decisions, not understanding the life-sustaining treatment she consented to.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 4) was free from unnecessary physical restraint when Resident 4's bed was placed against the wall with upper side rails raised. This failure resulted in Resident 4 being subjected to a restraint without clinical justification and had the potential for restricting Resident 4's freedom of movement, causing physical or psychological harm.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement individualized care plans for four of eight sampled residents (Resident 11, Resident 3, Resident 10, and Resident 57) when care plans were not developed to address:a. Resident 11's identified range of motion impairments and comfort-focused mobility needs.b. Resident 3's use of the anticoagulant (blood thinner) medication, Apixaban (a medication used to prevent blood clots).c. Resident 10's use of grab bars for safe transfers.d. Resident 57's hearing impairment and use of hearing aids. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 53) received nail care and grooming services. This deficient practice had the potential to result in Resident 53 experiencing infection, compromised hygiene, skin injury from scratching, and diminished dignity.

Inspectors wroteBased on interview and record review, the facility failed to implement the physician orders for Physical Therapy ([PT]- a licensed healthcare profession focused on restoring, maintaining, and promoting optimal physical function, movement, and quality of life) and Occupational Therapy ([OT]- enables people to engage in meaningful, everyday activities and promote well-being and independence) services for one of five sampled residents (Resident 12). This deficient practice placed Resident 12 at risk for avoidable decline in strength and functional status, increased dependence on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up on two of two sampled resident's (Resident 57 and Resident 42) audiology (examining hearing) and optometry (examining eyes for visual issues) referrals. This deficient practice resulted in Resident 57 being unable to use his hearing aids (small medical device worn in or behind the ear to amplify sound for individuals with hearing loss) since 9/29/2025 and continued to have difficulty hearing, and had the potential to result in miscommunication regarding Resident 57's care. This deficient practice also resulted in delaying Resident 42's ability to obtain glasses which resulted in difficulty seeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide visual monitoring every two hours and ensure floor mats were in place for two out of six sampled residents (Resident 23 and Resident 4). These deficient practices resulted in Resident 23 leaving the facility undetected and was later located approximately 9.5 miles from the facility placing the resident at risk for serious injury or harm. This deficient practice also placed Resident 4 at risk for injury from a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure titled, Catheter Care Urinary by not ensuring a resident's indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was maintained in a manner that prevented contact with contaminated surfaces during wheelchair mobility for one out of two sampled residents (Resident 2). This deficient practice resulted in Resident 2's catheter drainage bag being dragged on the floor on multiple occasions, which placed Resident 2 at risk for catheter contamination, urinary tract infection (UTI- an infection in the bladder/urinary tract), and accidental catheter dislodgement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen (a medical gas used to help with breathing) therapy in accordance with the facility policy and physician orders for two of six sampled residents (Resident 2 and Resident 94), when the facility failed to ensure:1. Oxygen therapy was administered per physician order for Resident 22. The nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was dated for Resident 94.3. Required humidification (adding moisture to oxygen) was provided for Resident 94's continuous oxygen therapy.4. Required oxygen-in-use signage was posted outside of Resident 94's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their process for proper use of side rails (short rails on one or both sides of the bed that can be used to assist in bed mobility) for two of two sampled residents (Residents 10 and 62) by failing to:1. Conduct an accurate Bed Rail Assessment prior to installing Resident 10 and 62's side rails.2. Obtain an Order for Resident 10's use of side rails.3. Verify informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained prior to Resident 10 use of side rails. These deficient practices had the potential for the unsafe use of Resident 10 and 62's side rails which could lead to entrapment (becoming caught, trapped, or tangled in between a small space) and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with professional standards of practice for two of six sampled residents (Residents 72 and 82) when Licensed Vocational Nurse (LVN) 1 failed to explain medications to Resident 72 prior to administration, failed to administer medications at the time they were prepared to Resident 82, and failed to ensure medications for more than one resident was not prepared at the same time. These deficient practices resulted in Resident 72 not being informed of the medications being administered, and had the potential to result in medication errors and compromise Resident 82's safety.

Inspectors wroteBased on interview and record review, the facility failed to monitor one of five residents (Resident 10) for side effects related to their use of divalproex sodium (an anticonvulsant medication, used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and other behavioral conditions). This deficient practice had the potential to result in undetected side effects which could negatively affect Resident 10's well-being and could result in delay in physician notification and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of five percent or greater, as evidenced by the identification of two medication errors out of 35 opportunities, resulting in a medication error rate of 5.71 percent for two of 24 sampled residents (Residents 72 and 82) when:1. Licensed Vocational Nurse 1 (LVN 1) did not inform Resident 72 of the medications being administered or the purpose of the medications prior to administration. 2. LVN 1 pre-prepared medications for Resident 82 and did not administer the medications at the time they were prepared, resulting in medications being stored in the medication cart prior to administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff followed fortified diet (diet to increase caloric intake) guidelines during lunch service when fortified diets were not prepared and were not served to nine residents who were on fortified diet. This deficient practice had the potential to result in meal dissatisfaction, decreased caloric intake, and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Arbitration Agreement (an agreement between the facility and the resident where they would resolve any disputes through a neutral person rather than going to court) was provided to and signed by an individual with decision making capacity for one of three sampled residents (Resident 10). This deficient practice resulted in Resident 10 being unaware of her right to resolve a dispute in court was waived after entering into the binding arbitration agreement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure titled, Food for Residents from Outside Sources, which indicated prepared food brought in for a resident must be consumed within one hour of receiving or stored in the facility kitchen, nursing station refrigerator, or resident's personal refrigerator for one of six sampled residents (Resident 53). This deficient practice had the potential to expose Resident 53 to foodborne illness, bacterial growth, contamination, and gastrointestinal infection due to improper storage and prolonged room temperature exposure of perishable food items.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was operational for one of six sampled residents (Resident 3). This deficient practice placed Resident 3 at risk for delayed response to care needs, unmet assistance requests, and potential harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft.- a unit of measurement) of room space per resident for 22 of 39 rooms. This deficient practice had the potential to result in inadequate space for daily living, and for facility staff to care for the residents.

Inspectors wroteBased on interview and record review, the facility failed to follow its readmission process to obtain and review clinical documents (medical records, consisted of patient's medical history, treatments, and discharge, which are reviewed prior to approving or denying an admission) for the determination to readmit one of two sampled residents (Resident 1) from the general acute care hospital (GACH) after being cleared by the GACH to return to the facility on 1/27/2026. This deficient practice resulted in the denial of Resident 1's right to return to the facility and resulted in Resident 1's unnecessary stay at the GACH for nine days.

Inspectors wroteBased on interview and record review, the facility failed to revise one of two sampled residents' (Resident 1) Care Plan based on the Interdisciplinary Team's (IDT- a group of individuals from different specialties who work together to create goals for better outcomes for the resident) recommendations to monitor the resident's aggressive behavior. This deficient practice resulted in the frequency Resident 1's aggressive behavior being unaccounted for and had the potential to result in Resident 1 not receiving the necessary care and services to treat his aggressive behavior.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall risk interventions such as visual checks and monitoring were implemented and documented for one of three sampled residents (Resident 93) who was identified as a fall risk. This deficient practice resulted in Resident 93 sustaining an unwitnessed fall.

Inspectors wroteBased on interview and record review, the facility failed to arrange a psychology consult (a form of therapy where a psychologist sees an individual for mental health or behavioral problems) for one of two sampled residents (Resident 1), after the resident exhibited behaviors. This deficient practice had the potential for Resident 1 to experience psychological distress, poor coping skills, and continuation of aggressive behavior.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nursing staff obtained informed consent for one of two sampled residents (Resident 1) prior to administering psychotropic medications (drugs that affect the brain and mind, altering a person's thoughts, emotions, feelings, awareness, and perceptions) for Resident 1. This deficient practice violated Resident 1's and/or Resident 1's responsible party's right to make an informed decision prior to the administration of a psychotropic medication and placed Resident 1 at risk for a medication error.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nursing staff revised a fall care plan for one of two sampled residents (Resident 1) after Resident 1's fall on 1/4/2025, 7/28/2025, 4/30/2025, and 7/28/2025. These deficient practices resulted in Resident 1 not having effective interventions in place to minimize future falls and injuries, placing Resident 1 at risk for future falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, document and communicate changes in condition for a resident following an unwitnessed fall for one out of three sampled residents (Resident 1) when the following occurred: 1. Certified Nursing Assistants (CNA) 1 and 2 observed new onset of shoulder pain and limited range of motion while assisting Resident 1 put on a sweater (on 11/3/2025 and 11/6/2025) but did not effectively communicate the change to the Licensed Vocational Nurse (LVN) and did not complete a Stop and Watch form (the facility CNA to LVN communication tool). 2. LVN 1 noted new skin redness to Resident 1's right shoulder on 11/6/2025 (three days after Resident 1's fall) but failed to document the finding, failed to assess for range of motion changes and failed to notify the physician or RN Supervisor. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse (RN) supervisor completed the post-fall incident report per facility Policy and Procedure (P&P), titled, Assessing Falls and Their Causes, for a resident who suffered an unwitnessed fall that resulted in the identification of right shoulder bruising and a clavicle fracture (broken collar bone) seven days after the fall for one of three sampled residents (Resident 1). This failure had the potential to result in a delay in an RN- level, thorough post-fall assessment of Resident 1's condition and had the potential to lead to missed opportunities to identify a developing injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' rights were respected for two of two sampled residents (Resident 1 and Resident 2) when: 1. Certified Nursing Assistant (CNA) 1 failed to provide dining assistance in a dignified manner to Resident 1.2. Licensed Vocational Nurse (LVN) 1 and CNA 1 failed to assist Resident 2 in filing a grievance after it was verbally reported to them. These deficient practices placed Resident 1 at risk of feeling rushed or undignified during the dining experience. These deficient practices also placed Resident 2 at risk of sustaining psychosocial distress related to her unaddressed and unreported grievance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) assessment for one of two sampled residents (Residents 1) was accurate. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 1's health status. This deficient practice also created the potential for Resident 1 to not receive the care and interventions needed to reach her highest practicable physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nursing staff accurately documented Resident 1's functional status (an individual's ability to perform daily activities and maintain their overall health and well-being) during daily Advanced Skilled Evaluations from 7/15/2025 to 7/20/2025. This deficient practice placed Resident 1 at risk of not receiving the skilled services (medical care and support provided by licensed nurses under the supervision of a physician, focusing on the treatment of injuries, illnesses, or chronic conditions, and often including rehabilitation services) she required for her upper and lower extremity impairments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), who was subjected to Resident 2's physical attack, who had diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning, may have grandiose delusions [strong beliefs of things that are untrue]). The facility failed to: - Implement the facility's policy and procedure (P&P) titled, Abuse Prevention/Prohibition, dated 11/2018, which indicated the facility would understand behavioral symptoms of residents that may increase the risk of abuse including aggressive and/or catastrophic reactions of residents, outbursts, or yelling out. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate resident supervision (oversight), and monitoring was implemented for one of three sampled residents (Residents 1), who was at high risk for elopement (leaving the facility without permission and supervision). This failure resulted in resident eloping the facility on 5/16/2025 and placed the resident at risk for missing scheduled medications, exposure to hot weather, accidents and other complications that can lead to severe injuries, hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident ' s blood pressure (the pressure of the blood in the circulatory system), and pulse rate (the number of times the heart beats within a certain time period) was assessed and documented before the administration of hydralazine and lisinopril (medications that lower blood pressure by making blood vessels widen so blood gets through more easily) as ordered by the physician and indicated in the care plan for one out of six sampled residents (Resident 1). This failure had the potential to cause a decrease in Resident 1 ' s blood pressure and result in a medical emergency.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of two staff were able to verbalize the policy regarding the use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This failure had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 88 of 88 medically compromised residents who store food in the resident's refrigerator.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection control practices were followed when: 1. Housekeeping personnel failed to perform hand hygiene after cleaning a resident's room. 2. Nursing staff failed to perform hand hygiene after coming in contact with a resident's body fluids. 3. Nursing staff failed to sanitize a high traffic surface area contaminated with body fluids. 4. Nursing staff failed to ensure Resident 56's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs), nebulizer mask (a face mask over the nose and mouth to deliver medication into the lungs), and tubing was not touching the floor, was dated, and stored properly. These deficient practices had the potential to expose Resident 56, other residents, staff, and visitors to infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure medications were stored separately from food items (Sriracha [a brand of spicy sauce] bottle) in one of one inspected medication room (Station A Medication Room). 2. Ensure removal of expired niacin (a vitamin B supplement to treat low level of vitamin B) tablets from one of one inspected medication room (Station A Medication Room). 3. Ensure medication storage area did not have an unidentified and/or unapproved container noted to be utilized during medication administration to measure water volume for G-tube flushes in one of two inspected medication carts (Medication Cart B). 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff were: a. Unable to verbalize the acceptable temperature for low temperature dishmachine and the correct chlorine concentration range. b. Unable to verbalize the process of checking quaternary ammonium compound (QUAT, a chemical that disinfect) sanitizer concentration testing for the red buckets and three compartment sink's (sink for dishwashing that have wash, rinse and sanitize compartments) use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of: a. Seventy five (75) of 88 residents on regular texture diet who received 1/3 cup (c., a household measurement) instead of ½ c of sweet corn salad. b. Four (4) of six (6) residents on renal diet received less portion instead of ½ c when staff used a regular serving scoop instead of using a perforated spoodle (kitchen utensils with holes that is part spoon and part ladle used to scoop and serve precise portions of food). These failures had the potential to result in a decrease in food and nutrient intake resulting in unintended (not planned) weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor, appearance, and appetizing temperature when: a. Sweet corn salad was at 62 degrees Fahrenheit (°F, a scale of temperature) and the lettuce was wilted. b. Broccoli did not have seasoning and flavor and was overcooked and mushy. These failures had a potential to result in 75 of 88 residents on regular texture (no restriction) on 2/10/2025 and 89 of 89 residents on 2/11/2025 facility residents getting food from the kitchen, including Resident 70 and 34 at risk of unplanned weight loss, a consequence of poor food intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree Cajun country rice was sticky, did not pass the spoon tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together), and did not hold its shape on the plate for residents on puree diet (foods that are smooth with pudding like consistency) /International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level four (4). These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 8 of 88 residents on puree diet, resulting to unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).

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. Kitchen equipment and kitchen areas were not cleaned and sanitized: a. Reach in freezer vents had dust buildup by the exit door. b. Reach in freezer bottom shelves had dirt debris. c. Three kitchen vents had dust buildup. d. Kitchen hood had dust and dirt buildup. e. Ice machine had brown and white dirt buildup. 2. Pans were stacked wet at the storage area. 3. Two (2) dented cans were stored with non-dented cans. 4. Staff did not perform handwashing: a. Staff touched the trash lid then held sandwiches without washing her hands. b. Staff [NAME] a plastic lid on the floor then proceeded handling clean coffee mugs on the resident's tray without washing hands. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the rights and dignity of residents were honored when the facility failed to ensure the following for two out of six sampled residents (Resident 3 and Resident 4): 1. Certified Nursing Assistant (CNA) 3 did not watch television on her personal cellular phone device with earphones in each ear as she fed Resident 3 his lunch meal. 2. A bioethics committee meeting (a committee designed to support patient rights and help the resident, and the health-care team make decisions about health care) was held on the behalf of Resident 3, who was deemed unable to make medical decisions as indicated by the physician's History and Physical, dated 2/10/2025, prior to the administration of psychotropic medications (drugs that affect the brain and nervous system, altering mood, behavior, and cognitive function). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent for the administration of psychotropic medications (drugs that affect the brain and nervous system, altering mood, behavior, and cognitive function) were properly and accurately obtained for two out of six sampled residents (Resident 3 and Resident 4). These failures resulted in the administration of psychotherapeutic medications and changes to the plans of care for both Resident 3 and Resident 4 without the consultation and knowledge of sound and reasonable decision-making parties or representatives.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of eight sampled residents (Resident 72 and 86). This deficient practice had the potential to result in a delay or an inability for the residents to obtain necessary care and services as needed.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a resident's low blood level concentration of phenobarbital (a drug used to control seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) for one out of six sampled residents (Resident 10). This failure increased the potential for Resident 10 to suffer from a bodily injury due to a seizure. Cross reference F656.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from physical and verbal abuse for one of six sampled residents (Resident 69). This deficient practice resulted in Resident 69 being verbally and physically abused by Resident 73, and had the potential for Resident 69 to have physical and/or psychological distress.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical and verbal abuse for one two of six sampled residents (Resident 69 and Resident 73), by failing to: 1. Ensure facility staff report no later than two hours, the alleged resident to resident physical and verbal abuse to the California Department of Public Health (CDPH). 2. Ensure the facility report the results of the investigation within five (5) working days. These deficient practices resulted in a delay of an onsite investigation by CDPH and had the potential to place all residents in the facility at risk for further abuse.

Inspectors wroteBased on interview, and record review, the facility failed to implement its policy and procedure (P&P) by failing to investigate a resident-to-resident physical and verbal abuse between two of six sampled residents (Resident 69 and Resident 73). This deficient practice resulted in unidentified abuse in the facility to Resident 69 and failed to protect other residents from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a resident assessment tool), for one of eight sampled residents (Resident 48) was accurately coded to reflect Resident 48's oral and/or dental status. This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 48's dentures (oral appliances that replace missing teeth) and had the potential to negatively affect Resident 48's care plan and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Preadmission Screening and Resident Review ([PASARR] - a federal 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 I screening by omitting a diagnoses of depression (a mental health condition characterized by loss of interest in activities that interfere with daily functioning) and anxiety (feeling of fear) for one of six sampled residents (Resident 80). This deficient practice had the potential for Resident 80 to not receive the necessary and appropriate care, treatment and services, and increased risk for a decline in the resident's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement the care plan for three of 18 sampled residents (Residents 48, 10, and 242) by failing to: 1. Develop and implement a comprehensive care plan for Resident 48's use of dentures (oral appliances that replace missing teeth). 2. Ensure Resident 10's care plan for seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) was implemented when the facility failed to notify Resident 10's physician of Resident 10's low blood level concentration of Phenobarbital (a medication used to control seizures). 3. Develop and implement a comprehensive, person-centered care plan for Resident 242's oxygen administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for one of eight sampled residents (Residents 86) by failing to keep Resident 86's fingernails clean and neat. This failure had the potential to result in a negative impact on Resident 86's quality of life and self-esteem and had the potential for the development of an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident, with severe, painful bilateral (pertaining to both sides) hand contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) was provided the application of hand splints (used to support and position the hand and wrist to help reduce pain and swelling, and to prevent further contractures) for four to five hours, as ordered by the physician, for one out of six sampled residents (Resident 3). This failure had the potential for Resident 3 to develop worsening pain, experience more frequent episodes of bleeding on Resident 3's inner palm (where his ring finger met the face of his palm), and worsen the condition of Resident 3's bilateral hand contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' environment remains as free of accident hazards as possible for three out of 15 sampled residents (Residents 72, 80, and 3), by failing to: 1. Ensure nursing staff followed the facility's policy and procedure (P&P) on fall prevention for Resident 72 by ensuring a footpath free of obstacles and the call light device was within reach at all times. 2. Ensure the leaking bathroom sink and drainpipe was repaired in Resident 80's bathroom. 3. Certified Nursing Assistant (CNA 3) did not watch television on her personal cellular phone device with earphones in each ear while she fed Resident 3 his meal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to place oxygen signage at the doorway indicating oxygen was in use for one of eight sampled residents (Resident 242) receiving oxygen therapy. This deficient practice had the potential to place all residents' and staff's safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Administer medications as per physician's orders and/or manufacturer specifications for two of eight sampled residents (Resident 50 and Resident 69) by failing to: a. Ensure Resident 50's Aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) chewable tablet was administered as chewable during medication administration. b. Ensure Resident 69's Quetiapine (a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought] and major depressive disorder (depression) with bipolar disorder [sometimes called manic-depressive disorder; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent (%) during medication pass for two of eight sampled residents (Residents 50 and 69) by failing to: a. Ensure Resident 50's Aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) chewable tablet was administered as chewable during medication administration. b. Ensure Resident 69's Quetiapine (a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought] and major depressive disorder (depression) with bipolar disorder [sometimes called manic-depressive disorder; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 80 square feet ([sq. ft.]- a unit of measurement) of room space per resident for 22 rooms out of 40 rooms. This deficient practice had the potential for inadequate space for each resident's privacy and safe nursing care.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician for one out of three sampled residents having a change of condition (Resident 2) by failing to: 1) Ensure the physician was made aware of Resident 2's wandering (aimlessly going from one location to another) behaviors on 12/30/2024, 1/1/2025, and 1/4/2025. 2) Ensure the Interdisciplinary Team (IDT) meeting assessed Resident 2's risk for wandering after resident 2 exhibited a change of condition, as indicated in the facility's Elopement Wandering policy.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse for two out of three sampled residents (Resident 2 and Resident 3) when the facility failed to: 1) Ensure Resident 1 ' s physicians ' order on 12/3/2024 to send out to the General Acute Center Hospital (GACH) for a psychiatric evaluation (the diagnosis, treatment, and prevention of mental health conditions) if Resident 1 displayed any further behaviors of physical aggression was written and carried out. 2) Ensure the physician was notified after Resident 1 displayed episodes of physical aggression on 12/4/2024 and 12/5/2024 with staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was initiated and implemented to address a resident's known wandering behaviors before the resident wandered into Resident 1's room and caused a physical altercation (on 1/23/2025) for one out of three sampled residents (Resident 2).

Inspectors wroteBased on interview and record review, the facility failed to ensure two of ten residents (Resident 6 and Resident 7) were free from physical abuse (intentional bodily injury) when: a. Resident 1 struck Resident 7 in the face unprovoked at Station A's hallway on 1/18/2025. b. Resident 5 slapped Resident 6 on the right side of the face near the vending machines because Resident 6 would not light Resident 5's cigarette on 1/7/2025. As a result of these failures, Resident 7 sustained an acute (severe and sudden in onset) depressed nasal bone fracture (a break in the nasal [relating to or having to do with the nose] bone that pushed the bone inward toward the maxilla [the bones that formed the upper part of the jaw, the roof of the mouth, and parts of the eye socket and nose] usually caused by a direct blow to the nose), and Resident 6 was physically abused by Resident 5.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality of care for seven out of ten residents (Resident 1,2,4,5,7,8, and 9) by failing to: 1. Ensure the facility documented the findings related to a change of condition (COC) that on 1/8/2025 Resident 1 slapped the hat off Resident 2, for Resident 1 on 1/8/2025 and 1/9/2025 3 p.m. -11 p.m. (evening) shifts nor on 1/9/2025 7 a.m. - 3 p.m. (morning) shift. 2. Ensure the facility completed documentation of nursing interventions for resident care on Resident 2's Medication Administration Record (MAR) on 1/1/2025, 1/9/2025, 1/10/2025, and 1/14/2025 evening shifts. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for one of ten residents (Resident 5), who was on one-to-one (1:1, a situation where a dedicated healthcare professional constantly observed and attended to a single resident, maintaining close proximity at all times to ensure their safety and intervene as needed) supervision, slapped Resident 6 on the right side of Resident 6's face on 1/7/2025 near the vending machines because Resident 6 would not light Resident 5's cigarettes. This deficient practice had the potential to negatively affect Resident 6's physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Change in a Resident's Condition, which indicated the facility will notify a resident's physician when there was a significant change (major decline or improvement in the resident's status that could not normally resolve itself without intervention by the staff) in the resident's condition by failing to notify a physician timely, for one of seven sampled residents (Resident 2) when: a. Resident 2 had a change of condition of a decreased oxygen saturation (the percentage [%] of oxygen in a person's blood, normal oxygen saturation level between 95 and 100 %] rate oxygen of 84 %. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise the person-centered care plan (document that helps nurses and other team care members organize aspect of resident care) for one of seven sampled residents (Resident 2), who refused skin check assessments during activities of daily living ([ADLs], activities such as bathing, dressing, and toileting a person performs daily). This failure had the potential to result in the mismanagement of Resident 2 ' s care by not having a guideline to follow for assessing and managing Resident 2 ' s skin integrity.

Inspectors wroteBased on interview and record review, the facility failed to provide ordered wound care treatments on 12/7/2024 and 12/28/2024, for one of seven sampled residents (Resident 2). This failure had the potential to result in the development of an infection and the potential for Resident 2 ' s wounds to worsen.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of accidents and hazards for two of seven sampled residents (Residents 1 and 2) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 reported Resident 1 ' s unwitnessed fall to the licensed nurses. 2. Ensure CNA 1 and CNA 2 followed the facility ' s procedure of not moving Resident 1, who fell, prior to being assessed by a licensed nurse. 3. Ensure Resident 1 did not experience a 2-hour delay in physical assessment, 72-Hour Neurological Check (serious of tests over a 72-hour period to assess for changes in neurological function) initiation, and care. 4. Complete Resident 1 ' s post-fall Fall Risk Evaluation. 5. Correctly complete Resident 2 ' s 72-Hour Neurological Check. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure, one of four sampled residents' (Resident 4), psychiatry note was readily available in resident's physical chart. This deficient practice had the potential to delay communication between the healthcare team involved in Resident 4's care and can affect the treament plan Resident 4 need.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimal Data Set ([MDS]- a resident assessment tool), was coded correctly for one of four sampled residents (Resident 1). This deficient practice resulted in incorrect data transmitted to the Center for Medicare and Medicaid Services (CMS) regarding Resident 1 ' s behavior (how person ' s mental health affects their actions), hallucinations (perceptual experiences in the absence of real external sensory stimuli), and verbal behavioral (e.g., screaming) (yelling) directed toward others.

Inspectors wroteBased on interview and record review, the facility failed to initiate and implement a comprehensive care plan for two of four sampled residents (Resident 1 and 3) by failing to: 1. Initiate a care plan with individualized approaches addressing Resident 1 ' s behavior (how person ' s mental health affects their actions) pacing (walking back and forth) in the hallway. 2. Initiate a care plan to address Resident 1 ' s medication administration and side effects of buspirone (medication to treat anxiety disorder). 3. Initiate a care plan to address Resident 3 ' s Restorative Nurse Aide (RNA) services.

Inspectors wroteBased on interview and record review, the facility failed to revise a behavior care plan one of four sampled residents (Resident 1) to reflect resident ' s behavior (-how person ' s mental health affects their actions) pacing (walking back and forth) in the hallway, verbal, and physical aggressing toward other residents in the facility. This deficient practice resulted to Resident 1 not having an individualized care plan that addresses specific interventions to establish effective behavior management and had the potential to affect the provision of necessary care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with or without limited range of motion (ROM-movement of the joints) receive appropriate treatment and services to increase, prevent, or maintain the ROM mobility (ability to move) for one of four sampled residents (Resident 3), by failing to: a. Implement the facility ' s policy on Resident Mobility and Range of Motion by not providing Restorative Nursing Assistant (RNA) to maintain and /or improve the resident ' s mobility and ROM. b. Ensure RNA services were provided as ordered by the physician for Resident 3. These deficient practices had the potential to place Resident 3 at a decline in physical function and at risk for decline in mobility.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was effective for one of three sampled residents (Resident 1) by failing to re-assess Resident 1 ' s pain after the resident complained of 6-8 pain (pain rating reference: 1-3 mild pain; 4-6 moderate pain; 7-10 severe pain) and licensed nurses ' administration of Oxycodone (a drug used to treat moderate to severe pain). This deficient practice had the potential to result in unresolved pain for Resident 1 and could negatively affect the resident ' s psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to the initiation and administration of lorazepam (an antianxiety medication which is used to treat anxiety [a feeling of fear, dread, and uneasiness]) to one of three sampled residents (Resident 1). This failure resulted in the removal of Resident 1 ' s right to make decisions about the care and treatments she were to receive in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the resident ' s comfort and health) for one of three sampled residents ' (Resident 1) use of lorazepam (an antianxiety medication which is used to treat anxiety[a feeling of fear, dread, and uneasiness]), clonazepam (a medication used to treat anxiety), Paxil (an antidepressant medication which is used to treat depression [a mood disorder that causes a persistent feeling of sadness]), and venlafaxine (a medication used to treat depression). [...]

Inspectors wroteBased on interview and record review, the facility failed to revise the person-centered care plan (document that helps nurses and other team care members organize aspect of resident care) for one of three sampled residents (Resident 1) who was unable to be redirected (a technique used to guide people towards more appropriate behaviors or actions) while having uncontrollable behaviors and was administered lorazepam (an antianxiety medication which is used to treat anxiety[a feeling of fear, dread, and uneasiness]) on 8/24/2024 and 8/30/2024. This failure had the potential to result in the mismanagement of Resident 1 ' s care by not having a guideline to follow after Resident 1 had a change in her behavior.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) ' s drug regiment was free of unnecessary medications by failing to: 1. Document the indication of Resident 1 ' s lorazepam (an antianxiety medication which is used to treat anxiety [a feeling of fear, dread, and uneasiness]) administration on 8/30/2024. 2. Discontinue and reevaluate the need for Resident 1 ' s pro re nata ([PRN], as needed) orders of lorazepam 1 milligram (mg, a unit of measurement) and clonazepam (a medication used to treat anxiety) 0.5 mg after 14 days. This failure had the potential to result in the administration of anti-anxiety medication unnecessarily to Resident 1, which could lead to side effects and adverse consequences.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a resident's refusal to take Clozapine ([antipsychotic] medication to treat mental health conditions) for one of five sampled residents (Resident 2). This deficient practice had the potential to result in Resident 2 experiencing visual hallucinations, and the potential for Resident 2 to engage in physical abuse with Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents have the right to be free from physical, and verbal abuse for three of five sampled residents (Resident 1, 3, and 5), by failing to: 1. Adequately redirect (change direction) Resident 2 to prevent Resident 2 from hitting Resident 1 after Certified Nursing Assistant 2 (CNA 2) observed Resident 2 demonstrate verbal and physical aggressive behaviors toward Resident 1. 2. Administer Clozapine ([antipsychotic] medication to treat mental health condition) as ordered by the physician for Resident 2 ' s visual hallucinations (person seeing images that are not actually there). 3. Protect Resident 5 from Resident 4's physical abuse. 4. Protect Resident 3 from CNA 1's verbal abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the State Survey Agency (Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Public Health), a written report of the findings for the investigation of an allegation of abuse within five (5) working days for an incident of physical abuse for one of five sampled residents (Resident 5). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of accidents and hazards for four of six sampled residents (Residents 1, 3, 5, and 6) by failing to: 1. Ensure a broomstick in the outside patio was inaccessible to Resident 1. 2. Provide one to one ([1:1], close supervision to a resident by staff) monitoring for Resident 5. These deficient practices resulted in Resident 1 striking Resident 3 on the forearm with the broomstick, and Resident 5 striking a staff and Resident 6.

Inspectors wroteBased on interview and record review, the facility failed to file a grievance for one out of five sampled residents (Resident 2). This deficient practice violated the residents' right to have his grievance addressed and followed-up.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure six of six sampled residents ' (Residents 1, 2, 3, 4, 5, and 6) personal property (debit cards) were safeguarded and were protected from potential financial abuse (deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent), by failing to ensure: 1. Implementation of its undated policy and procedures (P&P) titled, Abuse Prevention, Screening and Training Program, which indicated the facility should not condone (allow) any form of resident financial abuse and misappropriation (unlawful use) of resident property and wrongful use of resident ' s money without the resident ' s consent (permission). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of three sampled residents (Resident 2) was free from fiduciary abuse . This failure had the potential to impact the physical and mental well-being of the resident.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Implement its abuse policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating to ensure an allegation of abuse was reported to the California Department of Public Health (CDPH) within two hours, for one of three sampled residents (Resident 2). This deficient practice resulted to the delay in the abuse (monies) investigation by the CDPH and placed Resident 2 and others at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four residents (Resident 2) was free from physical abuse by Resident 1 by failing to: 1. Follow Resident 1 ' s Care plan to address the resident ' s episodes of mood swings, rapid fluctuations of emotion ranging from calmness to anger on 3/4/2024, 3/7/2024, 3/10/2024 and 3/11/2024. 2. Revise and individualize (tailoring to the resident) the Care Plan for Resident 1, who had a history of altercations and aggressive behavior. These deficient practices had to potential to result in Resident 2 sustaining injuries and negatively affecting the resident ' s psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to revise and individualize (tailoring to the resident) the Care Plan for Resident 1, who had a history of altercations and aggressive behavior. This deficient practice resulted in Resident 2 being physically abused by Resident 1 and had the potential to result in Resident 2 sustaining injuries or psychosocial harm.

Inspectors wroteBased on observations, interviews, and record review the facility failed to: 1. Ensure two (2) of two cooks were unable to verbalize the corresponding cutting board color for food items. 2. Ensure two of (2) staff was unable to demonstrate and verbalize proper dishmachine temperature checks. 3. Ensure two (2) of 2 staff were not following the manufacturer's guidelines when checking the concentration of the QUAT sanitizing (a chemical used for disinfection) solution. 4. Ensure one Nursing Supervisor was not able to verbalize the facility Resident's food from home policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. Ensure two (2) freezers and 2 refrigerators had dirt debris on the bottom shelves. b. Ensure pots and pans storage by preparation and trayline (an area where resident's foods are assembled) area had chipped paint. c. Ensure knife storage area did not have dust debris and dirt build up. d. Ensure the bottom shelves used for sheet pans storage were cleaned. e. Remove a dented (hallow or dip in a surface caused by pressure or blow) can in the dry storage area. f. Ensure internal parts of the mixer did not have dust buildup and oil residue. g. Chopping boards were not chipped or cracked. h. Clean the kitchen hood and exhaust. i. Ensure Resident's trays were not chipped, cracked, and stained. j. Ensure staff monitored the time and temperature for thawing of meat. k. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Dispose garbage and refuse properly by not covering the three (3) of 3 overflowing dumpster (a large trash container designed to be emptied into a truck) for two (2) hours. This deficient practice attracted flies to the dumpster area then flies were observed in the kitchen placing 98 of 98 facility residents getting food from the kitchen cross-contamination (a transfer of harmful bacteria from one place to another).

Inspectors wroteDuring an observation, interview, and record review the facility failed to: 1. Provide 80 square feet of room space per resident for 22 rooms out of 40 rooms. This deficient practice could potentially not provide residents privacy and could potentially affect residents health and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate low air mattress settings were set for two out of 33 residents (Resident 31 and Resident 84) by failing to: 1. Ensure air mattress setting was correct for a Resident that weighed 103 pounds (Resident 31) by setting mattress for a person that weighed 210 pounds. 2. Ensure air mattress setting was correct for a Resident that weighed 126 pounds (Resident 84) by setting mattress for a person that weighed 210 pounds. This deficient practice placed Resident 31 and Resident 84 on an air mattress that did not help with ulcer prevention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a tuberculin vial (medication use to detect a certain, active infection in a resident) was discarded in a timely manner. 2. Label and date an open vial of the influenza vaccine. 3. Discard a vial of Resident 99's Lorazepam (an anxiety [feeling of fear, dread, and uneasiness] medication) in a timely manner. 4. prevent employees from putting drinks Gatorades in the medication room refrigerator. 5. Store one unopened bottle of Humulin R (type of insulin that was used to treat high blood sugar) in the refrigerator for Resident 97. 6. Label a bottle of Lantus (type of insulin) was labeled with the open date for Resident 12. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a dignified existence when the facility failed to provide a resident with a clean room that was free of belongings that belonged to the former occupant, space for the resident's belongings, and a bedside table to eat breakfast on for one out of six sampled residents (Resident 297): This failure had the potential to make Resident 297 feel undervalued and exhibit feelings of anger or sadness after eating breakfast without a bed side table and not having adequate space in his room due to the size and amount of the former occupant's belongings that remained in the room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the call light device was within reach for one of 22 sampled residents (Resident 42). This failure had the potential to result in a delay or in the inability for Resident 42 to obtain necessary care and services from the facility staff.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and Responsible Party (RP) of a change in condition for two of eight sampled residents (Residents 78 and 247) by failing to: 1. Inform Resident 247's physician and RP when Resident 247 initially eloped (leaving the facility without notice or permission) from the facility. 2. Accurately inform Resident 247's RP of the details regarding Resident 247's elopement. 3. Inform Resident 78's RP when Resident 78 was found to have a stage three pressure injury (full thickness tissue loss where fatty tissue may be visible, but bone or muscle was not exposed) on his sacrum (area of the lower back and lower part of the spine) and when it progressed to a stage four (full thickness tissue loss with exposed bone, tendon, or muscle). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure residents' valuables were not stored inside the medication cart for one of one sampled resident (Resident 98) and other unidentified residents. This failure had the potential to result in the theft, loss, or bartering (exchanging of goods) of items left in a medication cart.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Inform the Responsible Party (RP) of the facility's bed hold policy and complete a Bed Hold Notification Form for one of three sampled residents (Resident 247) when Resident 247 was transferred to a general acute care hospital (GACH). This failure resulted in Resident 247's Responsible Party (RP) 1 to be unaware of Resident 147's right to return to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered care plan (document helps nurses and other team care members organize aspect of resident care) with measurable objectives, timeframes, and interventions to meet the residents' needs for one resident out of 22 sampled residents (Resident 83) by failing to: 1. Develop an individualized comprehensive care plan for Resident 83's oxygen administration. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 83.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Follow up the provision of a functional and working hearing aids to meet the hearing needs of a resident for one out of three sampled residents (Resident 88). This failure had the potential to make Resident 88 exhibit feelings of anger, frustration, and hopelessness when attempting to engage in meaningful conversations and dialogue with other residents and staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate oxygen administration practices for one out of 22 sampled residents (Resident 83) by failing to: 1. Ensure the humidifier bottle (medical device that increases the humidity in the nostrils while using supplemental oxygen) hooked up to an oxygen concentrator (a device that concentrates the oxygen from a gas supply by selectively removing nitrogen to supply an oxygen-enriched product gas stream) had enough water to prevent nostril dryness. 2. Ensure Resident 83 received oxygen per doctors order of 2 Liters per Minute (LPM). 3. Date Resident 83 nasal cannula (a plastic medical device to provide supplemental oxygen therapy to people who have lower oxygen levels, device goes directly into the nostrils) for oxygen delivery. [...]

Inspectors wroteDuring an observation, interview, and record review the facility failed to follow their policy and procedure (P&P) for medication administration for one of one sampled resident (Resident 22) the facility to: 1. Administer 9:00 a.m., 1:00 p.m., and 5:00 p.m. medications to Resident 22. 2. Document Resident 22's medications that was not administered. 3. Reorder medication on a timely manner and caused Resident 22 to not receive medications. This deficient practice caused Resident 22 to have an interruption with medication therapy and exposed Resident 22 to have a potential adverse effect to medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Implement effective infection prevention measures for one of eight residents (Resident 1) when Resident 1 had a cough and was not immediately tested for Coronavirus Disease 2019 (COVID-19, infectious disease that affects a person's organs and tissues that aid in breathing). This failure had the potential to result in the facility being unaware of Resident 1's COVID-19 status and had the potential to spreading COVID-19 to other resident, family members and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement adequate supervision and monitoring interventions for one of five sampled residents (Resident 2) who was identified with wandering and elopement (to leave unnoticed) risk behaviors. This deficient practice resulted in Resident 2 wandering into Resident 1's and Resident 4's room causing a physical altercation.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was pain free before providing care and ensure Certified Nurse Assistant (CNA 2) reported Resident 1's complaints of pain to the licensed nurse. This deficient practice caused Resident 1 to experience pain during routine peri-care (the cleaning of private parts) and when repositioning in bed.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop a comprehensive person-centered plan of care for one of five sample residents (Resident 1) to address Resident 1 ' s refusal to participate in Restorative Nursing Assistant ([RNA] provides care for residents to maintain or regain daily level of independence and functional ability) exercises as ordered by the physician. This deficient practice had the potential to result a delay or lack of provision of necessary care and services and for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to protect three of three sampled resident ' s (Resident 1, Resident 2, and Resident 3) right to be free from misappropriation of property when Activity Assistant 1 (AA 1) used Resident 1's and Resident 3's electronic benefit transfer card (EBT, an electronic system that allows state welfare departments to issue benefits via a magnetically encoded payment card) to shop and purchase food for Resident 1, Resident 2, Resident 3 and herself. This deficient practiced caused Resident 1 to be upset because of lost funds from the resident's EBT card account and caused Resident 1 to lose trust in staff who were to be watching out for the resident's best interest.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided adequate supervision for one of three sampled residents (Resident 1) while escorting the resident to pick up his personal belongings from his apartment. This deficient practice resulted in Resident 1 eloping (leaving without authorization and supervision) and had the potential to result in an accident and injuries for the resident.

Inspectors wroteBased on interview and record review, the facility failed to maintain accountability for all narcotics (class of medications used to treat pain often having a high potential for abuse) inside the Middle Cart (medication cart used by the charge nurses to dispense medication for the residents) when Registry Charge Nurse (RCN) 2 did not count the narcotics with a second charge nurse. This failure had the potential affect all 93 residents within the facility by potentially exposing the residents to unprescribed narcotics, and staff that may be providing care under the influence of narcotics that may not have been accounted for.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician for one of three sampled residents (Resident 1) when Resident 1 had an unwitnessed fall on the floor on [DATE]. This failure had the potential for Resident 1 to have suffered from undetected injuries to the head (such as a brain bleed) and possible undetected fractures (broken bones) to the upper and lower extremities, followed by a decline in health and even death.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan that addressed an actual fall for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential to result in Resident 1 and Resident 2 sustaining another fall.

Inspectors wroteBased on interview and record review, the facility failed to timely initiate and complete a 72-hour neurological check (assessment tool to identify any changes in a way a person thinks, speaks, and moves) for one of three sample residents (Resident 1) when Resident 1 had an unwitnessed fall. This failure had the potential to result in undetected changes in Resident 1's neurological status.