Sharon Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) who required assistance with activities of daily living (ALDs) received timely incontinence care. This deficient practice increased Resident 2 at risk for compromised skin integrity, discomfort, and avoidable decline in quality of care. During a review of Resident 2's admission record dated 7/17/2026, the admission record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses that included stroke (a condition happens when the brain suddenly can't get enough blood, a stroke will cause a person to have trouble speaking, one side of the face drooping, weakness in an arm or leg), seizure (a condition when the brain suddenly sends out a burst of fast, mixed up electrical signals. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate and complete documentation in the medical record for one of four sampled residents (Resident 1), by failing to ensure:There was a detailed cardiopulmonary resuscitation (CPR an emergency action used when a person's heart stops beating or they stop breathing) documentation, which included the date and time the CPR was performed and by whom;Documentation of the Emergency Medical Services (EMS, encompasses the system of professionals like paramedics, ambulances, and dispatchers that respond to 911 calls and provide urgent pre-hospital medical care and transport) arrive timeThe attending physician's progress notes regarding the cause of death. Include the name and title of the individual pronouncing the resident dead. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide dental visits per regulations for one of three sampled residents (Resident 2). This deficient practice resulted in Resident 2 experiencing discomfort while eating, potentially leading to malnutrition, weight loss, and hospitalization. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted on [DATE], with diagnoses including but not limited to type 2 diabetes (uncontrolled elevated blood sugar), right leg below the knee amputation (surgical removal of the lower leg) and hypertension (elevated blood pressure). [...]

Inspectors wroteBased on interview, and record reviews, the facility did not accurately document the administration of insulin for one of three sampled residents (Resident 1) This deficient practice had the potential to compromise Resident 1's safety by causing confusion among staff who administrate medications and potentially result in a medication error that could harm Resident 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] to the facility with diagnoses including but not limited to heart failure, hyperlipidemia (elevated cholesterols levels), Type 2 diabetes mellitus (DM-elevated blood sugar levels). [...]

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan regarding leave of absence without notice (LAWN, leaving the facility unsupervised) for one of three sampled residents (Resident 1) by failing to: -Ensure to address Resident 1's LAWN on 5/17/2026. This failure had the potential to for Resident 1 to leave unsupervised again.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was confused and had a diagnosis of dementia (a progressive state of decline in mental abilities) did not elope (the act of leaving a facility unsupervised and without prior authorization) the facility on 5/17/2026 at approximately after 10:45AM by failing to: - Ensure the Interdisciplinary Team (IDT, group of diverse health care professionals from different fields) assessed Resident 1 as at risk for elopement (leaving the facility unsupervised). This failure resulted for Resident 1 to leave the facility on 5/17/2026 unsupervised and placed Resident 1 at risk for harm, injury, and/or death.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the physician's order for bumetanide oral tablet (medication prescribed to treat excess fluid retention and swelling [edema]) was carried out timely for one of four sampled residents (Resident 1) per facility's policy and procedures (P&P) titled, Physician's Order. This deficient practice has the potential to result in Resident 1 in unintended complications related to the management of congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).

Inspectors wroteBased on interview and record review, the facility failed to provide necessary respiratory care services for one of three sampled residents (Resident 1), by failing to:Follow physician's order for bilevel positive airway pressure machine (BiPAP - a device that helps people breathe easier, especially when they have breathing difficulties like sleep apnea [a sleep disorder where breathing repeatedly stops and starts during sleep]) per facility's protocol. [...]

Inspectors wroteBased on interview and record review the facility failed to provide care and services to prevent a fall (unintentionally coming to rest on a lower-level surface) for one of three sampled residents (Resident 11) reviewed for accidents by failing to: -Ensure Certified Nursing Assistant 7 (CNA 7) provided a two-person physical assistance (help from two person) and use of a Hoyer Lift (a medical device designed to safely transfer residents with limited mobility between beds, chairs, and wheelchairs) to transfer Resident 11 from Resident 11's bed to the wheelchair on 4/20/2026 at 6:50 AM as indicated in Resident 11's care plan. As a result, on 4/20/2026 at 6:50 AM, Resident 11 sustained a fall, experience severe knee pain (disabling; unable to perform daily living activities), and inability to bear weight (unable to stand or walk). [...]

Inspectors wroteBased on interview and record review, the facility failed to attempt a gradual dosage reduction (GDR - a periodic attempt to reduce a dose of a medication in an attempt to mitigate potential side effects) or document a clinical rationale for contraindication (why the attempt would be clinically inappropriate) for risperidone (a medication used to treat mental illness) since 9/15/2022 in one of five sampled residents(Resident 4) reviewed unnecessary medications. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the needs of five of 18 sampled residents (Resident 2, Resident 9, Resident 11, Resident 40, and Resident 88) by failing to ensure to: 1. Implement Resident 2's care plan for at risk for skin breakdown. 2. Develop a care plan for Resident 9's language communication preference. 3. Implement Resident 11's care plan for Activities of Daily Living (ADLs, the basic self-care tasks such as bathing, dressing, eating, and mobility that individuals perform daily to maintain independence and hygiene) self-care performance deficit (when a resident cannot independently perform daily activities due to physical or mental health limitations). 4. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two out of six sampled employees (Registered Nurse 1 [RN 1] and Licensed Vocational Nurse 1 [LVN 1]) performing medication administration had yearly annual employee evaluations (a yearly, formal check-in between an employee and their manager to discuss achievements, set goals for the coming year, and identify professional development needs) including medication administration competencies (the core skills and knowledge health providers must have to safely give medications, focusing on preventing errors and ensuring patient safety) in their employee files. This deficient practice had the potential to affect residents' (in general) safety and had the potential for unsafe medication administration. Cross reference F759Findings: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five percent (%). Ten errors out of 29 total opportunities contributed to an overall error rate of 34.48 % affecting six of six (sampled) residents (Resident 44, Resident 47, Resident 86, Resident 96, Resident 97, and Resident 105) observed for medication administration. The errors noted were as follows:1. Licensed Vocational Nurse 1 (LVN1) administered the incorrect dose of thiamine (a vitamin supplement) to Resident 44 on 4/28/2026. 2. Registered Nurse 1 (RN1) omitted (medication not provided) vitamin D (a vitamin supplement) and a multivitamin (a vitamin supplement) for Resident 47 on 4/28/2026. 3. LVN 1 administered the incorrect doses of the following medications: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received meals that met their assessed nutritional needs and prescribed Kosher diet requirements for three of three meal trays reviewed for therapeutic diets. Kosher diet (Kosher foods meet the regulations established by Jewish dietary law and include requirements related to the preparation and serving of foods, including separation of meat and dairy products.) and protein (an essential nutrient necessary for growth, tissue repair, immune function, and maintenance of muscle mass) requirements were not followed when: 1. Two Kosher diet trays were served pureed green beans, pureed potato, and pureed bread without a protein source. 2. One Kosher diet was served pureed lasagna prepared with beef and dairy products in the same meal, which was not consistent with Kosher dietary requirements. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: 1. Bulk food (sugar, flour, breadcrumbs) were stored in bins lined with trash bags that were not food grade (refers to materials that are safe for direct contact with food, free from harmful substances, and designed to prevent contamination).2. The temperature of bottled juice and a gallon of milk used for lunch service was kept out at room temperature, not at safe temperatures (refrigerated). 3. Food brought to residents from outside of the facility, including leftovers were stored in the resident food refrigerator located in the facility's utility room with no label or received date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for three of five sampled residents (Resident 17, 19 and 28) by failing to: 1. Ensure Resident 17, who was re-admitted to the facility with a Peripherally Inserted Central Catheter (PICC-a long, thin flexible tube inserted through a vein in the upper arm, extending to the supervisor vena cava [a large valve in the heart] near the heart) and surgical wound, was placed in enhanced barrier precautions (EBP-infection control strategy for nursing home, requiring gowns and gloves to be used during high-contact care for residents with or at high risk for multidrug-resistant organisms [MDRO: bacteria, often called superbugs, that have evolved to resist the antibiotics designed to kill them]). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to renew an antidepressant medication (drugs that balance chemicals in the brain) informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) for one of five sampled residents (Resident 78) by failing to: -Ensure to renew Resident 78's Mirtazapine (a medication used to treat depression [a mood disorder marked by varying degrees of sadness]) informed consent from 11/15/2024 from Resident 78's responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so). This failure had the potential for Resident 78's responsible party to be denied the opportunity to give informed consent.

Inspectors wroteBased on observation, interview, and record review the facility failed to answer the call light (a device used by a resident to signal his or her need for assistance) for one of one sampled resident (Resident 103) as soon as possible, but no later than five minutes as indicated in the facility's policy. This failure had the potential not to meet Resident 103's needs timely.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 4 sampled residents (Resident 43 and 78) had documentation in the active medical record showing the residents and/or resident representatives were provided an Advanced Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) Acknowledgement Forms (a signed acknowledgment indicating the resident and/or resident representative were provided with information regarding creating an Advanced Directive. By failing to: Ensure Resident 43's Advanced Directed Acknowledgement Form dated 2/28/2026 was completed in its entirety. Ensure Resident 78 had a documented Advanced Directive Acknowledgement Form documented in the resident's medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect private health information by leaving confidential medical information easily accessible for two of two sampled residents (Resident 9 and Resident 40). This deficient practice had the potential to result in violation of Resident 9 and Resident 40's right to personal privacy and confidentiality of their medical records.

Inspectors wroteBased on interviews and record reviews the facility failed to submit the required complete information contained in the Minimum Data Set (MDS- standardized data collection tool used to assess cognitive and functional status, and care needs) for one of one sampled residents (Resident 84) within 14 days after discharge date (2/14/2026) to the Centers for Medicare & Medicaid Services (CMS: a federal agency within the United States Department of Health and Human Services) System. This deficient practice had the potential to deny Resident 84 proper healthcare monitoring to ensure all the necessary care and services were provided and had the potential for residents to be improperly billed for services not provided.

Inspectors wroteBased on interview and record review the facility failed to accurately code the Minimum Data Set (MDS - a resident assessment tool) for two out of five sampled residents (Resident 10 and Resident 43) by failing to: 1. Document Resident 10's peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs) wounds 2. Document Resident 43's tobacco use. These failures had the potential to result in a delay in the necessary care and treatment for Resident 10 and Resident 43.

Inspectors wroteBased on observation, interview and record review the facility failed to update and revise 1 of 3 sampled residents (Resident 78's) care plan titled The resident is at risk for fall dated 7/9/2025, after a physician's order for a low bed with bilateral floor mats for safety was received on 8/24/2024. This deficient practice had the potential to result in a delay of nursing care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an activity assessment was completed for one of one sampled resident (Resident 99) to evaluate the resident's preferences for activities. This failure had the potential for Resident 99 to feel bored and to affect Resident 99's quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) prevention care consistent with professional standards of practice and per physician's orders for two of four sampled residents (Resident 2 and Resident 8) on Low Air Loss Mattresses (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries). By failing to: 1. Ensure Resident 2's low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was at a proper setting per manufacturer's guideline.2. Ensure Resident 8's LAL mattress was working properly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 3) reviewed for urinary indwelling catheter (a hollow tube that is inserted into the bladder to drain or collect urine) received the necessary urinary catheter care by failing to: -Monitor Resident 3's urinary indwelling catheter for signs and symptoms of infection This failure had the potential for Resident 3 to develop an infection that was not timely identified or treated.

Inspectors wroteBased on observation, interview, and record review the facility failed to label with a date on the oxygen tubing and humidifier (a small plastic bottle filled with water that attaches to an oxygen concentrator [medical device that gives you extra oxygen] or tank that allows the oxygen to pass through the water to add moisture to the oxygen before it reaches the resident's nose to prevent dryness) for one out of one sampled resident (Resident 46). This failure had the potential for Resident 46 to experience respiratory infections (infection of the parts of the body involved in breathing) associated with using an unsanitary (dirty, unhealthy, or unclean way that could endanger health) oxygen tubing or humidifier.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain updated hemodialysis (HD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) access site (a surgically created site used to remove and return blood during HD) monitoring orders for one of two sampled residents (Resident 40) reviewed for dialysis by failing to: -Ensure to address Resident 40's right arm arteriovenous (AV) fistula/shunt (a surgically created connection linking an artery [a type of blood vessel that carries oxygen-rich blood the entire body] directly to a vein [a type of blood vessel that collected oxygen-poor blood and returns it to the heart]). This failure had the potential to damage Resident 40's (AV) fistula/shunt and compromised the HD access site.

Inspectors wroteBased on interview and record review, the facility failed to respond to the pharmacist's recommendation from February 2026 to remove heart rate hold parameters (clinical conditions that would require a medication to not be given) from amlodipine (a medication used to treat high blood pressure) in one of five residents sampled for unnecessary medications (Resident 4). The deficient practice of failing to respond to the pharmacist's recommendation to remove heart rate monitoring parameters for amlodipine increased the risk that Resident 4 may not have received his amlodipine regularly, possibly leading to an increase in blood pressure and an increased risk of heart attacks and strokes.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and 94) were free from unnecessary drugs (a medication that may be doing more harm than good or isn't needed for the resident's current condition) by failing to: 1. Limit the duration of treatment for Resident 1's metoclopramide (a medication used to treat nausea and vomiting) to 12 weeks or less as per Resident 1's care plan (a document containing a resident-specific plan of care for a resident's concerns or problems) for GERD, dated 2/8/26.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove one expired fluticasone/salmeterol (a medication used to treat breathing problems) inhaler from the medication cart affecting Resident 6 in one of two inspected medication carts (Medication Cart 3.) The deficient practice of failing to remove expired products from the medication cart increased the risk that Resident 6 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the minced and moist texture green bean was prepared according to the International Dysphagia Diet Standardization Initiative (IDDSI: standardized framework (0-7 levels) that uses consistent terminology, colors, and testing methods to define texture-modified foods and thickened liquids for people with swallowing difficulties [dysphagia] Level Five minced and moist foods - (All foods prepared for this diet must be soft, moist with all excess fluid drained, and minced to size no larger than 4mm fits through the gaps of fork prongs). This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake and increase choking risk for residents receiving a minced and moist diet due to food textures not prepared in accordance with IDDSI Level 5 requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodated resident preferences for two of four sampled residents (Resident 68 and Resident 72) by failing to: -Provide Resident 68 with food that did not contain beef. -Review and update Resident 72's food preferences quarterly (three-monthly).-Provide Resident 72 with a vegetarian diet (excludes meat, poultry, and fish, often focusing on plant-based foods like vegetables, fruits, whole grains, beans, and nuts). These failures resulted in Resident 68 and 72 not having their food preferences honored by the facility, which had the potential for Resident 68 and Resident 72 to experience weight loss due to not liking or eating the food provided by the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records for one of five sampled residents (Resident 94) by failing to ensure the electronic medication administration record (MAR) for Resident 94's midodrine (a medication used to treat hypotension [low blood pressure]) indicated if the medication was administered or held on 2/13/2026 and 2/25/2026. This deficient practice placed Resident 94 at risk of not receiving appropriate care due to inaccurate medical care information and the potential to result in confusion in the care and services provided to Resident 94.

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective infection prevention and control program for one of eight residents (Resident 76) sampled for immunizations, by failing to: 1. Ensure Resident 76 was assessed for and offered the influenza (Flu-common viral infection that can be deadly, especially in high-risk groups) vaccine, including documentation of administration and/or refusal, in accordance with facility policy and procedures (P&P) titled Influenza Vaccine reviewed by the facility on 12/18/2025 and current standards of practice. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accessible and adequate private closet space for one of one residents (Resident 88) reviewed for dignity and resident rights. By failing to ensure facility staff did not store pillows in Resident 88's assigned closet space. This deficient practice prevented Resident 88 from storing personal belongings in the closet and had the potential to cause Resident 88 emotional distress, loss of dignity, and compromised privacy.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light (a device used by a resident to signal his or her need for assistance) was within reach for one of four sampled residents (Resident 51). This failure resulted in Resident 51's call light resting on the floor, out of Resident 51's reach and had the potential to result in staff delay in meeting Resident 23's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 14 of 33 residents' rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) met the space requirements of 80 square feet (sq ft - a unit of area measuring the total space inside a room) for each resident in a room with multiple beds. This failure had the potential to result in inadequate (not enough) space to provide safe nursing care and privacy for the impacted residents (unidentified).

Inspectors wroteBase on observation, interview, and record review, the facility failed to implement its' infection control policy and procedures (P&P) for one of three residents (Resident 4) by failing to ensure Resident 4's Representative (RP) was provided a consent (give permission for something to happen) for Influenza (Inactivated or recombinant injection given to prevent influenza (flu) illness, Pneumonia (dangerous lung infections), and Covid (highly contagious respiratory illness which is airborne and transmitted through coughing or sneezing) vaccinations. This deficient practice deprived Resident 4 and RP of the right to make an informed decision and placing her (Resident 4) at a risk of contracting the Flu, Pneumonia, and or Covid illnesses. [...]

Inspectors wroteBased on interview and record review the facility failed to update the fall risk care plan (instructions to provide person centered care and future plans) for one of two sampled residents (Resident 1). This failure resulted in Resident 1 sustaining an assisted fall (an unplanned, sudden descent to the floor where a staff member or caregiver is present and acts to ease the resident's fall).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) for one of two sampled residents (Resident 5) reflected the diagnosis of depression (a serious mood disorder causing persistent sadness and loss of interest in activities, affecting how you feel, think, and handle daily life). This failure had the potential for Resident 5 not to have a proper assessment, management, and monitoring of the psychotropic medication (drugs that alter brain chemistry to treat mental health conditions).

Inspectors wroteBased on interview and record review the facility failed to ensure to develop a care plan for one of one sampled resident (Resident 2) reviewed for diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels). This failure had the potential to affect Resident 2's diabetes care.

Inspectors wroteBased on observation, interviews and record review, the facility failed to follow their own Policy and Procedure (P&P) by failing to provide access for medical records within 24 hours of Resident Representative (RP) request for one of the three sampled residents (Resident 2). This failure resulted in Resident 2's RP being denied the right to access the requested documents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a Comprehensive Care Plan (a personalized document that outlines a resident's needs, goals, and the specific services required to achieve them, ensuring consistent and holistic care) for one of four sampled residents (Resident 3), to address Resident 3's left ear hearing loss. This failure resulted in the absence of individualized interventions and assessments to manage Resident 3's reported loss of hearing to his left ear. [...]

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) who was at risk for dehydration (lack of drinking sufficient fluids to meet the body's need) and malnutrition (food ingested [eaten]) does not provide enough nutrients or the right balance for optimal health) did experience unplanned severe weight (wt.) loss (a body weight loss of greater than 7.5 percent [% - unit of measure] in three months). By failing to: 1. Implement physician orders for a Restorative Nursing Aide (RNA: a certified nursing assistant who has completed additional training in rehabilitation who helps people regain and maintain their ability to do everyday things like walking, eating, and bathing) feeding program for breakfast and lunch dated 9/24/205. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to report to the Medical Doctor (MD) when there was a change in condition (COC) for one of the three sampled residents (Resident 1) who was refusing to eat more than 50% of her meals. This deficient practice resulted in Resident 1 being severely dehydrated and possible deterioration of her (Resident 1) sacral (a triangular bone in the lower back) pressure ulcer (PU- localized damage to the skin and/or underlying tissue usually over a bony prominence). [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent the deterioration of pressure injuries and provided care and services consistent with professional standards of practice for one out of three sampled residents (Resident 1) by failing to:1. Change Resident 1's incontinence briefs when she was soiled.2. Follow the physician's order for intravenous (IV) fluids administration3. Implement the physician's order for registered dietician (RD) due to poor oral intake and weight loss.4. Report Resident 1's decreased oral intake upon identification on 10/29/2025 to the physician as well as Resident 1's healthcare proxy (a trusted person you legally appoint to make medical decisions for you if you become unable to communicate or decide for yourself, ensuring your healthcare wishes are followed even in an emergency or serious illness) FM 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct an Interdisciplinary Team (IDT- brings together knowledge from different health care disciplines to help people receive the care they need) which included resident and or responsible party (RP) for one of the three sampled residents (Resident 1). This deficient resulted in a failure to address Resident 1's non-compliance for care such as eating, personal care, and ordered procedure (laboratory draws and supportive treatments). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality by failing to carry out the physician's order for one of the three sampled residents (Resident 1) who had orders to check laboratory (lab) for blood and urine as well as intravenous (IV) fluids for poor oral intake. This failure resulted in the physician having limited information to determine the extent of Resident 1's health status and potentially worsening of Resident 1's hydration status leading to altered mental status (AMS). As a result, Resident 1 was transferred to General Acute Care Hospital (GACH) for failure to thrive (FTT- a complex syndrome characterized by a state of decline that includes weight loss, decreased appetite, poor nutrition, and inactivity), AMS, and sacral wound. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise:The care plan for one of two sampled residents (Resident 1) after the resident had his urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) removed and reinserted (to put something back in). This deficient practice had the potential to place the resident at risk for urinary retention (inability to fully empty your bladder when urinating), infection (harmful germs such as bacteria, viruses, or fungi, enter your body, multiply, and cause harm), hospitalization and sepsis (a life-threatening blood infection).2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses disposed of used tube feeding formula and tubing, discarded remaining formula, and tubing per facility policy for one of three resident (Resident 3). This failure placed Resident 3 at risk for contamination of enteral formula, bacterial growth, aspiration (The accidental breathing in of food or fluid into the lungs, potentially causing pneumonia or other lung problems), gastrointestinal infection, sepsis (systemic infection), and compromised nutritional status. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis of dysphagia (Difficulty or discomfort in swallowing), and gastrostomy (G-tube- tube inserted through the belly that brings nutrition directly to the stomach), COPD, and respiratory failure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to manage pain in the left arm, back, and head for one of three sampled residents (Resident 2) by failing to:1. Notify a physician that Resident 2 continued to remain in pain after three to four hours of pian medication Oxycodone-Acetaminophen 10-325mg (a strong pain reliver to treat moderate to severe pain) administration. 2. Notify a physician that Resident 2 has been asking for the pain medication Hydromorphone-Acetaminophen 10-325 mg to be given every four hours instead of every six hours for better pain relief. These deficient practices have caused Resident 2 remined uncomfortable and kept waiting for the six hours mark on 11/12/2025 while in pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist and make transportation arrangements for recurring chemotherapy (treatment for cancer [A disease in which abnormal cells divide uncontrollably and destroy body tissue]) appointments for one of the three sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1 missing the chemotherapy treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and ensure one of three sampled residents (Resident 11) had an order to self-administer a medication. This failure had a potential for Resident 11 to over or under medicate herself which could lead to complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide warm water for one of two sampled residents (Resident 2) to make tea during meals. This failure had the potential for Resident 2's preferences not to be honored and for Resident 2 to feel frustrated.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 2) had a homelike environment (creating a setting that feels more like a personal resident than a hospital-like institution) due to chip paint on the wall. This failure had the potential for Resident 2 not to have a comfortable homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of six sampled residents (Resident 37) had a comprehensive care plan (a detail individualized document that outlines a patient's goals, needs, and the interventions needed to achieve them across various care settings) when the facility identified Resident 37 had a hard time hearing. This failure had the potential not to meet Resident 37's needs.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide necessary treatment and services to minimize the risk of development of pressure injuries (PIs, areas of damaged skin caused by staying in one position for too long) for three of four sampled residents (Resident 28, Resident 35, and Resident 71) by failing to: -Ensure to provide a properly functioning low air loss mattress (LALM, pressure relieving mattress that is filled with air) for Resident 28. -Ensure to set Resident 35 and Resident 71's LALM at the correct weight setting in accordance with the attending physician's (MD) order. These failures had the potential for Resident 28, Resident 35, and Resident 71 to develop PIs and skin wounds to worsen.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe environment for two of two sampled residents (Resident 48 and Resident 11) by failing to ensure not to place an electrical extension cord in the residents' walk area. This failure had the potential for Resident 48 and Resident 11 to fall and sustain an injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary care and treatment for one of three sampled residents (Resident 51) who had an indwelling catheter (a medical device inserted into the bladder to drain urine continuously) by failing to notify the physician when there were sediment (the solid matter that settles to the bottom of a liquid, such as urine or blood) in the indwelling catheter's tubing. This failure placed Resident 51 at risk for urinary tract infection (UTI, an infection in any part of the urinary system).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to label and date the feeding tube syringe (a specialized syringe used to administer liquid formula or medication directly into a feeding tube) for one of one sampled resident (Resident 35) who had a gastrostomy tube (G-tube, is a tube that is placed directly into the stomach). This failure placed Resident 35 at risk for infection and G-tube complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two hemodialysis (HD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents (Resident 125) received dialysis care and services based on professional standards. Resident 125 did not have equipment or supplies, including an emergency kit consisting of clean gauze, tourniquet (a device used to compress a limb to stop bleeding) and tape necessary to manage emergencies such as bleeding at the bedside. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 4 (CNA4) and CNAs (in general) did not apply triamcinolone acetonide ointment 0.1 % (prescribed medication used to help relieve redness, itching, and swelling) to one of five sampled residents (Resident 11). This failure violated the facility's Administering Medications policy and procedure and had the potential for Resident 11 to use the medication inappropriately.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store two of 20 sampled residents (Resident 62 and Resident 52) medications in accordance with the facility's Storage of Medications policy and procedure (P&P). This failure had the potential to cause Resident 62 and Resident 52 to use the medication improperly which could lead to harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. In the refrigerator, there was no label or date on the sandwiches and the bin of expired butter cups were not discarded. These deficient practices had the potential to cause food-borne illnesses to the residents. -Ensure the low temperature dishwashing machine had the appropriate concentration of sanitizer.

Inspectors wroteBased on observation, interview, and record review the facility failed to practice effective infection control for one of two sampled residents (Resident 23) in accordance with the facility's Infection Prevention and Control policy and procedure by failing to keep Resident 23's urinal (a device for males to urinate) away from his food. This failure had the potential for Resident 23 to eat contaminated food and placed Resident 23 at risk for infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light (a device used by a resident to signal his or her need for assistance) for one of 20 sampled resident (Resident 2) functioned properly. This failure had the potential for Resident 2 not to be able to call for assistance.

Inspectors wroteBased on observation, interview, and record review , the facility failed to ensure 14 of 33 residents' rooms ( room [ROOM NUMBER], 8, 9, 11, 14, 15, 16, 17, 18, 19, 21, 24, 25) met the space requirements of 80 square feet for each resident in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the impacted residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident's (Resident 3) as needed (PRN) psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) had a documented 14-day limit for administration. This failure caused an increased risk in Resident 3's mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff properly assessed and document for one of three sampled residents (Resident 1) on Preadmission Screening and Resident Review, (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation). The deficient practice resulted in Resident 1 not receiving a PASRR II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) and subsequent follow up.

Inspectors wroteBased on interview and record review, the facility failed to notify a physician after a significant change (COC- a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) in the mental or physical condition of a resident who has mental illness for one of the three sampled residents (Resident 1). This deficient practice resulted in Resident 1 ' s increased behavioral, psychiatric, and mood-related symptoms requiring General Acuate Care Hospital (GACH) admission on [DATE]. Cross reference F645and F656.

Inspectors wroteBased on observations and record reviews, the facility failed to monitor one of the three sampled residents (Resident 1) by failing to: 1. Update Resident 1 ' s care plan for at risk for physical behavior towards others, after a Change of Condition (COC) on 1/14/2025 and 2/24/2025. 2. create an individualized and specific interventions for quetiapine fumarate (Seroquel- an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) and schizophrenia. This failure resulted in the escalation of behaviors requiring Resident 1 to be admitted to General Acute Care Hospital (GACH) on 3/6/2025.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan that meet the care/services based on the resident ' s individual assessed needs for one of five sampled resident (Resident 1) by failing to ensure a baseline care plan was initiated and implemented for Resident 1 ' s pain management and left lower leg fracture with splint. This deficient practice had the potential to result negative impact on Resident 1 ' s health and safety, as well as the quality of care and services received.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessment and monitoring of the left lower leg splint to one of one sampled resident (Resident 1). This deficient practice has the potential for Resident 1 to develop complications such as skin breakdown and possibly compartment syndrome (excessive pressure builds up inside an enclosed muscle space in the body which slows the flow of blood, oxygen and nutrients to and from the affected tissue).

Inspectors wroteBased on interview, and record review, the facility failed to ensure sufficient nursing staff was available to provide nursing and related services to meet the resident ' s needs safely and in a manner that promotes each resident ' s rights, physical, mental, and psychosocial well-being for three of five sampled residents (Residents 1, 4 and 5) by failing to: 1. Ensure prompt assistance with basic care for Resident 1. 2. Ensure scheduled showers were provided to Residents 4 and 5. These deficient practices resulted in Residents 1 waiting for more than three hours for basic care, while Resident 4 and 5 not receiving the scheduled shower which has the potential to affect the quality of life for Residents 1, 4 and 5.

Inspectors wroteBased on interviews and record review, the facility failed to ensure: 1. Licensed nurses had the skills and knowledge to identify a change in condition for one of the three sampled residents (Resident 1) who had a critically low platelet count (PLT- a laboratory test that measures the number of platelets in the blood. Platelets are small, cell-like fragments that play a crucial role in blood clotting by forming a plug at the site of injury) level of 33,000 (normal PLT is between 150,000 and 400,000 platelets per microliter [µL]). 2. The physician was informed immediately when the critically low PLT count as soon as it was called in by the laboratory staff. This failure resulted in Resident 1 ' s delay in getting transferred to General Acute Care Hospital (GACH) for treatment and placing him at a risk for spontaneous bleeding which could result in death. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the dinnerware and food service equipment was clean and in good condition by failing to: 1. Ensure the residents had cups that were free from stains, residue, and cloudy dishwasher cleaning build-up and the blue coffee pots had lids that were not worn out. 2. Ensure the residents water pitchers were changed out in a timely manner by staff for washing. These deficient practices had the potential to result in cross contamination or drink safety issues.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor food preferences for two of five sample residents (Resident 2 and 3). This failure resulted in Resident 2 and 3 only having canned fruits to eat, instead of the fresh fruits preferred.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) had a comprehensive care plan addressing Resident 3's bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs) and psychotropic medications (drugs that affect the brain and nervous system to treat mental illnesses). This deficiency had the potential for Resident 3 to have an adverse reaction that could go untreated.

Inspectors wroteBased on interview and record review, the facility failed to ensure one Licensed Vocational Nurse (LVN 1) employee file contained a yearly performance evaluation. This deficient practice caused an increased risk in resident safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled Certified Nurse Assistants (CNA 2) employee file contained a yearly skills competency checklist. This deficiency had the potential to have employees lacking safe, quality, and individualized care for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident 3) had a documented consent for psychotropic medications. This deficient practice caused an increased risk for Resident 3 to lack proper education regarding the medication.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy and procedures for two of 10 sampled residents (Residents 1 and 7). This deficient practice resulted in the resident-to-resident abuse incident was not reported to state licensing/certification office, police, and ombudsman, the incident was not investigated, and the residents were not separated (rooms changed) in a timely manner.

Inspectors wroteBased on interview and record review the facility failed to ensure residents are correctly identified for two of five sampled residents (Resident 1 and Resident 2). On 10/16/24, Resident 1 was for transfer to another skilled nursing facility (SNF) and Resident 2 had an appointment with the ophthalmologist (medical doctor with specialized training in medical and surgical eye care). The transportation company came and picked up Resident 2 and drove Resident 2 to the SNF instead of the ophthalmologist. This deficient practice resulted in Resident 2 stated that he felt mad and upset when the facility took him to the SNF resulting in Resident 2 missing his appointment with the eye specialist on 10/16/24.

Inspectors wroteBased on interview and record review the facility failed to provide care to the resident who had a fall in accordance with professional standards of practice for one of four sampled residents (Resident 1). For Resident 1 who had a fall on 10/16/24 during the night shift (11 p.m. to 6 p.m.), the facility failed to: 1. Assess Resident 1 immediately after the fall. 2. Notify Resident 1's physician and responsible party of the fall. These deficient practices resulted in Resident 1 not given immediate care after the fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had pressure ulcers (also known as a pressure injury, a localized area of damaged skin or tissue caused by prolonged pressure on the skin), was assessed quarterly using the Braden scale assessment (a tool used to assess a patient's risk of developing pressure ulcers). This deficient practice caused an increased risk in assessing a significant change to Resident 1's skin integrity.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a severe risk for developing a pressure ulcer (also known as a pressure injury, a localized area of damaged skin or tissue caused by prolonged pressure on the skin), received necessary treatment and services to promote healing of pressure sore by: -Failing to develop a care plan for Resident 1's right lateral (side) leg vascular wound (develop due to problems with blood circulation, often caused by peripheral vascular disease [PVD, a circulatory condition that occurs when blood vessels outside of the heart and brain narrow, spasm, or become blocked]). [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from verbal abuse (a form of emotional or psychological harm that involves the use of words to demean, insult, or manipulate another person) for one of three sampled residents (Resident 1) when on 8/12/2024 at 5:30 AM, CNA 1 stated a derogatory word in Resident 1's room. This deficient practice resulted in Resident 1 being subjected to verbal abuse while under the care of the facility and had the potential to cause Resident 1 mental anguish.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1): 1. had and initial care plan developed for G-tube dislodgment and revised after the second dislodgement, to include new interventions. 2. had Interdisciplinary team meetings completed in a timely manner after G-tube dislodgement. This failure resulted in seven instances where Resident 1 ' s G-tube was dislodged and required replacement.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2), was not billed for a single room during the time another resident was on bed hold (bed at the facility is held for a resident during hospitalization up to seven days and paid for), in the same room as the resident. This failure resulted in the resident not receiving the single room they were paying for.

Inspectors wroteBased on interview and record review the facility failed to follow Registered Dietician (RD) recommendations made during the interdisciplinary team (IDT, different health care disciplines get together to review the plan of care of the resident) meeting to change the residents gastrostomy (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach) feeding formula (nutrition) for one of five sampled residents (Resident 1). This failure resulted in recommendations for a change in Resident 1's G-tube formula to be delayed for 51 days and the resident losing six pounds (4% of their weight).

Inspectors wroteBased on interview and record review, the facility failed to perform staff competencies upon hire and/or annually for three of five sampled staff (Certified Nursing Assistant [CNA] 8, 10 and Licensed Vocational Nurse [LVN] 4). This deficient practice had the potential for residents to not receive the appropriate level of care needed affecting quality of care and potentially leading to resident harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure the nurses were rotating the insulin (a medication that regulates sugar in the blood) injection site for two of five sampled residents (Resident 21 and 75). This failure had the potential to result in bruising, pain, lipohypertrophy (a lump or accumulation of fatty tissue under skin), and/or localized cutaneous amyloidosis (-a condition caused by the buildup of abnormal proteins in the skin) to Residents 21 and 75.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Residents 11 and 55) were provided with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN, a form issued in order to transfer financial liability to beneficiaries before the SNF provides an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or is custodial in nature). This deficient practice had the potential to result in Resident 11 and Resident 55 not being given the information needed to make informed decisions about their care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up on missing eyeglasses for one of six sampled residents (Resident 13), after the resident informed facility staff the eyeglasses were missing. This deficient practice had the potential to for Resident 13 to not have her missing items replaced.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Notice of Transfer/Discharge Form was sent to the Office of the State Long-Term Care Ombudsman (representatives that assist the residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) for one of six sampled residents (Resident 8). This deficient practice had the potential to result in an unsafe discharge and/or denying the resident the right to appeal the discharge.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan for Lexapro (a medication used to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily living]) for one of six sampled residents (Resident 27). This deficient practice had the potential for Resident 70 to not receive adequate and appropriate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six sampled residents (Resident 69 and Resident 80) received care and treatment in accordance with professional standards of practice by failing to: -Implement Physician's Orders in a timely manner for Resident 69's orthopedic consultation (a type of physician who treats conditions related to the musculoskeletal system). This failure resulted in the delay of physical therapy (PT-medical treatment used to restore standing, walking, and movement of different body parts) treatment for Resident 69. -Ensure staff followed up with the physician and obtain orders for Testosterone injections (treatment for individuals whose bodies do not make enough natural testosterone, a hormone that is responsible for many of the physical characteristics specific to adult males) for Resident 80. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 30) received care and services necessary to prevent accidents and falls by failing to provide a fall mat, per Resident 30's risk for fall care plan. This deficient practice placed the resident at increased risk for injury after a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 68), who was experiencing unplanned severe weight loss (greater than five [5] percent [% - unit of measure] in one month), received the care and services necessary to prevent severe weight loss. Facility staff did not input into the electronic chart Resident 68's weekly weights, nor implement the care plan interventions of a frozen nutritional treat every day at lunch. These deficient practices placed Resident 68 at risk for continued nutritional decline and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consent for psychotropic medication (drugs that act on the brain to alter mood and behavior) use for two of three sampled residents (Resident 67 and Resident 290) when the following occurred: -Resident 67 gave verbal consent for a Quetiapine (a medication used for schizophrenia; a disorder that affects a person's ability to think, feel, and behave clearly), despite not having the mental capacity to make his own medical decisions. -There was no physician (MD) signature on the psychotropic medication administration disclosure form (form given to the resident with the risks and benefits for psychotropic medications) for Resident 67 and Resident 290. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove and replace expired medication in one of two Medication Storage Rooms. This deficient practice had the potential to result in a resident receiving expired or the wrong medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary food storage practices in the kitchen freezer area for one of two freezer floor areas located in the kitchen. The kitchen had trash littered on the floor where the frozen food was kept for resident consumption. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of bacteria from one object to another) that could lead to foodborne illness in 80 of 80 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care was consistently provided for one of 23 sampled residents (Resident 38), who received hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill), by failing to maintain an integrated hospice binder that included: -Calendar of hospice staff visits. -Certification of Terminal Illness. -Ensure that hospice staff provided nursing/visitation notes to the facility. -Specific and resident centered end stage/hospice care plan. These deficient practices had the potential to lead to the resident not receiving the needed and necessary services timely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of six sampled residents (Resident 8). This deficient practice had the potential to result in the resident not being able to call nursing staff for assistance when needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 14 of 33 resident rooms (room [ROOM NUMBER], 8, 9, 11, 14, 15, 16, 17, 18, 19, 21, 23, 24, 25) met the space requirements of 80 square feet for each resident in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the impacted residents.

Inspectors wroteBased on interview, and record review the facility failed to ensure one out of six sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice and physician's orders. By failing to apply bilateral (both sides) compression (a garment that applies gentle pressure to the limb to prevent fluid buildup in the tissues to manage swelling) sleeves for arms and stockings for legs for the management of lymphedema (swelling caused by a blockage of the lymphatic system [part of the body's immune system, made up of organs, tissues and vessels that protect the body from disease and infection] drainage). This failure had the potential to result in Resident 1's arms and legs to become swollen, painful, decrease blood flow, and tissue death.

Inspectors wroteBased on observation, interview, and record review the facility failed to remove discontinued medication from the medication cart for one of six sampled residents (Resident 1). For Resident 1 who had a discontinued order for gabapentin 300 milligrams (mg, unit of measurement) for neuropathic pain (pain caused by disease or injury of the nervous system [includes the brain, spinal cord, and nerves) dated [DATE], the facility continued to store the discontinued gabapentin 300 mg. inside the medication cart. This deficient practice had the potential for medication error by giving the wrong dose of the gabapentin to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report to the local California Department of Public Health (CDPH) within two hours of the physical altercation that occurred on 2/27/2024 involving two residents (Resident 1 and 2). This deficient practice resulted in a delay of an onsite inspection by the California Department of Public Health (CDPH) to ensure circumstances were investigated and had the potential to place Resident 1 and 2 at further risk for injury and abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure that COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) vaccination was offered/ re-offered and/or administered for six of six sampled residents (Residents 1, 2, 3, 4, 5 and 6) per facility policy. This deficient practice resulted COVID-19 infection to Residents 1, 2, 3, 4, 5 and 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control measure and prevention by failing to ensure three of 19 sampled facility staff (Cook [CK], Dietary Aid 2 [DA2], and Dietary Aid 3 [DA3]) were wearing a mask while working together at the kitchen. This deficient practice had the potential to result in the spread of COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) infection to residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure Influenza (Flu-common viral infection that can be deadly, especially in high-risk groups) vaccine was offered to two of six sampled residents (Resident 3 and 5) per facility policy. This deficient practice placed Resident 3 and 5 at a higher risk of acquiring and transmitting Flu infection to other residents and staff in the facility.

Inspectors wroteBased on interview and record review the facility failed to respond timely to resident's requests for one of four sampled residents (Resident 1). The facility failed to: 1. Assess Resident 1 when Resident 1 complained of headache on 11/7/2023 (unknown time) and administer acetaminophen (Tylenol, medication for pain) 650 milligrams (mg. unit of measurement) as needed (PRN) as ordered by the physician and based on the assessment, give the acetaminophen when indicated. 2. Licensed Vocational Nurse (LVN 1) went for her meal/rest break before administering the acetaminophen to Resident 1 on 11/7/2023. 3. Treat Resident 1 with respect when Resident 1 requested LVN 1 to lower her voice during the early morning hours. (Date unknown). LVN 1 did not lower her voice. These deficient practices resulted in Resident 1 stated she felt mad at LVN 1 and that LVN 1 was rude and disrespectful .

Inspectors wroteBased on interview and record review, the facility failed to implement its policy to conduct a psychosocial (regarding how social factors influence the individuals mind or behavior) follow up for one of three sampled residents (Resident 1), after an alleged abuse incident report. This deficient practice had the potential to result in Resident 1 ' s care needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to arrange for a home health visit for one of three sampled residents (Resident 3), after Resident 3 was discharge from the facility. This failure had the potential to result in rehospitalization or risk residents ' safety.

Inspectors wroteBased on interview and record review, the facility failed to conduct an interdisciplinary team meeting (IDT - a group of experts from several different fields) for one of three sampled residents (Resident 3), per the facility ' s policy. This deficient practice had the potential to result in Resident 3 ' s care needs not being met comprehensively when resident/resident ' s representative were not involved in developing a care plan and making decisions for Resident 3.

Inspectors wroteBased on interview and record review the facility failed to protect residents right to be free from physical and mental abuse (willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish) by three facility employees for one of six sampled residents (Resident 1) on 7/6/2023 at 4:30 a.m., in accordance with facility's policy and procedures titled, Resident Rights Under Federal Law revised 3/1/2023, and Abuse Prohibition revised on 10/24/2022, by failing to: 1. Honor Resident 1's wishes when she stated to stop during the collection of urine sample using the straight catheter (a flexible tube placed in the bladder [body organ that stores urine] to obtain urine) without her consent. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain physician's order to collect urine sample by straight catheter (a flexible tube placed in the bladder [body organ that stores urine] to obtain urine) for three of six sampled residents (Resident 1, Resident 2, and Resident 3) in accordance with the facility's policy and procedure (P&P) titled, Procedure Specimen (sample) Collection: Urine, revised on 2/1/2023, P&P titled, Physician Advanced Practice Provider (APP) Orders revised 3/1/2022, and P&P titled, Catheter: Urinary -Justification for Use, revised on 8/7/2023. 1. [...]

Inspectors wroteBased on interview and record review, for one of six sampled residents (Resident 1), the facility failed to revise Resident 1 ' s care plan to accurately reflect the correct Advance Directive (legal document that provide instructions for medical care when a person lose the ability to make their own decisions) status and the correct Physician Orders for Life-Sustaining Treatment (POLST, written medical order that helps give people with serious illness more control over their own care by specifying the types of medical treatment they want to receive during serious illness) status in accordance with the facility ' s policy and procedures titled, Person-Centered Care Plan, revised on 10/24/2022. This deficient practice resulted in failing to reflect Resident 1 ' s treatment options during medical emergencies and follow Resident 1 ' s wishes.