Sequoia Vista

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Resident Personal Belongings for two of 51 sampled residents (Resident 26 and Resident 41) when Resident 26 and Resident 41's personal belonging were lost. This failure had the potential to negatively affect residents' dignity and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual abuse prevention training was completed for three of nine sampled employees (Certified Nursing Assistant [CNA] 2, Dietary Aide [DA], and Housekeeping/Laundry Supervisor [HLS]). This failure had the potential to result in staff's inability to recognize, report, and respond appropriately to allegations or signs of abuse, placing residents at risk for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of nine registered nurses (RN 2 and Director of Nursing [DON]) received education on use of an intravenous (IV- in the vein) pump (an electronic device that allows the nurse to program the rate and volume of the infusion), prior to the IV pumps being used. This failure had the potential for residents to have a delay in receiving their prescribed medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure competency evaluations were completed upon hire and annually for six of seven sampled employees (Certified Nursing Assistant [CNA] 2, CNA 3, CNA 1, Licensed Vocational Nurse [LVN] 1. LVN 2, and LVN 3). This failure resulted in the facility not being able to ensure staff possessed competency to provide care and services to meet resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store over-the-counter medications (medication that does not require a prescription) in a clean and sanitary area. This failure had the potential for medications to become contaminated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a recipe was followed when preparing a pureed (food blended to a pudding like consistency) diet. This failure had the potential for pureed food to not conserve its nutritive value, flavor, or the proper consistency for a pureed diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and date three open boxes of food items in one of one freezer (Freezer 1) in the kitchen. This failure had the potential for residents to consume expired food.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Binding Arbitration Agreement (BAA - a way to resolve disputes between healthcare providers and residents) for three of three sampled residents (Resident 32, Resident 41, and Resident 80) when admission staff did not provide documentation and explanation in the residents' primary language. This failure had the potential for Resident 32, Resident 41, and Resident 80 to not be aware or fully understand the legal document they signed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: The laundry room had two large plastic containers with colored liquid that were stored on the floor. The laundry room had an uncovered trash bin between two washing machines. Two of four sampled clean linen closets (CLC 2 and CLC 3) had dirty equipment stored and touching clean linen. Two of four sampled staff (Minimum Data Set Coordinator [MDSC] and Treatment Nurse [TN]) entered a contact isolation room (rooms where anyone entering must wear a protective gown and gloves, and wash their hands when entering and exiting the room to prevent the spread of infection) without wearing Personal Protective Equipment (PPE- wearable devices, clothing, or equipment to protect from infections.)The TN did not disinfect the surface before placing wound dressing supplies. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party (RP) for one of 51 sampled residents (Resident 5) when a referral to a specialist (a medical doctor who has training in a specific field of medicine) was made . This failure had the potential for RP not being aware of Resident 5's treatment plan.

Inspectors wroteBased on interview and record review, the facility failed to ensure care conferences were conducted at least quarterly for one of four sampled residents (Resident 6). This failure had the potential for care needs to go unmet.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medication was available to administer for one of four sampled residents (Resident 8). This failure had the potential for Resident 8 to experience symptoms of anxiety (a feeling of worry).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Resident 20) received a diet as ordered by the physician. This failure had the potential to result in choking, difficulty chewing and swallowing, and inadequate nutritional intake.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective antibiotic stewardship program (a coordinated healthcare initiative that ensures antibiotics are prescribed only when necessary and used correctly) for one of five sampled residents (Resident 35). This failure had the potential for Resident 35 to receive inappropriate antibiotics and had the potential for untreated infections.

Inspectors wroteBased on interview and record review, the facility failed to develop a plan of care for the refusal of immunizations (the process by which a person's immune system becomes fortified against an infectious disease through vaccination) for one of five sampled residents (Resident 18). This failure had the potential for staff to be unaware of monitoring the risks for the Resident 18, who did not receive immunizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 51 sampled residents (Resident 7) call light system was functioning properly. This failure had the potential to place Resident 7 at risk for delayed staff response to urgent needs and medical emergencies.

Inspectors wroteBased on interview and record review, the facility failed to verify one of four sampled respiratory therapists (RT 1) were licensed by the state, prior to hiring and performing respiratory care. This failure resulted in RT 1 providing respiratory care to residents without a state license and the potential to put residents at risk for harm.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when one of three sampled residents (Resident 1) was refusing multiple doses of medications. This failure resulted in the physician being unaware of Resident 1's refusals and the potential for Resident 1 to experience adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified when one of three sampled residents (Resident 1) anti-psychotic medication (used to manage psychotic symptoms such as delusions [false belief], hallucinations [perception of something not present], paranoia [irrational and excessive mistrust], and disordered thought [disruption in the ability to organize, process, and articulate thoughts] was not available. This failure had the potential to result in Resident 1 experiencing an adverse reaction and/or an increase in behaviors.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure for Medication Administration to administer medication at the right dosage and address a medication alert (automated notification feature designed to warn clinicians and staff about specific resident, clinical, or safety concerns) for one of three sampled residents (Resident 1) on methotrexate (medication that treats rheumatoid arthritis [RA - a disease that causes pain, stiffness, and swelling in the joints [the spots in your body where two or more bones meet] by decreasing the activity of your immune system [the body's complex, built-in defense network that works to keep germs and foreign substances out, while destroying any that get inside]). [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's order and notify the physician when one of three sampled residents (Resident 1)'s blood sugar was above 250. This failure had the potential for Resident 1 to experience adverse side effects from an elevated blood sugar.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure when annual Performance Evaluations (PE) were not completed for two of six sampled staff (Certified Nursing Assistant [CNA 1, CNA 2]). This failure resulted in overdue performance evaluations. FindingsFindings:a. During a review of the facility's Employee Roster (ER) undated, the ER indicated CNA 1 was hired on 5/1/19. During a concurrent interview and record review on 3/9/26 at 1:04 p.m. with Human Resource/Payroll Manager (HRPM), CNA 1's employee file was reviewed. The last PE was completed 7/17/2024. HRPM stated CNA 1 should have had a PE completed in July of 2025.b. During a review of the facility's ER undated, the ER indicated CNA 2 was hired on 5/1/19. During a concurrent interview and record review on 3/9/26 at 1:06 p.m. with HRPM, CNA 2's employee file was reviewed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported to the abuse coordinator for one of two sampled residents (Resident 1). This failure had the potential for the residents to be at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to monitor and document whereabouts (the place where someone is) every hour according to the care plan (CP) for one of two sampled residents (Resident 1) when Resident 1 was a known high risk for elopement (occurs when a resident leaves the facility without authorization and/or any necessary supervision). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its own policy and procedure (P&P) titled, Resident and Family Grievances, when no investigation was done for one of six sampled residents' (Resident 1) grievance. This failure resulted in no resolution in Resident 1's grievance and violation of Resident 1's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. notify the responsible party (RP) when one of three sampled residents (Resident 1) was involved in a resident-to-resident altercation.2. assess, treat, monitor and notify the physician and the responsible party (RP) when one of three sampled residents (Resident 1) had a cut under his left eye, bruising on his left cheek and scabs to the left side of his nose and under his left eyebrow. These failures resulted in the physician and the RP being unaware of the wounds and the RP being unaware of the resident-to-resident altercation.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was treated with respect and dignity. This failure resulted in Resident 1 feeling intimidated and bullied.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure for one of three sampled residents (Resident 1) when an alleged misappropriation of resident property was not reported to Department of Public Health, Ombudsman, Adult Protective Services and Law Enforcement Officials within 24 hours. This failure resulted in a delay of the investigation.

Inspectors wroteBased on interview and record review, the facility failed to permit one of three sampled residents (Resident 1) to return to the facility after hospitalization. This resulted in Resident 1 having an unnecessary stay in the hospital and violated Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) for one of three sampled residents (Resident 1) when the Inventory of Personal Effects (IPE) was not signed by the resident upon admit. This failure had the potential to result in missing personal effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) choice to stay in room during a routine deep cleaning was respected and followed. This failure resulted in Resident 1 being forced out of her own room, in her bed and into the hallway for approximately one hour and resulted in Resident 1 feeling anxious (feeling of unease), almost in tears and violation of Resident 1's rights.

Inspectors wroteBased on observation, interview, and record, review the facility failed to:Provide an advance written notice of a new roommate assignment for one of six sampled residents (Resident 2). Monitor compatibility (being a good match, getting along well) for one of six sampled residents (Resident 2) when Resident 3 was moved into Resident 2's room. These failures resulted in a resident-to-resident altercation between Resident 2 and Resident 3, Resident 2 unable to sleep and violation in Resident 2's rights.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide written grievance decision for one of six sampled residents (Resident 1). This failure resulted in violation of Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure supervision was provided for one of six sampled residents (Resident 5) with a known behavior of attempting to leave the facility unsupervised. This failure resulted in Resident 5 eloping from the facility without staff knowledge and having the potential for injury.

Inspectors wroteBased on interview, and record review, the facility failed to address one of three sampled residents' (Resident 1) change in condition when Resident 1 had below normal blood pressure (BP-the force of blood pushing against artery walls as your heart pumps) (normal BP is around 120/80 mm Hg {unit of measurement-millimeters of mercury} and low BP is a reading of lower than 90/60 mm Hg). This failure had the potential for Resident 1 experiencing adverse health outcomes.

Inspectors wroteBased on observation and interview, the facility failed to ensure two of three sampled resident's (Resident 1 and Resident 2) were provided nail care. This failure resulted in Resident 1 and Resident 2 having debris under their fingernails and untrimmed fingernails.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted.

Inspectors wroteBased on interview and record review, the facility failed to ensure Performance Evaluation (PE-a process to give employees feedback on their job performance) for three of eight sampled employees (Certified Nursing Assistance [CNA] 54, CNA 88, Terminated [T]CNA) were completed. This failure had the potential for staff not being aware of their need improvement in certain areas, which could affect patient care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was adequate communication to and from the Dietary Manager and RD for proper guidance to ensure food safety when a one of two sampled refrigerator unit (Refrigerator 1) that was not in good working condition remained in use to store TCS foods (Time Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria.) This failure had the potential to result in residents nutritional need not being met in safe manner.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper storage, preparation, and distribution of food was in accordance with professional standards for food service safety when: 1. Kitchen had unsanitary food preparation conditions. 2. Facility only had non pasteurized eggs available for use. 3. Certified Nursing Assistant (CNA) 81 walked an uncovered salad to a resident's room down the hallway. 4. Did not ensure cold food storage refrigerator maintained a minimum temperature of 41 degrees. These failures had the potential for residents in the facility to develop foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 13 and Resident 22) smoking assessment was completed timely. This failure resulted in residents not being assessed for safety while smoking and had a potential for residents to be burned while smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate was five percent or less when five medication errors were observed out of 43 medication administration opportunities, which yielded a medication error rate of 11.63 percent. These failures had the potential for residents to not receive the therapeutic effects of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of eight sampled residents (Resident 82, Resident 79, Resident 238, Resident 239, Resident 241) with indwelling devices (device inserted into the body) had Enhanced Barrier Precautions (infection control intervention designed to reduce transmission of bacteria) in place. This failure had the potential to cause infection and adverse outcomes.

Inspectors wroteBased on interview and record review, the facility failed to have accurate informed consent (IC- process that ensures a person is provided the risks and benefits of treatment) for a psychotropic (medication to treat mental disorders) medication for one of six sampled residents (Resident 49). This failure had the potential for Resident 49 not being aware of the risks and benefits of taking psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote care for one of 44 sampled residents (Resident 10) to maintain dignity and respect. This failure had the potential to affect Resident 10's individuality and psychological needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 44 sampled resident's (Resident 75) choices were being accommodated to get out of bed daily. This failure resulted in Resident 75 not participating in group activities and had a potential to result in psychosocial harm and a reduction in quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Responsible Party (RP) for one of five sampled residents (Resident 22) was notified when Resident 22 had a change of condition and had to be admitted to an acute care hospital setting. This failure resulted in Resident 22's RP being unaware of Resident 22's health status.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Give one of five sampled residents (Resident 192) the Advanced Beneficiary Notice (ABN- a form which gives the resident the choice to continue services under private pay if Medicare does not provide payment) with the appeal contact information. 2. Accurately complete the ABN for one of five sampled residents (Resident 195) when form was left incomplete and Resident 195 signed the form. These failures resulted in Resident 192 and Resident 195 not having the choice to appeal the decision or have knowledge of the costs to continue treatment in the facility.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the annual pre-admission screening assessment and resident review (PASRR-federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting) for two of six sampled residents (Resident 13, Resident 42). This failure had the potential for Resident 13, and Resident 42 to be placed in an inappropriate setting and not receive required services.

Inspectors wroteBased on interview and record review the facility failed to obtain a diet order upon admission to the facility for one of one sampled residents (Resident 22). This failure had the potential to resulted in unmet nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 10) was given the appropriate care and services to improve hearing and communication. This failure resulted in Resident 10 not having her communication needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to document the quantity consumed of a nutrition beverage supplement ordered to address significant weight loss for one of one sampled residents (Resident 22) ensuring the accuracy of nutrition assessments and ability to monitor effectiveness. This failure had the potential to ineffectively evaluate and delay timely revision of nutrition interventions needed to meet residents' nutrition needs.

Inspectors wroteBased on observation, interview, and record review, one of four sampled Licensed Vocational Nurses (LVN 2) failed to: 1. Ensure a controlled medication was not accessible to staff and residents during medication pass. 2. Ensure a controlled medication was properly disposed of. These failures had the potential to result in diversion of a controlled medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the meal tray ticket and/or planned menu for two out of three sampled residents (Resident 62 and Resident 83). This failure had the potential for Resident 62 and Resident 83's nutritional goals not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the therapeutic diet was served in accordance with the diet order for one of three sampled residents (Resident 22). This failure had the potential for Resident 22 to choke.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, FOOD FOR RESIDENTS FROM OUTSIDE SOURCES for one of one resident designated refrigerator (RDR). This failure resulted in undated and unlabeled food and had the potential for food contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff treated one of three sampled residents (Resident 1) with respect when Certified Nursing Assistant (CNA) 1 was using profanity when providing care. This failure resulted in Resident 1 not being treated with respect and had the potential for emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's policy and procedure was followed when employment references were not checked prior to hiring for one of three sampled employees' (Certified Nursing Assistant - CNA 1). This failure had the potential to put residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) responsible party (RP) was notified of Resident 1's redness to bilateral buttocks. This resulted in Resident 1's responsible party not being aware of the resident's redness on bilateral buttocks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with respect and dignity. This failure resulted in Resident 1's rights being violated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure in-service training was provided for one of two sampled Certified Nursing Assistant (CNA 1) before returning back to work when one of two sampled resident (Resident 1) had alleged CNA 1 and CNA 2 of having bad attitude and rushed care . This failure had the potential for CNA 1 to continue providing Resident 1 with a bad attitude and rushing while providing care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified when medication was not administered as ordered for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to experience an adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled resident ' s (Resident 1) ' s personal belongings were not taken by a staff member. This failure resulted in misappropriation of Resident 1 ' s property.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision for one of three sampled residents (Resident 1). This resulted in the staff being unaware Resident 1 had eloped from the facility and was sent to the acute hospital.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for one of three sampled residents (Resident 1) when Resident 1 was receiving wound care. This failure had the potential for staff to be unaware of how to care for Resident 1's wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a TDC (Tunneled Dialysis Catheter- used to remove blood and return blood to the blood stream during dialysis) was monitored for signs and symptoms of infection after it was no longer in use for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to experience complications.

Inspectors wroteBased on interview and record review, the facility failed to follow up on a medical appointment for one of three sampled residents (Resident 1) when Resident 1 no longer required dialysis and was to have a tunneled dialysis catheter (TDC-used to remove blood and return blood to the blood stream during dialysis) removed. This failure resulted in a delay in the removal of the TDC and had the potential to result in Resident 1 acquiring an infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents completed an Advance Directive (AD- legal document which specifies a person's health care related choices and what actions should be taken when the person is no longer able to make decisions for themselves because of illness or incapacity) Acknowledgement (ADA- asks if resident had or did not have an advanced directive) or were given the option to formulate an AD, for 16 of 20 sampled residents (Resident 63, Resident 16, Resident 66, Resident 4, Resident 21, Resident 5, Resident 45, Resident 19, Resident 51, Resident 14, Resident 1, Resident 44, Resident 55, Resident 81, Resident 10, and Resident 11). This failure had the potential for health care decisions to not be honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure a notice of transfer was sent to the Ombudsman (representative who assist residents in long-term care [LTC] facilities with issues related to day-to-day care, health, safety, and personal preferences) for six of six sampled residents (Resident 2, Resident 19, Resident 36, Resident 56, Resident 84 and Resident 91). This failure had the potential to result in residents being discharged inappropriately and for their admission, discharge, and transfer rights to not be honored.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Accurately complete the Minimum Data Set (MDS - comprehensive assessment tool identifying resident specific healthcare needs) assessment for two of two sampled residents (Resident 8 and Resident 61). 2. Ensure Brief Interview for Mental Status (BIMS- assessment to evaluate memory and orientation) assessments for two of two sampled residents (Resident 85 and Resident 91) were accurately completed. These failures had the potential to result in residents' health and mental status to not be appropriately incorporated into their plan of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR or PASSARR- screening potential residents for developmental or intellectual disabilities and/or serious mental illness and determine if a Level II evaluation is necessary to ensure the facility can provide necessary services for the resident) Level 1 Screening was accurately completed or revised as needed for six of 17 sampled residents (Resident 66, Resident 45, Resident 11, Resident 44, Resident 40 and Resident 68). This failure had the potential for residents to be placed in an inappropriate setting and not receive necessary services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Develop a care plan to include safe swallow strategies for one of one sampled residents (Resident 64). 2. Develop a care plan to address the residents preference of keeping his bed in a high position despite being a high risk for falls for one of one sampled residents (Resident 73). These failures had the potential to result in negative health outcomes for vulnerable residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure care conferences (Interdisciplinary meeting to plan resident's care) were conducted at least quarterly for one of six sampled residents (Resident 4). This failure resulted in Resident 4's right to be informed of and participate in his care planning to not be honored and had the potential for care needs to go unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete resident assessments timely and accurately for seven of seven sampled residents (Resident 63, Resident 4, Resident 11, Resident 91, Resident 40, Resident 2 and Resident 73). This failure resulted in residents not being assessed, not being assessed accurately, appropriate care not being provided, and had the potential to result in other changes in residents status which could impact their quality of care to go undetected.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the controlled substance (highly addictive drug or chemical regulated to prevent abuse) count was being completed before and after each shift for two of five sampled medication carts (100 hall medication cart and 200 hall medication cart). This failure had the potential to result in loss or diversion (concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use) of controlled substances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Implement infection control standards for three of four sampled residents (Resident 63, Resident 12, and Resident 195). 2. Follow their infection prevention and control program when: Certified Nursing Assistant (CNA) 11 was observed not performing hand hygiene after coming out of a resident's room and before entering another resident's room, and not performing hand hygiene after removing her gloves. These failures had the potential to place residents, staff, and visitors at risk for the spread of infectious diseases.

Inspectors wroteBased on interview and record review, the facility failed to complete a fall risk assessment quarterly for one of one sampled resident (Resident 73). This failure had the potential to not reflect Resident 73's most recent fall risk status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the needs of one of five sampled dependent residents (Resident 4) were met. This failure resulted in Resident 4's fingernails being long and dirty.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 31), was treated for constipation (difficulty in emptying the bowels, usually associated with hardened stool). This failure resulted in a delay of diagnosis and treatment for Resident 31 and had the potential to result in other complications of bowel obstruction (a partial or complete blockage of the intestine) like perforation (a hole that develops through the wall of a body organ) and peritonitis (when the thin layer of tissue inside the abdomen becomes inflamed, usually infectious, and often life-threatening).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 17) received proper treatment and care for Resident 17's toenails. This failure resulted in Resident 17's toenails to become long and thick.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Foley catheter (A small flexible tube that helps drain urine from the bladder) care in accordance with professional standards of practice for one of one sampled resident (Resident 11). This failure had the potential to result in trauma, infection, and other complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 8) had a timely weight variance committee meeting conducted when Resident 8 had a 6.63% (percentage- parts of a whole) unplanned weight loss. This failure had the potential for Resident 8 to have adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately monitor identified behaviors for one of one sampled resident (Resident 68). This failure had the potential to negatively impact the care provided to meet the behavioral needs of Resident 68.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Dietary Aide (DA) followed the policy and procedure (P&P) titled, Dish Washing when she did not correctly check the dishes for effective sanitization. This failure had the potential for residents to acquire foodborne (resulting from unsafe food practices) illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 13, Resident 63 and Resident 11) planned meal tray ticket (guidance to staff on what to serve for a meal to a resident) was accurate and followed. This failure had the potential to result in a negative health outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure raw turkey, chicken, and pork were stored correctly to prevent cross-contamination. This failure had the potential to cause foodborne (resulting from unsafe food practices) illness to the residents currently residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure wound care was provided for one of three sampled resident (Resident 1). 2. Provide one of three sampled resident (Resident 1) with a Low Air Loss (LAL) mattress (help prevent skin breakdown) as ordered by the physician. These failures had the potential to result in the worsening of Resident 1's wounds.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported timely for one of three sampled residents (Resident 1). This failure had the potential to place all residents at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to re-admit one of two sampled residents (Resident 1) back to the facility when a male bed became available. This failure resulted in violation of Resident 1's rights and unnecessary hospitalization stay for 21 days.