Santa Fe Lodge

Inspectors wroteBased on interview and record review, the facility failed to develop a specific and individualized care plan (CP) for one of two (Resident 1) sampled resident that addressed Resident 1's wandering, into other resident rooms, behavior. This deficient practice had the potential to result in unmet individualized needs for Resident 1 and the potential to affect Resident 1's physical and psychosocial well-being. Cross Reference F689Findings:During a review of Resident 1's Facesheet (FS, admission record), the FS indicated the facility admitted Resident 1 on 4/28/2026 with diagnoses that included dementia (a progressive state of decline in mental abilities), encephalopathy (broad term for any disease, damage, or malfunction of the brain). During a review of Resident 1's CP, initiated 5/1/2026, the CP indicated Resident 1 was at risk for purposeless wandering and potential for self-injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision for one of two sampled residents (Resident 1), who had a history of wandering (walking aimlessly with no specific direction) into other resident rooms. This deficient practice resulted in Resident 1 wandering into Resident 2's room on 6/13/2026 and Resident 1 getting close to Resident 2 leading to Resident 2 scratching Resident 1's left upper lip. Cross Reference F656Findings:During a review of Resident 1's Facesheet (FS, admission record), the FS indicated the facility admitted Resident 1 on 4/28/2026 with diagnoses that included dementia (a progressive state of decline in mental abilities), encephalopathy (broad term for any disease, damage, or malfunction of the brain). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents and/or the residents' responsible parties (RP) were informed in advance, of the risk and benefits of psychotropic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) for two of five sampled residents (Residents 7 an 8) when:1. Resident 7's Quetiapine (Seroquel) was restarted on 3/26/2026 without an informed consent (IC-a form indicating a resident or responsible party voluntarily agree to a medical treatment or procedure after understanding the risks, benefits, and alternatives) after the Quetiapine was discontinued on 10/3/2025.2. [...]

Inspectors wroteBased on interview and record review the facility failed to follow the facility's policy and procedure (P&P) for psychotropic medications titled, Psychotherapeutic Medications, undated for two of two residents (Residents 1 and 7) by: A. failing to monitor for side effects of Resident 1's mirtazapine (medication used to treat depression.)B. failing to have adequate indication for the use Seroquel for Resident 7 (Quetiapine -Quetiapine is FDA approved for schizophrenia [mental disorder characterized by abnormal social behavior and failure to understand what is real], acute manic episodes [ A manic episode is a stretch of time when you have one or more symptoms of mania. An episode typically lasts for a week or longer, unless treatment cuts it short] and monitor a specific behavior for it's use. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to reduce the potential for accidents and/or hazards for two of two residents (Residents 23 and 34) by failing to ensure:1. Resident 23's bed-exit alarm (designed to inform staff by letting them know when a person is attempting to leave the bed, has gotten out of bed. Whether directly attached to the resident as a garment clip or position change alarm, or part of the bed itself [e.g., pressure-sensitive mats, bedside infrared beam detectors, or in-bed pressure sensors] was kept in a place where the alarm could easily be heard by staff and was not muffled. 2. A spray bottle of bleach was not left unattended at Resident 34's bedside table. These deficient practices resulted in Resident 23's fall on 5/5/2026 and had the potential to cause harm to Resident 34.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 13) received the right amount of water flush and enteral feeding via gastrostomy feeding tube (G-tube - a device used for providing nutrition directly to the stomach) as ordered by the physician. These deficient practices had the potential for Resident 13 to experience further weight loss and dehydration.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 10 sampled residents (Resident 4 and Resident 7) were free from unnecessary medications:1. For Resident 4, the resident did not meet the Mc Geer's criteria (a criteria used to define true infections by providing surveillance criteria the Infection Preventionist (IP) is required to report for definitive case events (i.e., diagnosed infections) and to estimate the actual incidence/prevalence of disease conditions) for the use of Levaquin on 3/19/2026 and ciprofloxacin on 4/22/2026 for true infections. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices at one of one nurse's station when the residents' (in general) food from home refrigerator was observed with debris and dried liquid on the shelves for two consecutive days. This failure had the potential to result in pests and cross-contamination (transfer of harmful bacteria from one place to another) placing residents (in general) at risk and significantly impacting the residents' health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's antibiotic stewardship program (a coordinated healthcare initiative designed to promote the most appropriate, safe, and effective use of antibiotics [medication that kills or stops bacteria from reproducing]) for one of three sampled residents (Resident 4) by failing to,A. Ensure Mc Geer's criteria (a standardized, evidence-based definitions used to identify and track infections in long-term care facilities, allows healthcare workers to accurately count and monitor infections) for infection surveillance was met for Resident 4 for the use of the Levaquin (antibiotic used to treat serious bacterial infections). B. [...]

Inspectors wroteBased on interview and record review the facility failed to provide discharge notification documentation for one of one sampled resident (Resident 49) as indicated in the facility's Policy and Procedure (P&P) titled, Transfer or Discharge Notice, when Resident 49's Notice of proposed transfer and discharge (a document a nursing facility must give a resident and/or their representative before the resident is moved out of the facility, explaining why the resident is being discharged , where they are going, the effective date, their right to appeal, and how to contact the State Long Term Care Ombudsman [an advocate who helps protect the rights, safety, and well-being of residents in nursing homes and other long-term care facilities]) was not given to the Ombudsman following Resident 49's discharge on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident's (Resident 1) diagnosis of depression was accurately reflected in the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/14/2026. This deficient practice resulted in inaccurate Medical Record for Resident 1 and had the potential for Resident 1 to have unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a liquified diet was served as ordered by the physician for one of one sampled resident (Resident 3) who had a history of dysphagia (difficulty swallowing). The deficient practice had the potential to result in complications like aspiration pneumonia (lung infection [the invasion and growth of germs in the body] caused by inhaling foreign substances like food into the airways rather than swallowing them), choking, and a physical decline to Resident 3.

Inspectors wroteBased on interview and record review, the facility failed ensure three of six sampled staff (Certified Nursing Assistant [CNA] 1, CNA 2, and Licensed Vocational Nurse [LVN] 1) understood the facility's Policies and Procedures (P&P) on abuse reporting when:1. CNA 1, CNA 2, and LVN 1 did not know who the facility's Abuse Coordinator (a designated staff member responsible for managing and addressing issues related to abuse or neglect within the facility) was.2. CNA 1, CNA 2, and LVN 1 did not know that allegations of abuse must be reported to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement within 2 hours. This failure had the potential for residents (in general) to be subjected to abuse while residing at the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) and to the local law enforcement, within two hours, in accordance with the facility's policy and procedure (P&P), titled Abuse Prevention and Prohibition Program, revised 11/28/2022. This failure resulted in a delay in notification to the Department, the Ombudsman, and local law enforcement, and had the potential for Resident 1 to be subjected to abuse while at the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow through (follow up) on one of four sampled resident's (Resident 1), who was at risk for falls, fall that occurred on 1/9/2026, in accordance with the facility's policy and procedure (P&P) titled, Change of Condition. The facility failed to assess Resident 1 after the fall, report the fall to Resident 1's physician (Medical Doctor [MD] 1), and complete a change in condition (COC, an alteration in a resident's physical health that differs from their previous baseline) for Resident 1. This deficient practice had the potential to result in Resident 1 not receiving the necessary care and services affecting Resident 1's physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure informed consents were obtained for one of one sampled resident (Resident 94) as indicated in the facility's policy and procedure (P&P), titled, Informed Consent and Alarm Monitor, by failing to: a. Ensure an informed consent was completed prior to the use of the bed/wheelchair alarms (a safety device, often a sensor pad or clip, that alerts caregivers when a patient attempts to leave their bed or chair, helping to prevent falls and injuries) b. Ensure informed consents were completed prior to the use of Lexapro (anti-depressant, medication used to treat depression [serious illness that negatively affects how one feels, thinks and acts]) and Remeron (medication used to treat depression). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and ensure Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) were kept in 3 of 5 sampled resident's (Residents 14, 145, 38) medical records. This failure had the potential to cause confusion among the healthcare providers in the event Residents 14, 145 and 38 required immediate medical care and/treatment and had the potential for the residents to receive inadequate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment.

Inspectors wroteBased on interview and record review, the facility failed to obtain weekly weights for three of three sampled residents (Resident 34, 28, and 145) as indicated in the facility's policy and procedure (P&P) titled, Weight Change, as evidenced by: A. Resident 34's weight was not taken upon readmission to the facility on 3/14/2025 and not taken on 3/18/2025 per the physician order. B. Resident 28 weight was not taken weekly as ordered by the physician. C. Resident 145's weight was not taken on 3/18/2025 as per the physician's order. This deficient practice had the potential to result in physical declines to Residents 34, 28, and 145 due to untreated weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure proper food storage, in one of one kitchen walk-in refrigerator (Refrigerator 1), consistent with the facility's policy and procedure (P&P), titled, Refrigerator/Freezer Storage, by failing to: a. Ensure a transparent container with sliced cheese was labeled with an open date (date to indicate when it was opened). b. Ensure a halfway-filled pickle jar was labeled with an open date. c. Ensure two unopened plastics of whipping cream were labeled with a received date. These failures had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) to the residents consuming the facility's food.

Inspectors wroteBased on interview and record review, the facility failed to ensure its binding arbitration agreements (AA, a contractual promise where parties agree to resolve disputes through arbitration instead of litigation) included a selection that allowed the residents or their responsible parties/resident representatives to communicate with federal, state, or local officials for two of two sampled residents (Residents 34 and 38). This failure had the potential to violate Resident 34 and Resident 38's rights and result in unjust arbitration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection (the invasion and growth of germs in the body) prevention and control practices for 6 of 6 sampled residents (Residents 14, 16, 38, 40, 18 and 34) by failing to ensure: a. personal toiletries and resident care items were labeled and not stored inside the [NAME] and [NAME] restroom (a restroom that has two doors and is sandwiched between two bedrooms and is accessible by both bedrooms) of Residents 14, 16, 38 and 40. b. communal drinks were not accessible for Resident 18 to pour water by himself. c. the lint traps for 2 of 3 sampled dryers (Dryer 1 and Dryer 2) were kept clean and did not have a heavy thick accumulation of lint. d. Resident 34's bed sheets were clean from smeared stool. e. Proper storage/disposal of a used cup set on top of the handrail outside of room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 145) was treated with dignity by failing to provide privacy and failing to cover Resident 145's right flank (the area on the side of the body between the ribs and the hip) while Resident 145 was in the shower chair. This deficient practice resulted in exposure of Resident 145's right flank to Resident 145's right thigh and had the potential to result in a psychosocial decline to Resident 145.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 14) call light (a device used by a resident to signal the need for assistance) was within reach. This failure had the potential to result in Resident 14's needs to not be met in a timely manner and/or the potential for Resident 14 to experience harm if Resident 14 was unable to alert staff during an emergency.

Inspectors wroteBased on interview and record review, the facility failed to complete an assessment after a significant change in condition for one of one sampled resident (Resident 41) to include a bipolar disorder (mental health condition that causes clear shifts in a person's mood, energy, activity levels, and concentration) diagnosis as indicated in Resident 41's physician order for Depakote (medication used to treat certain psychiatric conditions such as bipolar disorder). This deficient practice had the potential to result in unmet needs for Resident 41.

Inspectors wroteBased on interview and record review, the facility failed to complete an evaluation for Level II Pre-admission Screening and Resident Review (PASARR, a federal assessment requirement to help ensure individuals who have mental disorders or intellectual disabilities are placed in facilities that can provide the appropriate care) for one of one sampled resident (Residents 43). This failure had the potential to result in unmet individualized services to Resident 43.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan related to bipolar disorder (mental health condition that causes clear shifts in a person's mood, energy, activity levels, and concentration) for one of one sampled resident (Resident 41). This deficient practice had the potential to result in Residents 41 not to receive the necessary care and services according to Resident 41's specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 20 out of 23 resident rooms (Rooms 1, 2, 3, 4, 5, 6,7, 8, 9, 10, 11, 12 ,16, 17, 18, 19, 20, 21, 22, and 24) met the minimum requirement of 80 square feet (sq. ft. - unit of measure) per resident in bedrooms with more than one resident. This deficient practice had the potential to result in the residents not to have enough room or inability to move freely throughout their rooms and limit the space for facility staff to provide necessary services and treatments.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) who was at risk for elopement (when a resident leaves the facility without authorization) was monitored in the hallway and re-directed away from the exit door as indicated in the facility's policy and procedure (P&P) titled, Safety of Residents. Resident 1 eloped from the facility on 10/19/2024 without being noticed by staff and was not found until 10/21/2024. Resident 1 sustained a skin abrasion (scrape) above the left elbow. This deficient practice had the potential to result in serious bodily injury and physical decline to Resident 1 during the time Resident 1 was absent from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's temperature was in an acceptable range as indicated, in the facility's policy and procedure (P&P), titled, Homelike Environment, for six resident's rooms, one dining room, and one hallway out of 23 resident's rooms, two dining rooms, and two hallways. This deficient practice had the potential to place the residents, visitors, and staff members at risk for serious illness, harm, and/or death.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive person-centered care plans for two of two sampled residents (Residents 15 and 11) when: a. For Resident 15, The facility failed to develop a care plan that included interventions to address Resident 15's urinary incontinence (loss of bladder control). b. For Resident 11, the facility failed to develop a care plan that included goals and interventions to address Resident 11's rash located on Resident 11's left and right buttocks. This failure had the potential to result in unmet individualized needs for Residents 15 and 11 and the potential to affect the resident's physical and psychosocial well-being. (Cross reference F690 and F580)

Inspectors wroteBased on interview and record review, the facility failed to review and revise comprehensive care plans for two of two sampled residents (Residents 41 and 18) by failing to: a. For resident 41, the facility failed to review the comprehensive care plan for falls, as indicated in the facility's policy and procedure (P&P), titled, Initial Fall Risk Assessment. b. For Resident 18, the facility failed to ensure bilateral knee extension splints (B knee splints, material used to extend or straighten the knees as much as possible) and left ankle pressure-relieving ankle foot orthosis (L PRAFO, device to maintain foot/ankle stability while in bed) care plans (CPs) for Resident 18, who had range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility limitations, were in accordance with the physician's orders. [...]

Inspectors wroteBased on interviews and record review, the facility failed to follow its policy and procedures (P&P) regarding the role of the interdisciplinary team (IDT, staff with varied clinical backgrounds-including nursing staff and resident's physician-that combine experience and knowledge when evaluating the resident's strengths, needs, and preferences to attain the best quality of care and life for the resident), for one of 13 sampled residents (Resident 1), who lacked the capacity to make healthcare decisions by failing to: Ensure the IDT consisted of Resident 1's attending physician (MD), registered nurse (RN) responsible for the resident, responsible party (RP), and other appropriate staff in accordance with the facility's P&P. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one sampled resident's (Resident 11) physician was notified of the development of a rash on Resident 11's left and right buttocks. This deficient practice had the potential to result in a delay in treatment and/or services and could result in a physical decline to Resident 11.

Inspectors wroteBased on interview and record review, the facility failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, notice of liability) and Notice of Medicare Non-Coverage (NOMNC) letters/forms to one of one sampled resident (Resident 196) three days prior to Resident 196's last day covered as indicated in the facility's policy and procedure (P&P), titled, Understanding Medicare Denial Letters,. This deficient practice had the potential to result with Resident 196 to not be aware of possible charges for services rendered that were not covered after the last Medicare coverage day.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive assessment of the functional limitation in range of motion (ROM, full movement potential of a joint [where two bones meet]) of one of two sampled residents (Resident 18) with mobility and ROM limitations, was complete and accurate. This failure had the potential to lead to Resident 18's worsened contractures and increased risks for pain and skin breakdown related to incorrect treatments and plan of care.

Inspectors wroteBased on observation, interviews, and record review, the facility staff failed to administer Simbrinza 1% - 2% (brinzolamide/brimonidine tartrate, eye drops to treat glaucoma [progressive eye disease causing vision loss and blindness due to the damage to the optic nerve]), in accordance with the professional standards of practice to one of one sampled resident (Resident 7), who was selected for medication administration observation. This failure had the potential to result in worsened vision to Resident 7 due to decreased medication efficacy (ability of the medication to produce the maximal desired effect) due to the systemic absorption of the eye drops and/or subtherapeutic dose (concentration of a drug lower than what is usually prescribed to treat a disease effectively).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 9) was provided a communication tool or resources to effectively communicate Resident 9's needs when Resident 9 spoke Cantonese (a Chinese dialect). This deficient practice had the potential to result in Resident 9's needs not effectively conveyed to facility staff which could lead to a decline in Resident 9's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 18) with limited mobility or range of motion (ROM, full movement potential of a joint [where two bones meet]) by failing to: A. Ensure an accurate assessment of Resident 18's ROM on both upper extremities (BUEs) on 10/20/2023. B. Properly assess Resident 18's tolerance to the right elbow extension splint (R elbow splint, material used to extend or straighten the elbow as much as possible) after the resident readmitted to the facilltiy on 10/19/2023. C. [...]

Inspectors wroteBased on interview and record review, the facility's interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) failed to accurately assess a resident's fall risk and reassess fall prevention interventions quarterly for one of one sampled resident (Resident 41) who was at high risk of falling, as indicated in the facility's policies and procedures (P&P). These failures had the potential to result in harm and Resident 41 to sustain injury and/or harm due to falls. (Cross reference F657)

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate treatment to restore continence, to the extent possible, by failing to implement a prompted toileting program (caregiver prompts the resident to use the toilet) for one of one sampled resident (Resident 15). This failure had the potential to result in incontinence and urinary tract infections (UTIs, an infection in any part of the urinary system [system of organs that makes urine]) to Resident 15.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy consultant recommendations were followed for one of one sampled resident (Resident 9). The facility did not act upon recommendations to include ferritin/iron panel (a lab test that determines if the body has enough iron in the cells) in Resident 9's routine labs. This deficient practice had the potential to result in a physical decline to Resident 9.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Lithium (medication used to treat mood disorders) level (blood drawn to check the Lithium level in the blood and determine if the level is within the therapeutic range [quantitative measurement of the relative safety of a drug], subtherapeutic [concentration of a drug lower than what is usually prescribed to treat a disease effectively], or indicating Lithium toxicity[an adverse drug reaction due to increased drug concentration in the blood]) for one of one sampled resident (Resident 6) was obtained as ordered by the physician. This failure had the potential to cause lithium toxicity, worsened behavioral symptoms due to not enough drug in the blood, and a decline in Resident 6's physical and psychological well-being due to a delay in services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date one opened bag of egg noodles and two open bags of chips in one of one food storage rooms (Food Storage room [ROOM NUMBER]), according to the facility's policy and procedure (P&P) titled, Labeling: Food. This failure had the potential to result in residents to experience food-borne illnesses (illnesses caused by contaminated food).

Inspectors wroteBased on interviews and record review, the facility failed to ensure the medical records for one of one sampled resident (Resident 6) were complete and accurate. This deficient practice had the potential to lead to inconsistent and/or inaccurate treatments provided.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the signed binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by an arbitrator [third party decision-maker] instead of a judge or jury in court) for two of two sampled residents (Residents 40 and 18) provided for following: A. For Resident 40, the signed BAA failed to provide for the selection of a convenient venue (location to carry out arbitration proceedings agreed upon and suitable to both parties) and a neutral arbitrator (impartial or unbiased third-party decision maker, contracted with, and agreed to by both parties to resolve their dispute). B. For Resident 18, the signed BAA failed to provide for the selection of a convenient venue and a neutral arbitrator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and implement its Infection Control Program to prevent the transmission of disease and infection for one of two sampled resident (Resident 41) when CNA 2 failed to wear personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while CNA 2 provided care to Resident 41 in accordance with the facility's policy and procedure (P&P). This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria and viruses [organisms that cause disease] from one surface to another) and the spread of infection to Resident 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal the need for assistance) system was within reach for one of one sampled resident (Resident 41) as indicated in the facility's policy and procedure (P&P) titled, Call Lights. This failure had the potential to result in unmet needs for Resident 41 or the potential to result in Resident 41 to experience harm if Resident 41 was unable to alert staff during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' bedrooms measured at least 80 square feet (sq. ft., a unit of measurement) per resident in multiple resident bedrooms for 20 of 23 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12,16, 17, 18, 19, 20, 21, 22, and 24). Nineteen resident rooms: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12,16, 17, 18, 19, 20, 21, and 22 had two beds inside each room and one resident room: 24, had four beds inside the room. This deficient practice had the potential to result in the residents not to have enough room or move freely throughout their rooms and limit the space for facility staff to provide services and treatments for the residents residing in the rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 10 sampled residents (Residents 1, 2, and 3) were free from involuntary seclusion (separation of a resident from other residents or from her/his room or confinement to her/his room with or without roommates against the resident's will, or the will of the resident representative) by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 did not use two utility/linen carts (material handling cart used for bedding, linens, and other supplies) to block the entrance/exit (only one entrance and exit) to Resident 1, 2, and 3's Room (RM 1) after CNA 1 witnessed Resident 1 spilling liquid on the floor. As a result, CNA 1 violated Resident 1, 2 and 3's rights and prohibited (not allowed) Residents 1, 2, and 3 from leaving RM [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement the care plan (CP) for one of 10 sampled residents (Resident 1) when Resident 1 was walking around the facility, spilling liquid on the floor. This failure resulted in Certified Nurse Assistant (CNA) 1 barricading (improvised barrier erected to prevent or delay of movement of residents getting through) Residents 1 ' s doorway with two utility/linen carts (material handling cart used for bedding, linens, and other supplies) to block the entrance/exit (only one trance and exit). This deficient practice had the potential for Residents 1 to experience further incidents of involuntary seclusion that could lead to psychosocial (mental, emotional, social, and spiritual effects) harm, serious injury, serious harm, serious impairment, or death. (Cross reference F603)