Seal Beach Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure one of five sampled residents' (Resident 5) responsible party was notified prior to the resident receiving grooming services. * Resident 5's responsible party (Family Member 1) was not notified the resident received a hair cut from an unauthorized staff member (CNA 3). This failure resulted in Resident 5 receiving a haircut from an unauthorized staff member without prior notification to the Resident 5's responsible party.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure reasonable accommodation of needs was provided for one of five sampled residents (Resident 3). * Resident 3's call light was not within reach of the resident. This failure had the potential to negatively impact the resident.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure an allegation of resident to resident physical abuse was reported as required to the appropriate agencies for one of five sampled residents (Resident 3). * The facility did not report Resident 3's allegation of Resident 4 telling Resident 3 to shut up, using profanity and hitting Resident 3's hands and feet to the appropriate agencies on 7/4/26. This failure had the potential to negatively impact the well-being of the residents in the facility.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure an allegation of resident to resident physical abuse was investigated as required for one of five sampled residents (Resident 3). * The facility did not investigate Resident 3's allegation of Resident 4 telling Resident 3 to shut up, using profanity and hitting Resident 3's hands and feet after it was reported to the facility on 7/4/26. This failure had the potential to negatively impact the well-being of the residents in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure comfortable home like environment was provided for five of 35 final sampled residents (Residents 22, 50, 79, 93, and 142) and two nonsampled residents (Resident 177 and 204) reviewed for home like environment. * The facility failed to provide an environment with comfortable sound levels for Residents 50, 79, 93, 142, 177, and 204. * The facility failed to ensure Resident 22's room (Room A) was in good repair, when there was a large area of chipped paint and a non-penetrating hole on the wall near Resident 22's bed. These failures had the potential to prevent the residents from resting or sleeping, negatively impact their health and psychosocial wellbeing, and diminish their overall quality of life.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for four of 35 final sampled residents (Residents 5, 96, 116, and 166) and one nonsampled resident (Resident 38). * The facility failed to ensure oxygen was administered to Resident 5 in accordance with the physician's order. * The facility failed to ensure Resident 38's nasal cannula for her portable oxygen and for the oxygen concentrator were both dated and labeled. * The facility failed to ensure Resident 96's oxygen set up was administered and was connected to a humidifier per physician's order. * The facility failed obtain a physician's order or develop a care plan for Resident 116's use of CPAP. * The facility failed to ensure Resident 166's oxygen nasal canula tubing was labeled with a date. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed for 17 residents who received a fortified diet. * The facility failed to ensure one ounce of margarine was added to the lunch meal trays, and whole milk was provided to breakfast meal trays for the residents who were on fortified diets. This failure had the potential to not meet the resident's nutritional needs for the 17 of 173 residents who received a fortified diet.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's medical record was accurate for four of 35 final sampled residents (Residents 16, 59, 93, and 201). * Resident 16's POLST was incomplete and failed to show the resident had an inaccurate date for the resident's current Advance Directive. * Resident 59 and 201's MARs were incomplete. * The facility failed to ensure Resident 93 had signed a COVID-19 vaccine declination. These failures resulted in incomplete and inaccurate medical records, which have the potential to negatively impact continuity of care and clinical decision making.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed for two of two final sampled residents (Residents 7 and 22) and six nonsampled residents (Residents 29, 65, 99, 130, 176, and 202) reviewed for infection control. * The facility failed to ensure the staff performed hand hygiene after administering a GT medication and before administering a Lovenox (blood thinner) injection to Resident 202. * The facility failed to ensure the staff sanitized the inhalers after administering a dose to Resident 7 and before storing it in the medication cart. * The facility failed to ensure Resident 99, who had an active C-diff infection, was properly isolated and not cohorted with Resident 29, who had a history of C-diff. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their antibiotic stewardship program to ensure physician notification for three nonsampled residents (Residents 65, 130, and 176) who received antibiotics for infections that did not meet McGeer's criteria. * The facility failed to notify Resident 65's physician to reassess the need for continued antibiotic therapy after the resident's symptoms failed to meet the criteria for a UTI. * The facility failed to notify Resident 130's physician to reassess the need for continued antibiotic therapy after the resident's symptoms failed to meet the criteria for a UTI. * The facility failed to notify Resident 176's physician to reassess the need for continued antibiotic therapy after the resident's symptoms failed to meet the criteria for a UTI. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs for one of 35 final sampled residents (Resident 8) * The facility failed to ensure Resident 8's call light was within the resident's reach. This failure had the potential to delay care and negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain a copy of an advance directive in the medical record for two of five sampled residents (Residents 50 and 154) reviewed for advance directives. * The facility failed to follow up and obtain a copy of Resident 50 and 154's advance directive, and did not maintain it in the medical record. These failures had the potential to prevent Resident 50 and 154's healthcare and treatment decisions from being honored.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to follow the resident's plan of care and document behavior monitoring for one of two final sampled residents (Resident 79) investigated for behavior and emotional status. * Resident 79's medical record did not show behavior monitoring for the resident's behaviors targets valproic acid (a psychotropic medication used for mood-stabilizing). This failure resulted in a lack of data available for monitoring the resident's behavioral trends, to evaluate the effectiveness of nursing and medical interventions, and the potential to negatively impact the resident's health outcomes and psychosocial well-being.

Inspectors wroteBased on observation, interview, medical record review, and P&P review, the facility failed to develop a comprehensive person-focused care plan for one of 35 final sampled residents (Resident 112). * The facility failed to develop a care plan to address Resident 112's use of positioning pillows (a device used to help prevent bedsores, reduce pain, and improve circulation for elderly individuals). This failure posed the risk of not providing appropriate, consistent, and individualized care to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for one of two final sampled residents (Resident 97) reviewed for pressure injuries. * The facility failed to ensure Resident 97's LAL mattress is not set in static mode while resident in bed. This failure had the potential for Resident 97 to develop pressure injuries or worsening of the existing pressure injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate care and services for the use of the GT for one of one nonsampled resident reviewed for tube feeding. * The facility failed to ensure LVN 1 elevated Resident 202's head of bed (HOB) to 30 degrees or higher during GT feeding and prior to administering the medication through the GT. This failure posed a potential risk for aspiration, which could result in respiratory complications, including aspiration pneumonia.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the vascular access device was maintained consistent with professional standards of practice for two of 35 final sampled residents (Residents 6 and 154). * The facility failed to provide IV heplock dressing changes every seven days and as needed to Resident 6. * The facility failed to change Resident 154's IV fluid bag of normal saline within 24 hours. These failures had the potential to compromise the effectiveness of the IV therapy, and negatively impact the residents' health outcomes.

Inspectors wroteBased on observation, interview, medical record review, and facility record review, the facility failed to ensure the administration of the oxygen was not performed by a CNA for one nonsampled resident (Resident 38). * CNA 2 was observed removing Resident 38's portable oxygen via nasal cannula, and administering oxygen with an oxygen concentrator via nasal cannula. This failure had the potential for the resident to experience a negative outcome due to oxygen being administered by non-licensed nursing staff.

Inspectors wroteBased on observation, interview, medical record review, and the facility's P&P review, the facility failed to ensure the medications were administered as ordered by the physician for three of 35 final sampled residents (Residents 7, 53, and 201). * Resident 201's glipizide (medication to lower blood sugar level), Mobic (nonsteroidal anti-inflammatory drug to relieve pain, swelling, and stiffness), and pantoprazole (medication to reduce excess acid in the stomach) medications were not administered as ordered. * The facility failed to ensure the licensed staff did not cut the divalproex (medication used to treat epilepsy/seizure, prevent migrained headaches, and manage manic episodes in bipolar disorder) sodium delayed release tablets in half, prior to the administration to Resident 7. * The facility failed to ensure full dose of the IV antibiotic was administered to Resident 53. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were safely and securely stored for one of 35 final sampled residents (Resident 187). * A bottle of Medline Remedy antifungal powder was found at Resident 187's bedside. This failure posed the risk of an unauthorized access to the medications and had the potential to lead to medication errors. In addition, the failure had the potential to place the resident at risk for receiving the wrong type of medication.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when the facility failed to ensure the kitchen equipment was maintained and cleaned properly. * Six plastic food bowls had numerous cuts, scratches and permanent staining. This failure had the potential to pose a risk of exposure to food-borne illnesses in a medically vulnerable population of 173 residents who received food prepared in the kitchen.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure education was provided to the staff on safe food handling of outside food. * The facility failed to ensure the staff were aware of the proper temperatures to reheat food brought from outside sources. This failure had the potential to cause foodborne illnesses for the medically vulnerable resident population who consumed food brought from outside sources.

Inspectors wroteBased on observation, interview, and P&P review, the facility failed to ensure the lid of a garbage dumpster bin located outside on the facility grounds was tightly closed. * The green food scraps dumpster bin had an ill-fitting lid with a gap. There was additional refuse, including dirty gloves and food waste, scattered on the ground beneath and around the bin. This failure had the potential to cause unsafe sanitary conditions and potential to harbor pests and rodents.

Inspectors wroteBased on observations, interviews, medical record review, and facility P&P review, the facility failed to ensure the bilateral grab bars attached to the resident's bed was properly installed for one of 35 final sampled residents (Resident 137). * Resident 137's bilateral grab bars were observed to be loosely installed as evidenced by them moving sideways, backward, and forward. Upon inspection by the Maintenance Director, it was determined that both grab bars with screws at the bases were loosely attached to the bed frame. This failure posed the risk for accidental fall and/or entrapment between the grab bar and bedframe and/or mattress, potentially causing serious injury to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure resident equipment was maintained in a clean and sanitary condition for one of 35 final sampled resident (Resident 15). * Resident 15's fan was observed with heavy dust and lint. This failure had the potential to expose the resident to airborne contaminants, increasing the risk of respiratory irritation or infection.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 12 sampled residents (Resident 1) was free from abuse. * Dietary Aide 1 yelled, cursed, and made derogatory comments to Resident 1. This failure negatively impacted Resident 1's emotional wellbeing and posed the risk of Resident 1 suffering physical symptoms from verbal abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary services and interventions to maintain the highest practicable well-being for one of 12 sampled residents (Resident 1). * The facility failed to conduct all of the required nursing assessments and monitoring on Resident 1, following a change of condition involving verbal abuse. This failure posed the risk of changes in Resident 1's emotional and physical well-being not being identified and potentially delayed the necessary care and treatment for the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) received the appropriate care and services to prevent the occurrences of complications with a GT. The facility failed to conduct an assessment and document in the resident's medical record regarding the possible causes of Resident 1's GT being dislodged on multiple occasions. In addition, the facility failed to ensure interventions were updated or modified to prevent further dislodgement of Resident 1's GT. These failures posed the risk of developing complications related to the GT, which had the potential to negatively impact Resident 1's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop an individualized plan of care and implement the care needs to minimize the risk of dislodging the GT for one of three sampled residents (Resident 1) who was at high risk for dislodging the GT. Resident 1 had multiple documented incidents of the GT being dislodged. This failure resulted in not providing appropriate, consistent, and individualized care to Resident 1.

Inspectors wroteBased on observation, interview, facility document and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: - The cool down process for TCS food was not monitored. - Hand washing was not performed by two of three cooks (Cooks 1 and 2). - The food preparation surfaces were not sanitized properly. - The kitchen floor was not in a cleanable condition. - One of two food preparation sinks did not have an air gap. - The kitchen equipment was not kept in clean condition. - The goods in the dry storage were not stored to prevent for possible pest contamination. - Two of four Dietary Aides (Diaetary Aides 2 and 3) wore large false eyelashes during the food preparation. These failures posed the risk for food borne illness in a highly susceptible resident population of 156 facility residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure two of two ice machines were cleaned and maintained as per the manufacturer's guidelines. This failure posed the risk of ice contamination and the equipment to not function in the way it was intended.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 32 final sampled residents (Resident 730) and one nonsampled resident (Resident 780) were thoroughly assessed to self-administer their medications. * The facility failed to assess and develop a care plan problem to address the self-administration of medications when Resident 730 had bottles of refresh liquigel lubricant eye gel (medication use for dry eyes) and refresh tears lubricant eye drops (medication use for dry eyes) at the bedside and self-administered these medications. * Resident 780 was observed to have the miconazole nitrate 2% (an antifungal powder) medication at the bedside cabinet and had self-administered the medication. [...]

Inspectors wroteBased on interview, medical record review, and facility's P&P review, the facility failed to ensure the resident's wishes and instructions for healthcare were followed for two of 13 final residents (Residents 19 and 141) reviewed for the advance directives * The facility failed to follow Resident 141's advance health care directive's designating Family Member 2 as her agent, and the resident's choice not to prolong her life. * The facility failed to maintain a copy of Resident 19's advance healthcare directive in the resident's medical record and readily retrievable. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of 32 final sampled residents (Residents 48 and 171). * The facility failed to develop a care plan to address Resident 48's use of the apixaban (anticoagulant) medication. * The facility failed to develop a care plan to address Resident 171's weight loss of 6.5% in one month. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on interview, medical record review and facility document review, the facility failed to ensure the professional standards of quality were met when the facility diet manual was not followed for diabetic diets. This failure had the potential to adversely affect the quality of life for the 51 residents who received an RCS diet.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 32 final sampled residents (Resident 43) reviewed for ADL care received the adequate personal hygiene care. * The facility failed to provide the nail care for Resident 43 which caused self-inflicted excoriations (scratches on skin). This failure had the potential to not meet the personal care needs of the residents in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of the pressure injuries for one of the six final sampled residents (Resident 163) reviewed for pressure injury as evidenced by: * The facility failed to provide a low air loss mattress for Resident 163 who had an unstageable pressure injury on the sacrum. * The facility failed to ensure the accurate skin assessment of Resident 163's blisters. * The facility failed to follow the physician's order for a wound consult for Resident 163. These failures had the potential for deterioration of Resident 163's pressure injuries as well as the development of new pressure injuries.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure two of 32 final sampled residents (Residents 15 and 20) and one nonsampled resident (Resident 83) were free from the accident hazards. * The facility failed to ensure no resident's belongings were placed on top of Resident 15's overhead light fixture. * The facility failed to ensure no items were placed on top of Residents 20 and 83's overbed light fixtures. These failures had the potential for increased risk of accidents or injuries to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to monitor the new onset of weight loss for one of five final sampled residents (Resident 103) reviewed for nutrition. * The facility failed to monitor Resident 103 after the resident had a significant weight loss of 6.71% for one month. This failure had the potential for not providing the necessary care and services if the resident had a change in condition.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for one of one final sampled resident (Resident 37) reviewed for enteral feeding care. * The facility failed to ensure Resident 37 was positioned safely at 30 to 45 degrees during the enteral feeding via GT. In addition, the facility failed to ensure Resident 37's GT feeding bag was labeled with the date when it was hung. These failures posed the risk for developing complications related to the residents' GT.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for four of four final sampled residents reviewed for respiratory care (Residents 32, 37, 39, and 136) and three nonsampled residents (Residents 24, 55, and 118) reviewed for respiratory care. * The facility failed to ensure a physician's order was obtained and a care plan was developed to address Resident 37's use of oxygen. In addition, the facility failed to obtain a physician's order was obtained to suction the resident. * The facility failed to administer Resident 136 was receiving the correct rate of oxygen as per the physician's order. In addition, the nasal cannula tubing was undated and the set-up bag was dated 3/13/25. * The facility failed to ensure the nebulizer mask was dated and the set-up bag was changed weekly for Resident 32. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the performance evaluations were completed every 12 months for one of two CNAs' employee files (CNA 1) reviewed. This failure had the potential for the staff to not maintain competencies to provide the residents with needed and appropriate care and services.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure dementia (a decline in mental ability severe enough to interfere with daily life) care interventions were being implemented for one of two final sampled residents (Resident 135) reviewed for dementia care. This failure had the potential for Resident 135 to not receive the appropriate treatment and services needed for her dementia.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the proper accounting and safeguarding of the controlled medications to prevent loss, diversion, or accidental exposure. * The facility failed to ensure complete and accurate documentation of the Narcotic Card/Bottle Count Sheets on Medication Cart C for February and March 2025 and Medication Cart D for February and April 2025. This failure had the potential for controlled substance diversion.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 23.07%. Three of three licensed nurses (LVNs 3, 7, and 9) who were observed during medication administration were found to have errors. * LVN 3 failed to ensure an unscored tablet was not cut when administering an oral medication to Resident 25. * LVN 3 failed to administer the correct dosages of medications to Resident 46 as per the physician's orders. LVN 3 failed to ensure the medications were not administered together when administering medications via the GT to Resident 46, and to flush the GT in between the medications. LVN 3 failed to check if Resident 46 had loose stools prior to administering the stool softener medication. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff implemented the proper storage, labeling, and disposal of medications and supplies in a safe manner. * The facility failed to ensure Treatment Cart 1 was free from expired treatment supplies. * The facility failed to ensure Medication Storage room [ROOM NUMBER] was free from staff's personal belongings. Additionally, Mediation Storage room [ROOM NUMBER] had transdermal (application of medication through the skin, usually via a patch) patches stored with the oral medications. * The facility failed to ensure the medication refrigerator in Medication Storage room [ROOM NUMBER] was maintained at the appropriate temperature. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the cooks followed the proper procedure for the preparation of the pureed food. This failure had the risk for an inconsistent pureed product and the potential to not meet the nutritional needs of the 16 residents who received a pureed diet.

Inspectors wrote4. Review of the facility's P&P titled Charting and Documentation dated 7/2017 showed documentation of procedures and treatmnet will include carespecific details, including: a. The dated and time the procedure or treatment was provided b. The name and title of the individuals who provided the care. c. The assessment data and or any unsual findings obtained during procedure or treatment. d. How the resident tolerated the procedure or treatment. e. whether the resident refused the procedure or treatment. f. Notification of family, phsycian or other staff if indicated and g. The signature and title of the individual documenting. Closed medical record review of Resident 54 was initiated on [DATE]. Resident 54 was admitted to the facility on [DATE]. Review of Resident 54's Documentation Survey Report V2 dated [DATE] showed the following entries: [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 163) reviewed for hospice services received the necessary care and services. * The facility failed to ensure the hospice visit calendar and the physician certification of terminal illness were available in Resident 163's medical record. Additionally, the facility failed to ensure the staff knew who the hospice coordinator was. These failures posed the risk of delayed communication and provision of hospice care between the hospice provider and the facility.

Inspectors wrote3. Review of the facility's P&P titled Enhanced Barrier Precautions dated 10/2024 showed the EBPs are used an infection prevention and control intervention to reduce the spread of MDRO to residents. EBPs employ targeted gown and glove us during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity as opposed to before entering the room. Examples of high contact resident care activities requiring the use of the gown and gloves for EBPs include: - Dressing; - Bathing/ showering; - Transferring; - Providing hygiene; - Changing linens; - Changing briefs or assisting with toileting; - Device care or use (central line, urinary catheter, feeding tube, tracheostomy/ ventilator, etc.); and - Wound care (any skin opening requiring a dressing). [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the resident care was provided in a manner to promote dignity and respect for two of 32 final sampled residents (Residents 20 and 59). * The facility failed to ensure the staff sat next to Residents 20 and 59 while assisting the residents to eat. This failure had the potential to negatively impact the resident's feelings of self-worth and well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the resident's personal health information was maintained in a confidential manner for one nonsampled resident (Resident 431). * The facility failed to ensure the laptop displaying Resident 431's personal health information was safeguarded when left unattended. This failure had the potential for unauthorized access to Resident 431's medical record information.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide a safe, clean and homelike environment for three of 32 final sampled residents (Residents 65 and 123). * Resident 65's room (Room B) wall had multiple vertical scratches and chipped paint extending down to the base board, with non-penetrating holes. * Resident 123's room (Room C) wall had chipped wood and paint and multiple scratches extending down to the baseboard, with non-penetrating holes. These failures had the potential to negatively impact the resident's quality of life

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to send a copy of the notice of transfer/discharge to the representative of the Office of the State LTC Ombudsman for one of five final sampled residents (Resident 680) reviewed for discharge and transfer. This failure posed the risk of the LTC Ombudsman not being aware of the circumstances of the resident's transfer/discharge should an appeal be filed or requested by the resident or their representatives regarding the transfer.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident or the resident's representative was provided the written or verbal notice of the facility's bed hold (holding or reserving a resident's bed while the resident in the acute care hospital) policy upon transfer to the acute care hospital for one of five final sampled residents (Resident 680) reviewed for discharge and transfer. This failure had the potential for the resident and the resident's representative to be unaware of their rights to return to the facility following a hospitalization.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate services for one of 32 final sampled residents (Resident 141). * The facility failed to ensure Resident 141 had a functioning call light in order to summon staff for assistance. This failure had the potential for Resident 77 not having her needs known to the staff and may result in not receiving assistance in a timely manner.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe, functional, and sanitary environment in multiple areas throughout the facility was maintained as evidenced by the following: * Black residue was observed along the walls in Shower Rooms B and D. The facility failed to maintain the integrity of the walls and sanitary conditions in Shower Rooms B and D. * The facility failed to maintain the sanitary condition in Shower Room D. The lid of the linen barrel was open, with an overload of soiled linen. An unlabeled portable toilet basin was found on the floor and a diaper was observed on top of a wheeled commode chair. * A shower chair was observed with a brownish stain on the foam seat, appearing to be a fecal matter, in Shower Room C. These failures had the potential for development and proliferation of disease-causing microorganisms.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections for three of five sampled residents (Residents 1, 2, and 3). * The facility staff failed to don PPE prior to entering the residents ' rooms (Rooms A and B) which were on contact isolation. This failure posed the risk for transmission of disease-causing microorganisms.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary care and services to assist the residents in carrying out their activities of daily living and services for personal hygiene for two sampled residents (Residents 7 and 8). * The facility failed to ensure the staff provided the residents' ADL care needs in a timely manner. This failure had the potential to result in poor hygiene, injury, and decreased psychosocial well-beings for the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure ulcers for one of eight sampled residents (Resident 1). * The facility failed to notify Resident 1's RP for changes in Resident 1's skin condition, failed to develop and implement a care plan addressing multiple changes in skin condition for Resident 1, and failed to follow Resident 1's care plan intervention to float heels while in bed. These failures had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure injuries for two of six sampled residents (Residents 2 and 3). * The facility failed to complete the discharge skin assessment for Resident 2's coccyx Stage 2 pressure injury. * The facility failed to ensure Resident 3's low air loss mattress was plugged in for Resident 3 who had an unstageable pressure injury to the sacrum. These failures had the potential for not providing the necessary care and services for Residents 2 and 3.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical information was complete and accurate for one of six sampled residents (Resident 2). This failure had the potential to Resident 2 to receive inadequate care as the clinical information was not available.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the call light was within reach for Resident 5. This failure had the potential for the delayed provision of assistance to Resident 5.

Inspectors wroteThe following reflects the findings of the California Department of Public Health during an ABBREVIATED survey for COMPLAINT Numbers: CA00912961 and CA00913318, and FACILITY REPORTED INCIDENT (FRI) Numbers: CA00915155 and CA00915180. The survey team entered the facility on 8/14/24 at 1252 hours. The facility identified the census as 186. The survey sample size was 3. Inspection was limited to the complaints and FRIs investigated and did not represent the findings of a full inspection of the facility. * FOR COMPLAINT NUMBER: CA00912961, NO DEFICIENCIES WERE IDENTIFIED. * FOR COMPLAINT NUMBER: CA00913318, NO DEFICIENCIES WERE IDENTIFIED. HOWEVER, DURING THE ABBREVIATED SURVEY, ADDITIONAL DECIFIENCIES WERE IDENTIFIED AND CITED AT F584 * FOR FRI NUMBER: CA00915155, NO DEFICIENCIES WERE IDENTIFIED. * FOR FRI NUMBER: CA00915180, NO DEFICIENCIES WERE IDENTIFIED. GLOSSARY OF ABBREVIATIONS: [...]

Inspectors wroteBased on observation and interview, the facility failed to provide reasonable accommodation to meet the needs for one of five sampled residents (Resident 5) and two nonsampled residents (Residents B and E). * The facility failed to ensure the TV remote controls were available for Residents 5, B, and E. This failure had the potential to negatively impact the residents' physical and psychosocial well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to complete the weekly and discharge skin assessmentsfor one of five sampled residents (Resident 1). This failure had the potential for not providing necessary care and services to Resident 1.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was informed of the dosage changes for their psychotropic medications. * The facility failed to ensure Resident 1 was informed of the decrease in dosage of amitriptyline (antidepressant medication) and sertraline (antidepressant medication). * The facility failed to ensure Resident 1's informed consent was obtained prior to administering the increase in dosage of amitriptyline and sertraline. These failures had the potential for Resident 1 not be informed of the medications and their potential side effects.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of two sampled residents (Residents 1 and 2) were invited to the interdisciplinary team behavior management conference. This failure had the potential for the residents to not be able to participate in choosing their treatment options and making decisions in care planning.

Inspectors wroteBased observation and interview, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment. * The licensed nurse placed the personal belongings on top of the treatment cart. * Resident 3's nasal cannula was observed on the floor. These failures had the potential for cross contamination and promote the development of transmission of diseases and infection.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure three of eight sampled residents (Residents 4, 8, and 9) were provided quality care when: * The facility failed to assess Resident 8, notify the physician, and document the change of condition regarding an unwitnessed fall. * The facility failed to ensure complete monitoring of the neurological status was conducted after a fall with head injury for Residents 8 and 9. * The facility failed to notify the physician related to the low oxygen saturation levels for Resident 8. * The facility failed to document and obtain a physician's order for a manual fecal disimpaction for Resident 4. * The facility failed to administer the PRN BM medications as ordered for Resident 4. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of two sampled residents (Resident 9) remained free from accident hazards. * The facility failed to implement the floor mats as per the physician's order and resident's plan of care. This failure had the potential to place the resident at risk for serious injury.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 8) was free from the unnecessary drugs. * The licensed nurses administered midodrine (medication for blood pressure support) outside of the physician's ordered parameters. This failure had the potential for the resident to experience adverse side effects that could affect the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop and implement the plan of care to reflect the individual care needs for one of five sampled residents (Resident 8). * The facility failed to ensure Resident 8 had a plan of care to address use of a CPAP. This failure posed the risk of not providing appropriate, consistent, and individualized care to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the medications was administered as ordered for one of two sampled residents (Resident 1). * Resident 1's sevelamer carbonate (phosphorus binder-medication used to lower phosphorus levels) was not administered as ordered on the hemodialysis days (Tuesdays, Thursdays, and Saturdays). This failure had the potential for the residents' medical needs to go untreated.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the discharge process was properly followed for Resident 1. * Resident 1's medical record failed to show the physician's documentation to show Resident 1 was ready for discharge. This failure had the potential for Resident 1 to unsafely discharge from the facility.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the quality care and services were provided to promote healing of surgical wounds for one of eight sampled residents (Resident 6). * LVN 1 failed to administer the wound treatments as per the physician's orders and did not inform the physician of the unavailable supplies. This failure had the potential to delay healing of Resident 6's surgical wounds.

Inspectors wroteBased on interview, medical record review, and facility P&P, the facility failed to ensure one of eight sampled residents (Resident 5) was free from unnecessary drugs. * The licensed nurse did not clarify the hydrocodone-acetaminophen (a narcotic pain medication) order with the physician and failed to inform the physician of the resident's pain levels of 0, 1, and 2 (on a 0 to 10 pain scale with 0 = no pain and 10 = worst pain) on multiple occasions with the routine administration of hydrocodone-acetaminophen every six hours to reevaluate the pain medication regime. This failure had the potential for the resident to experience adverse effects that could affect the resident's well-being.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was implemented to reflect the individual care needs for one of eight sampled residents (Resident 5). * The facility failed to ensure Resident 5 was checked for incontinent episodes every two hours as per the resident's care plan. This failure had the potential for the resident not being provided with appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the physical well-being was maintained at the highest practicable level for one of two sampled residents (Resident 1). * The facility failed to ensure Xanax (antianxiety medication) was reordered by the physician and available for Resident 1 as needed. This failure posed the risk of Resident 1 not being provided appropriate care and treatment.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify the RP of the room change for one of nine sampled residents (Resident 8) prior to a room change. This failure put Resident 1 at risk of having their rights being violated.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of nine sampled resident (Resident9) attained and maintained their highest practicable physical well-being. * The facility failed to administer Resident 9's medications as per the physician's orders. This failure had the potential of the resident not receiving the appropriate care and services to treat their medical conditions.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the nursing staff provided the care related to the indwelling urinary catheters for one of nine sampled residents (Resident 1) and one of 11 nonsampledresidents (Resident A) * The facility failed to ensure the indwelling urinary catheter care was provided as ordered for Residents 1 and A. This failure had the potential to result in inadequate care and risk for adverse complications for the residents with an indwelling urinary catheter.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were properly stored and labeled. This failure had the potential for the unauthorized staff to have access to the medications and posed the risk for the residents receiving expired medications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department as evidenced by: * The Chef was unable to correctly read the measurement of the ingredients per the recipe during the pureed food preparation observation. * [NAME] 1 was unable to show the correct procedure of the thermometer calibration. * [NAME] 2 was unable to correctly show how to check the freezer temperature. * [NAME] 3 was unable to show how to change the Celsius to Fahrenheit mode in a digital thermometer. * Dietary Aide 1 was unable to correctly state the process for testing the sanitizing solution for the manual washing. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed as evidenced by: * The facility served regular bread rolls instead of garlic bread per the facility's menu spreadsheet. * [NAME] 1 failed to follow the recipe for pureed chicken supreme by placing 5.8 cups of water instead of 5/8 cup per the recipe during the pureed food preparation. * The wrong scoop size was used to serve the stewed tomato with basil for residents on pureed diet. * The wrong scoop size was used to serve paprika noodles for residents on regular diet. * The supersoup (soup with extra nutrients added) was not served to the residents on fortified diet. The facility failed to provide supersoup to Residents 103, 148, and 924. * The facility failed to ensure the spreadsheet was followed for the puree/level 4 diet. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the proper labeling and dating of the foods in the kitchen were utilized once the food item was opened. * The facility failed to ensure the proper labeling and dating of the foods in refrigerator was in placed for the residents' food brought in by visitors. In addition, the facility failed to ensure the food items were discarded after 72 hours. * The facility failed to ensure the expired food items in the kitchen were discarded. A bin containing sugar had a use-by date of 4/26/22, and a bin containing powdered milk had a use-by date of 4/25/23 were seen the kitchen's storage. In addition, the facility failed to ensure the plastic liner for the powdered milk and all-purpose flour were not torn and frayed. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to maintain an accurate infection control surveillance program for the months of May and June 2023. The facility conducted surveillance only on residents who exhibited signs and symptoms of an infection and were prescribed antimicrobial medications. The facility failed to include the residents who exhibited signs and symptoms of infection; however, were not prescribed antimicrobial medications. The facility failed to ensure the Surveillance Data Collection Form was complete and accurate to determine whether the resident's infection met the McGeer's criteria for true infection. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the entrapment assessments were accurate or the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for all 31 residents with side rails. These failures had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain the informed consent from one of 36 final sampled residents (Resident 72) or resident's legal representative for the use of psychotropic medications. This failure posed the risk for Resident 72 or resident's legal representative to not be informed of the benefits and risks of the psychotropic medications and not have the opportunity to decline the proposed treatment.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure four nonsampled residents (Residents 14, 124, 136, and 146) who were assessed to not self-administer the medications had the medications at the bedside. This failure had the potential to negatively impact the residents' physiological well-being and could administer the medications inaccurately.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for six of 36 final sampled residents (Residents 10, 103, 157, and 922) and six nonsampled residents (Residents 3, 52, 112, 119, 161, and 874). * The facility failed to ensure the call lights for Residents 3, 10, 52, 103, 119, 161, and 922 were within the residents' reach. * The facility failed to ensure Residents 112, 157, and 874 were provided with assistance in a timely manner. These failures had the potential to negatively impact the residents' physical and psychosocial well-being or would result in delayed provision of care.

Inspectors wrote3. Medical record review for Resident 103 was initiated on 6/21/23. Resident 103 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 103's H&P examination dated 3/25/23, showed Resident 103 did not have the capacity to understand and make decisions. Review of Resident 103's Advance Healthcare Directive Acknowledgement Form dated 3/23/23, showed Resident 103 had an advance healthcare directive; however, there was no indication whether or not Resident 103's advance directive was requested or available in medical record. Review of Resident 103's Physician Orders for Life-Sustaining Treatment (POLST) undated, failed to show whether Resident 103 had an advance directive or not. On 6/26/23 at 0855 hours, an interview and concurrent medical record review was conducted with the SSD. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the privacy was provided for one of 36 final sampled residents (Resident 723) and two of 34 nonsampled residents (Residents 13 and 1074). * The facility failed to ensure Residents 723 and 1074 were provided a dignity bag for their indwelling urinary catheter (a catheter drains urine from the bladder into a bag outside the body) drainage bag. * The facility failed to ensure visual privacy was provided during the G-tube medication administration for Resident 13. These failures had the potential to violate the resident's right to privacy.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain a clean, sanitary, and homelike environment for the dining room and residents' rooms for two of 37 final sampled residents (Residents 4 and 76) and two of 34 nonsampled residents (Residents 62 and 90) when: * The air vents and surrounding tiles around the air vents in the dining room were observed with blank powdery-like substance. * Resident 4 and Resident 90's room was observed with food particles on the bottom of the window close to the bathroom on bottom wall board and crumbled paper. Resident 4's bed side table and the top of drawer with liquid spills. Resident 4's room floor was sticky. Resident 90 did not feel good when the room or the floor was dirty. * Two dusty electric stand fans were observed inside Resident 76's room. [...]

Inspectors wroteBased on interview, medical records and facility P&P review, the facility failed to ensure one of 36 final sampled residents (Resident 72) had a mental disorder was referred to state PASARR representative for Level II evaluation and determination screening process. This failure pose risk for resident not to receive adequate level of services, comprehensive assessment, intervention and evaluation for conditions related to mental disorder.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for six of 36 final sampled residents (Residents 37, 72, 105, 147, 723, and 922). * The facility failed to develop a comprehensive person-centered care plan to address the use of bilateral grab rails for Resident 723; the use of bilateral floor mats for Residents 70 and 105; Resident 147's change in condition blood in urine and oxygen therapy; Resident 37's order to be up on wheelchair 3 times per week; and Resident 114's use of antibiotic for treatment of infection. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was revised to reflect specific care needs for three of 36 final sampled residents (Residents 70, 72, and 922). * Resident 70's care plan for activity did not reflect Resident 70's activity preference. * Resident 922's care plan did not reflect no longer use of Indwelling urinary drainage catheter (a catheter inserted through the urethra into the bladder to drain urine). * Resident 72's plan of care for care plan problem of pain was not revised to reflect the accurate location of Resident 72's pain. This failure had the potential risk for Resident 72 to receive adequate assessment, intervention, and evaluation of his pain. These failures posed the risk for not providing the residents with individualized and person-centered care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 34 nonsampled residents (Resident 113) was provided with the tools necessary to maintain and improve the resident's communication abilities when a communication board was not available when required by Resident 113 for communication. This failure had the potential to impede the resident in maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide an ongoing in room activity program to meet the needs and interests of two of 36 final sampled residents (Residents 70 and 87). * Resident 87 was assessed to prefer watching television and listening to music. However, Resident 87 was observed in bed with no sensory stimulation. * The facility failed to provide meaningful activities to meet the Resident 70's interests. These failures posed the risk for the residents to feel isolated.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure two of 36 final sampled residents (Residents 99 and 147) and one nonsampled residents (Resident 137) were provided with the necessary services to meet their highest practicable physical, mental, and psychosocial well-being. * The facility failed to ensure the change of condition evaluation was completed for Resident 147 a timely manner. This failure had the potential for Resident 147 to not receive the appropriate care and services in timely manner. * The facility failed to ensure the physician was notified promptly when Resident 99 refused to take medications. This failure had the potential to negatively impact the resident's well-being. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure ulcers (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure ulcer for two of 36 sampled residents (Residents 58 and 125). * The facility failed to ensure Resident 125 was repositioned at least every two hours as per the resident's care plan; and wound treatments were administered as per the physician's order. These failures put Resident 125 at higher risk for developing new pressure ulcers and worsening of the existing pressure ulcer on the sacral area. * The facility failed to ensure LAL mattress setting was consistent with Resident 58's weight. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate care and services related to GT were provided to one of 36 final sampled residents (Resident 105) and one non-sampled resident (Resident 13). * The facility failed to check the GT placement for Resident 13 prior to the administration of the medications through the GT. * The facility failed to ensure Resident 105's enteral formula bottle, fluid bag, and syringe were labeled and dated. * The facility failed to ensure Resident 105's head of bed was elevated during GT feeding to reduce the risk for aspiration. These failures had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, record review, and facility P&P review, the facility failed to provide the necessary respiratory care for three of 36 final sampled residents (Residents 76, 103, and 147) and five nonsampled residents (Residents 27, 44, 77, 172, and 60). * Resident 44 was administered oxygen four liters per minute via nasal cannula, instead of two liters per minute per the physician's order. In addition, the facility failed to ensure the nasal cannula tubing was dated, and the empty humidifier bottle was discarded properly. * Resident 60 was administered oxygen 2.5 liters per minute via nasal cannula, instead of two liters per minute per the physician's order. The facility failed to ensure the nasal cannula tubing was dated. In addition, a suction set-up was observed dated 12/29/22, and there was no physician's order to suction Resident 60. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to offer or provide the adequate and appropriate pain management for two of 36 final sampled residents (Residents 74 and 72). * The facility failed to ensure Resident 74 was administered the pain medication per the physician's order. * The facility failed to ensure Resident 72 received timely assessment and intervention to ease pain to the resident's left upper arm to neck. This pose risk for Resident 72 experiencing pain not managed accordingly consistent with professional standards of practice. These failures had the potential for not effectively managing these residents' pain.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to attain the highest physical wellbeing for two of 36 final sampled residents (Residents 54 and 107) who required dialysis. * The facility failed to ensure the following for Residents 54 and 107: - Complete the dialysis communication record forms which included Residents 54 and 107's pre dialysis assessment (for blood sugars, vital signs, access site, skin integrity, medications sent with resident, or any information for the dialysis center) and post dialysis assessment (for vital signs, access site, skin integrity, and special instructions, recommendations, or information from the dialysis center). - Accurately assess for Residents 54 and 107's dialysis site. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the assessment, physician's order, informed consent, and least restrictive alternative measures were implemented prior to the use of side rails for one of 36 final sampled residents (Resident 723). These failures had the potential to put Resident 723 at risk for serious injury.

Inspectors wroteBased on observation, interview, facility document review and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate reconciliation, administration, and disposal as evidenced by: * The facility failed to ensure the MARs for Residents 13, 80, and 140 were signed by LVN 11 immediately after the medication administration and refusal. These failures posed risks for double-dosing and missed doses of prescribed medications which may compromise resident safety. * The facility failed ensure non-controlled medications were discarded by two licensed nurses and identify method of disposal. This failure had the potential for the inaccurate reconciliation and medication administration error. * The facility failed to ensure the medications prescribed to treat depression (amitriptyline) were administered as per physician orders for Resident 76. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the drug regimens reviewed and any irregularities found were acted upon for two of 36 final sampled residents (Residents 103 and 147). These failures posed the risk of the residents not receiving the necessary care and services or receiving unnecessary medications.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure four of 36 final sampled residents (Residents 21, 147, 155, and 168) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure Resident 168's target behavior for the use of quetiapine fumarate (antipsychotic medication) was monitored accurately. * The facility failed to ensure Resident 21's monthly behavior summary was completed for the use of quetiapine (medication used to treat schizophrenia), and sertraline (medication used to treat depression). [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 48.39%. Two of two licensed nurses (LVNs 1 and 11) were found to have made errors during the medication administration. * The facility failed to ensure Resident 140's calcium tablet 500mg and lubricant eye drops were administered as ordered. * The facility failed to ensure Resident 13's ferrous sulfate oral syrup 300 (60 Fe) mg/5ml 5.4ml and folic acid 1mg as ordered. * The facility failed to ensure Resident 13 was assessed for loose stools as ordered prior to the administration of Miralax * The facility failed to ensure Resident 137's Aspirin chewable (medication to prevent a stroke) was administered as ordered. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to ensure proper storage, labeling, and disposal of medications. This failure had the potential for unauthorized residents and staff to have access to the medications; and posed the risk for the residents receiving expired medications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medical records for two of 36 final sampled residents (Residents 41 and 72) were complete and accurately documented as evidenced by: * Resident 41's Controlled Drug Record and Emergency Kit Pharmacy Log failed to show documentation on 6/17 and 6/19/23 at 1700 hours, for a scheduled pain medication that was administered to the resident. * The facility failed to ensure Resident 72's medical record had the completed POLST Form of the resident on file. These failures had the potential for the residents' care needs not being met as the clinical information was not complete.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to inform the physician of the residents who had not met the McGeer's Criteria and were prescribed antibiotics for two of 36 final sampled residents (Residents 43 and 160) and one of 34 nonsampled residents (Resident 11). This posed the risk for the continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics, and the development of antibiotic resistant bacteria.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment used to prepare, serve, and store food in the facility. * The facility failed to ensure Freezer #4 was functioning properly to maintain the required temperature of 0 degrees F or lower. * The facility failed to ensure the thermometers were calibrated weekly per the facility's P&P. These failures had the potential for equipment not functioning in the way they were intended and in turn cause contamination of food, leading to food-borne illnesses for the residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate services for one nonsampled resident (Resident 77). * The facility failed to ensure Resident 77 had a functioning call light in order to summon staff for assistance. This failure had the potential for Resident 77 not having his needs known to the staff and may result in not receiving assistance in a timely manner.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain an effective pest control program to prevent the presence of small flies in the kitchen. This failure had the potential to lead to food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites or toxins) in the facility residents who eat food prepared in the kitchen.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide one of 23 nonsampled residents (Resident 725) with the Notice of Medicare Non-coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055. The NOMNC and SNF ABN Forms were used to inform the residents of their potential financial liability and appeal rights and protections should they wish to receive care and services that may not be covered by Medicare. This had the potential of not allowing Resident 725 to make an informed decision regarding their Medicare services.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to dispose and store trash in a sanitary manner. * The trash bins inside the kitchen were observed to be left open. In addition, empty boxes were observed on top of the trash bins and the cooler. * The four out of six dumpsters were overflowing with garbage which prevented for the lids to be fully closed These failures posed the risk for the development of odors, attract and harborage or breeding place of insects and rodents, and a possible source of contamination of food, equipment, and utensils.