Shasta View Care Center

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that three of three sampled Resident Council members (resident run group that meet to discuss concerns and offer suggestions about their care) concerns about long call light wait times were addressed when the facility had not completed a Department Response Form to show any follow up or actions taken. This failure resulted in care concerns to go unrecognized and violated the residents' rights.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide one out of two sampled residents (Resident 1) with the necessary care and services to prevent the development of three facility acquired Pressure Injuries (PI-skin and tissue loss with exposed fat, muscle, or bone) a Stage 4 PI on the coccyx (tailbone), a Deep Tissue Pressure Injury (DTI, serious type of PI that caused damage to the tissue or muscle) to the posterior (back of) right heel, and a DTI to the tip of the right big toe when: 1. Licensed Nurses (LN) and Certified Nurse Assistants (CNA) did not identify the progression of skin changes, over a 24 day period, which led to the discovery of the PI's at advanced stages. 2. The facility had not ensured Resident 1 was repositioned and turned per the facility's policy and procedure (P&P). 3a. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure two Treatment Nurses (TNs are also Licensed Nurses) and three Certified Nursing Assistants (CNAs) possessed specific competencies and orientation (a measurable pattern of knowledge and behaviors required to provide care) and skill sets necessary to provide safe and effective care to the residents when the facility did not complete or maintain competency evaluations. This failure had the potential to place residents at risk for avoidable harm due to improper assessments, delayed recognition of changes in condition, and inadequate delivery of required care.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure infection control practices were maintained when: 1. Certified Nurse Assistants (CNAs) did not wear required personal protective equipment (PPE, gowns, gloves, and masks) during resident care for two out of two sampled Residents (Residents 1 and 2).2. Treatment Nurse (TN) C pulled her face mask down past her mouth and pulled it back up to cover mouth with dirty gloves while providing care to one out of two sampled residents (Resident 2).3. TN C did not maintain infection control prevention before or after providing wound care for one out of two sampled residents (Resident 1). These failures had the potential to increase the risk of infections and cause a delay in wound healing.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure staff developed and implemented a resident specific care plan (a plan that detailed resident goals and care instructions for facility staff), for one of two sampled residents (Resident 1) when the care plan did not include instructions that directed Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs) to assist Resident 1 with turning and repositioning. This failure had the potential to prevent Resident 1 from maintaining or attaining their highest practicable physical, mental, and psychosocial well-being. And resulted in the development of three pressure injuries (bed sores from pressure on the skin). Refer to F686Findings: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure one of two sampled residents (Resident 2) was free from accident hazards when Treatment Nurse (TN) C used an oil-based product on a resident that received oxygen (extra air that was administered through a tube into the nose and was highly flammable). This had the potential to cause an injury and a decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that medication administered to one out of two sampled residents (Resident 2) was safe when Treatment Nurse (TN) C provided medication without a Physician's order. This had the potential to cause a decline in resident health status.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the environment was safe and sanitary when there was a large piece of plastic bag hanging from the ceiling in the rehabilitation room (where residents exercised and received therapy services) and was draining roof leakage water into a five-gallon bucket that was foul smelling, stagnant (motionless or trapped) water that also contained trash. This had the potential for mold or bacteria to grow which could negatively affect the safety and health status of residents, the public, and facility staff who utilized the physical therapy room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was treated for pain in a timely manner and reassess the pain level after pain medication had been administered. This failure had the potential to result in the residents' need of pain management to not be identified, feeling depressed with poor self-esteem, and had the potential to negatively impact the resident's ability to attain or maintain their highest practicable level of well-being. During a review of the facility's policy and Procedure (P&P) titled, Administering Pain Medication, revised 3/2024, the P&P indicated, The purpose of this procedure is to provide guidelines for assessing resident's level of pain and administering analgesic (pain reliever) pain medication. [...]

Inspectors wroteBased on interviews and record reviews the facility did not ensure the process for discharging residents was followed for two out of two residents (Residents 1 and 2) when they were provided with an incomplete notice of discharge and there was no discharge plan in place. This failure could prevent the resident from attaining or maintaining his/her highest practicable level or result in a decline in the resident's physical, mental or psychosocial well-being.

Inspectors wroteBased on interviews and record reviews, the facility did not ensure that one of two sampled residents (Resident 1) was free from unnecessary medications when there was no behavioral monitoring in place. This had the potential for Resident 1 to not maintain their highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement their Infection Control Program policies and procedures for controlling the spread of a communicable disease and infection when four of seven sampled residents (Resident 4, 5, 6 and Resident 7), tested positive for Influenza A (influenza, a contagious respiratory illness caused by the influenza), and all residents in close contact were not tested in a timely manner, in accordance with the facility's infection control policy. This failure put the residents, staff and families at risk for contracting Influenza A infections and had the potential to result in serious negative clinical outcomes for this vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to revise a wound care plan for one of three sampled residents, (Resident 1) when a new physician wound care order was prescribed for a wound vacuum-assisted closure (wound vac, medical device that uses gentle, constant suction to heal complex wounds), to be placed and maintained to the left hip pressure ulcer (a deep wound caused from pressure to the area). This failure had the potential for Resident 1's wound care not to be managed appropriately which could result in discomfort, further deterioration of the wound, and possible infection and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to protect two of five sampled residents, (Resident 1 and Resident 2) from financial abuse, manipulation and exploitation when:1. The Activity Assistant (AA) J played on Resident 1's sympathy and manipulated Resident 1 out of $800, and promised services she never delivered. 2. AA J loaded Resident 2's bank card onto her personal well-known online shopping website to buy her coffee creamer, when the facility could have bought the coffee creamer for Resident 2, without using her bank card. These failures caused Residents 1 and 2 anxiety, embarrassment, and humiliation and the potential for negative emotional and psychosocial outcomes.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate a financial abuse allegation and report the results of their investigation within five (5) days to the California Department of Public Health (CDPH) for one of five sampled Residents. (Resident 1)Refer to F600 This failure had the potential to result in further financial abuse to other residents.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to appropriately implement their infection control program to mitigate the spread of COVID-19 (symptoms include fever, fatigue, cough, breathing difficulties, loss of smell, and taste). Both Certified Nursing Assistant (CNA) A and Activity Assistant (AA) did not adhere to the necessary precautions for isolation rooms when they did not follow the proper procedures for putting on or taking off Personal Protective Equipment (PPE, masks, gowns, gloves and eye protection) as per the facility policy. These lapses in following standard protocols posed a significant risk by potentially facilitating the development and transmission of COVID-19 within the facility. This could lead to severe adverse consequences for residents, staff, and visitors. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one out of three sampled residents (Resident 1) was fully informed of treatment that was provided when the consent form for a psychotropic medication (a medication that alters mood and behavior), was missing important information and not complete. This violated Resident 1's rights to be fully informed of treatment and could negatively affect psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of three sampled residents (Resident 1) was provided with appropriate Preadmission Screening and Resident Review (PASARR, a screening, that was done prior to admission to the facility or as needed, and screened residents for possible serious mental health illness) when: The PASARR completed prior to facility admission did not accurately reflect Resident 1's serious mental health illnesses (SMHI); and The facility did not follow up on a subsequent PASSAR that indicated a Level 2 screening (a State agency performed a comprehensive evaluation and made recommendations for care and services) was required. These failures had the potential to cause a decline in psychosocial well-being or cause a delay in required mental health services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) rights were protected when the facility attempted to transfer Resident 1 to another facility out of the area without his permission, or the permission of his Responsible Party (RP). This failure caused Resident 1 to feel anxious and had the potential to result in emotional stress, embarrassment, feelings of neglect, and the potential for negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of 15 sampled residents (Resident 1, 2, 4, 7, and Resident 15) had a safe, comfortable and home like environment when the facility air conditioning was not working adequately. This failure caused restlessness, irritability, increased anxiety (a feeling of fear, dread, and uneasiness), insomnia (loss of sleep) and the potential for negative clinical outcomes. Based on observation, interview, and record review, the facility failed to ensure five of 15 sampled residents (Resident 1, 2, 4, 7, and Resident 15) had a safe, cool, and home-like environment when the facility's air conditioning was not working effectively. This failure caused restlessness, irritability, increased anxiety (a feeling of fear, dread, and uneasiness), insomnia (loss of sleep) and the potential for negative clinical outcomes.

Inspectors wroteBased on interview and nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours per day, 7 days a week. This failure had the potential to adversely affect oversight and direction regarding resident's quality of care and quality of life directly impacting overall health and well-being of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met in the kitchen when: the blender was not air dried, two of four non-stick coated frying pans did not have a cleanable surface, and the hood over the stove had greasy, black debris on it and was not clean. These failures had the potential to place the 52 residents who received food prepared in the facility kitchen at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure essential equipment was maintained in safe operating condition when the walk-in freezer had not kept frozen food frozen and there was excessive ice build-up on the freezer floor. These failures had the potential for the freezer to not function in the way it was intended which could lead to contamination of food, and in turn food-borne illnesses for the 52 residents who received food prepared by the kitchen. Excessive ice build up could pose a safety hazard and accidents for vendors and employees who enter the walk-in freezer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care to residents in accordance with professional standards of practice for four of 19 sampled residents (Resident 17, 50, 21, and 23) when: 1. Resident 17 had continuous oxygen (02) administered with no Medical Doctor (MD) order. 2. Resident 50 did not have medication administered as directed by MD order. 3. Resident 50 did not have 02 tubing changed weekly and labeled per resident centered care plan, nor professional standard of practice. 4. Resident 21's treatment was not completed as directed by MD order. 5. Resident 23 did not have 02 tubing labeled and dated per resident centered care plan, nor professional standard of practice. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide 80 square feet per resident per room in 12 of 22 resident rooms, as required by regulation (Rooms 1, 2, 3, 4, 5, 17, 18, 19, 20, 21, 22, and 23). This failure had the potential to result in inadequate space for care and services provided as well as potential to negatively affect resident physical and emotional comfort and feelings of overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Physical Therapy (PT) in a timely manner to meet the needs of one of 19 sampled residents (Resident 31) when needed therapy services were delayed due to an insurance transfer from another facility. This failure caused Resident 31 to feel angry, sad, and had the potential for a functional decline.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of 19 sampled residents (Resident 21) was treated with dignity and respect when Registered Nurse (RN) G was rude during direct resident care. This failure had the potential to result in emotional stress, embarrassment, feelings of neglect, increased anxiety, and the potential for negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents sampled for Abuse (Resident 7), was free from verbal abuse when Certified Nurse Assistant (CNA) I verbally abused Resident 7. This failure had the potential to negatively impact Resident 7's sense of security, emotional, and psychological well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the Interdisciplinary Team (IDT, the facility managers who meet to discuss the care needs of the residents) developed care plans for one of nineteen sampled residents (Resident 23), when there was no care plan developed for pain management or oxygen use for Resident 23. This failure had the potential for staff to not be fully informed on Resident 23's needs regarding pain control and respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized patient -center care plan for one of two sampled residents (Resident 1) with dementia (loss of memory, language, and problem-solving) when: 1. Resident 1 became physically aggressive when given a shower and Certified Nursing Assistant (CNA) A did not follow interventions to leave and return 5-10 minutes later and try again. 2. Interventions were not developed to address Resident 1's preference of taking showers in the afternoon. These failure contributed to Resident 1 becoming combative, and CNA A grabbing onto Resident 1's wrist which became red, swollen and tender.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a care plan for one of three sampled residents (Resident 2) was revised and updated to reflect current individual needs for a change in condition after a hospitalization to include comfort care (end of life care wishes) with new pain medications. This failure resulted in Resident 2's individualized care needs to go unrecognized, and the potential for a further decline in Resident 2's physical, mental, and psychological status.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a skin assessment was completed upon re-admission to the facility for one of two sampled residents, (Resident 2). This failure had the potential for a negative clinical outcome, re-hospitalization, and Resident 2 had specific skin treatment needs that were not identified in a timely manner.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of abuse involving two residents (Residents 1 and 2) and provide the California Department of Public Health (CDPH) with the 5-day investigation results. This failure had the potential for abuse allegations to go uninvestigated and placed residents living at the facility at risk for harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure that only staff with a verified license were assigned to care for patients when one staff member was assigned nursing duties before the facility verified she had obtained a nursing license. This had the potential to effect the safety and quality of care for all residents of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a full time Registered Dietician (RD) or a clinically qualified nutritional professional (CDM) to provide direct oversight of dietary staff to deliver safe and sanitary food service for 49 of 49 residents when: 1. Dietary staff did not follow safe and sanitary food service practices. Refer to F 802 and F 812. 2. RD, Unqualified Dietary Manager (UDM), and CDM did not ensure all dietary staff had required state and federal competencies to work in the kitchen upon hire. Refer to F 802 3. RD did not ensure all identified issues in the kitchen/sanitation audits were acted upon and resolved. Refer to F 812 4. RD, UDM, and CDM members of the facility weight committee, did not ensure one of two residents (Resident 22) reviewed for weight loss, received interventions to prevent severe weight loss. Refer to F 692. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status when staff did not identify insidious weight loss (gradual, unintended, progressive weight loss over time), implement, or modify a plan of care that was individualized and consistent with the resident's needs or preferences for one of two sampled residents (Resident 22). These failures resulted in severe weight loss and put Resident 22 at risk for further health decline. Refer to F 801.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing staff for the first and second quarters of the year of 2024. This failure had the potential to result in the facility to not provide necessary care and services to meet the need of the resident, and maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Registered Nurse (RN) was on duty at least eight consecutive hours a day, seven days a week for the first and second quarters of the year of 2024. This failure had the potential to result in the facility to not provide care and services to meet the residents' needs for nursing care in a manner and in an environment which promoted each resident's physical, mental, and psychosocial well-being, thus enhancing their quality of life.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure the kitchen had sufficient and competent dietary staff in the position to perform their related duties when: 1. Eight out of 10 kitchen staff did not have the required competencies and training to peform their job duty requirements. 2. Two of 10 kitchen staff were unable to verbalize and demonstrate how to test the sanitizing solution and how to set up an emergency 3-compartment sink (wash by hand) according to the manufacturer guidelines. 3. One of 10 kitchen staff did not know the correct temperature of walk-in freezer and did not report the issues to adminstrative staff. These failures had the potential to result in foodborne illnesses from cross contamination or the growth of microorganisms for the 49 residents eating food prepared in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in accordance with professional standards for food service safety when: 1. Freezer temperatures were not maintained within range. 2. Food was improperly dated in refrigerator and dry storage. 3. Two of 10 kitchen staff were unable to verbalize and demonstrate how to test the sanitizing solution and how to set up an emergency 3-compartment sink (wash by hand) according to the manufacturer guidelines. 4. Flies and other pests throughout the kitchen during cooking and plating food (tray-line). 5. Dirty scoop, mixing bowl and garbage can lid. 6. Dietary staff did not wash hands before handling food in kitchen. 7. Non dietary staff service vendor entered tray-line cooking area multiple times during meal preparation without hair and face net. [...]

Inspectors wroteBased on interview, and record review, the facility's Administrator (ADMIN) failed to ensure effective oversight and necessary resources to ensure resident care services were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when: 1. The ADMIN failed to ensure a full time Registered Dietician (RD) or a Certified Dietary Manager (CDM) to provide direct oversight of dietary staff to deliver safe and sanitary food service for 49 of 49 residents. a. Dietary staff did not follow safe and sanitary food service practices. Refer to F 802 and F 812. b. RD, Unqualified Dietary Manager (UDM), and CDM did not ensure all dietary staff had required state and federal competencies to work in the kitchen upon hire. Refer to F 802 c. RD did not ensure all identified issues in the kitchen/sanitation audits were acted upon and resolved. [...]

Inspectors wroteBased on interview and record review, the facility's Governing Body (GB, legally responsible for establishing and implementing facility policies) failed to effectively manage the facility when: 1. The GB did not ensure adequate oversight and monitoring of the dietary department. Refer to F 801, F812. 2. The GB failed to ensure and effective Quality Assessment and Assurance Program to identify, implement corrective actions and evaluate their effectiveness. This resulted in an Immediate Jeopardy (IJ - a situation where a provider's noncompliance with requirements has, or could, result in serious harm, injury, impairment, or death to a resident) for failure to provide qualified oversight to perform daily kitchen inspections, provide feedback to staff, ensure kitchen staff is competent in performing their job duties effectively. Refer to F 801.

Inspectors wroteBased on interview and record review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) committee when they did not identify nor correct facility issues to ensure care and services met resident needs when: 1. There was no full time Registered Dietician (RD) or a Certified Dietary Manager (CDM) to provide direct oversight of dietary staff to deliver safe and sanitary food service for 49 of 49 residents. This resulted in an Immediate Jeopardy (IJ - a situation where a provider's noncompliance with requirements has, or could, result in serious harm, injury, impairment, or death to a resident) for failure to provide qualified oversight to perform daily kitchen inspections, provide feedback to staff, ensure kitchen staff is competent in performing their job duties effectively. Refer to F 801. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to have an effective Quality Assessment and Assurance (QAA) program, when the QAA committee did not adequately identify, address, implement or monitor the effectiveness of implemented plans of action to correct deficiencies when: 1. There was no full time Registered Dietician (RD) or a Certified Dietary Manager (CDM) to provide direct oversight of dietary staff to deliver safe and sanitary food service for 49 of 49 residents. This resulted in an Immediate Jeopardy (IJ - a situation where a provider's noncompliance with requirements has, or could, result in serious harm, injury, impairment, or death to a resident) for failure to provide qualified oversight to perform daily kitchen inspections, provide feedback to staff, ensure kitchen staff is competent in performing their job duties effectively. Refer to F 801. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the essential facility equipment was maintained when: 1. Communication call light system was working for two rooms. This failure had the potential for residents with non-working call light systems to be at risk for accidents and their care needs not being met. 2. Walk-in freezer was not keeping food at the required 0 or below degrees Fahrenheit (F). 3. Dishwasher in the kitchen was not working. The dietary department equipment not in working order which had the potential for all residents to be at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure they maintained an effective pest control program when flies and other pests were observed throughout the building. This resulted in residents to experience flies landing on them during meals and did not honor their right to have a home environment free from pests.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a reasonable accommodation(s) of resident needs and preferences for three of 33 residents (Resident 45, 38 and 35) in room [ROOM NUMBER] with less than 80 square feet per resident. This resulted in Resident 35 not being able to achieve independent functioning, dignity, and put all residents in room [ROOM NUMBER] at risk for accidents and hazards. Refer to F 912.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Interdisciplinary Team (IDT, the facility managers who meet to discuss the care needs of the residents) reviewed and revised the care plan for three of seven (Resident 8, 15, and 52)) sampled residents when: 1. Resident 15 had two falls without injury and the care plan was not revised or reviewed which resulted in Resident 15 having another fall with injury. Refer to F689. 2. Resident 8 had two Hoyer lift (a mechanical device use to lift an individual from a bed or wheelchair) incidents and the care plan was not revised or reviewed timely. 3. Resident 52 who had multiple fall history, the care plan was not revised or reviewed timely. These failures had the potential for staff to not be fully informed of the residents' health status to determine the need for further assessment and intervention.

Inspectors wroteBased on interview and record review, the facility's nursing staff failed to assess and reevaluate the continued need for a suprapubic urinary catheter (a hollow flexible tube inserted through a cut in the abdomen that is used to drain urine from the bladder into a bag) for one of four sampled residents (Resident 12). The delay in identifying a change in condition resulted in emergent hospitalization, pain, and urinary tract infection (UTI - bacterial infection in urinary system).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure social services met the needs for four of 12 sample residents (Resident 6, 8, 12, and 303) when: 1. Weekly telehealth psychic assessment and evaluation was ordered for Resident 6. This had the potential that mental health resources were overused and wasted, and unnecessary medical treatment was provided to Resident 6 who did not exhibit any behavior issue. 2. Quarterly care conference was not arranged for Residents 8. This failure resulted in Residents 8 missing the opportunities to discuss and express the concerns related to the care Resident 8 had received. 3. Discharge Care Planning was not developed for Resident 303. This had the potential for Resident 303 to not be emotionally prepared for discharge. 4. Urology consult was not arranged for Resident 12. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store drugs under proper temperature controls and failed to label drugs in accordance with professional standards when: 1. The medication room (where medications were stored) had temperatures that exceeded manufacturer's recommendations. This failure had the potential to compromise the medications stored in the medication room. 2. One of nine resident's (Resident 302), sampled for medication administration, had physician's instructions on the Medication Administration Record (MAR) for potassium chloride to be given with a full glass of water and the pharmacy label instructions for administration of the medication to be given with food. This failure had the potential for Resident 302 to experience abdominal discomfort if potassium chloride was not given as indicated by the manufacture instructions.

Inspectors wroteBased on observation, interview, and document review, the facility did not provide 80 square feet per resident, as required by regulation, in 12 resident rooms (Rooms 1, 2, 3, 4, 5, 17, 18, 19, 20, 21, 22, and 23). This had the potential to result in inadequate space for care or services and impact a residents' right to an environment that meets the unique needs and preferences and prevents them from achieving independent functioning, dignity, and well-being. Refer to F558.

Inspectors wroteBased on interview and record review, the facility failed to ensure two Quarterly Minimum Data Set Set (MDS, a standardized assessment of an adult's functional, medical, psychosocial, and cognitive status) assessments were accurate for one of seven (Resident 15) residents sampled for falls, when the fall section of the MDS did not identify Resident 15's two falls. This failure resulted in Resident 15 having multiple falls due to having an inaccurate reflection of what care was needed to prevent falls.

Inspectors wroteBased on interview and record review, the facility failed to complete baseline care plans (initial goals with interventions based on admission orders and assessments, which provide instructions for immediate care of the resident) for two of seven residents (Resident 15 and 303) when Resident 15 and Resident 303 did not have a baseline care plan developed for being at risk for falls in the first 48 hours of admission to the facility. This failure resulted in Resident 15 and Resident 303 not having appropriate care needed to prevent falls.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive care plans for two of seven sampled Residents when: 1. Resident 15 was at risk for falls and there was no comprehensive Fall Care Plan developed with interventions to prevent Resident 15 from falls. This failure resulted in three falls for Resident 15. 2.a. Resident 303 was at risk for falls and there was no comprehensive Fall Care Plan developed to prevent 303 from falls. b. Resident 303 was planning on going home but there was no Discharge Care Plan developed. These failures put Resident 303 at risk for falls and the feeling of being uniformed of her discharge plans.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that two of seven sampled residents (Resident 15 and 303) who were evaluated for their risk for falls, reevaluated after falls, or had care planned interventions to prevent falls and/or further falls when: 1. Resident 15 had inaccurate and absent Fall Risk Evaluations, (an assessment that checks a resident's risk of falling by assessing clinical conditions including mental status, history of falls, vision, walking and balance, blood pressure, and medications that would increase a risk of falling.) and did not have Fall Care Plans developed with interventions to prevent falls. 2. Resident 303 had an inaccurate Fall Risk Evaluation and did not have a Fall Care Plan developed with interventions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain medication was administered as per physician order for one of nine residents (Resident 303), sampled for medication administration, when gabapentin (a pain medication) was not administered as prescribed by the physician. This failure placed Resident 303 at risk for poor pain control and a decrease in health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents had a safe, comfortable, and homelike environment and implement their policy titled, Loss or Heating or Cooling (undated) when: 1. Six of 16 residents (Resident 1, 2, 3, 4, 5, and 6) complained of their room and the dining room being too hot for them. 2. The facility did not take immediate actions to fix the air-conditioner (AC) as per their policy, when one of two ACs was not working on June 3, 2024. 3. The facility did not report the interruption of the essential services (air conditioning) to the California Department of Health (CDPH) as per their policy titled, Unusual Occurrence Reporting (undated). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident care equipment was maintained in a safe operating condition when a large metal meal tray cart (tray cart, large metal cart on wheels that was used to transport resident meal trays) fell over when the housekeeper (HK) moved the tray cart out of her way. This failure had the potential to cause physical and psychosocial injury to residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that dignity and privacy were maintained for two residents (Resident 1 and Resident 3) when a psychiatric tele health (appointment with a health care provider conducted remotely on a video screen), visits were conducted in a public location. This had the potential for other residents, staff, and visitors to overhear protected and private information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, safe and homelike environment for two of four non-smoking residents (Resident 4 and 5), sampled for the effects of smoking in the facility when; 1. Resident 4 had to keep her curtains and window closed in her room because the dedicated smoking section was right outside her window and residents would peer into her room while smoking. 2. Resident 5 had to keep her window closed in her room because the dedicated smoking section was right outside her window and when smoke came in her room, she would experience breathing issues. This failure had the potential to negatively affect the quality of life for Resident 4 and 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety for three of nine residents (Resident 1, 2, and 3), sampled for safe smoking, when: 1. Resident 1's Safety Smoking Evaluation identified Resident 1 to have unsafe smoking behaviors but determined him to be an independent smoker (safe to smoke unsupervised) and was observed to have unsafe smoking behaviors. Residents 1 was observed smoking without using a smoking apron (a covering to protect the resident from dropping hot ashes on their clothes), an ashtray, and was smoking outside in an undesignated smoking section (a designated smoking area was where smokers are instructed to smoke and was equipped with a fire extinguisher, smoking blanket, and an ash tray), which did not have a fire extinguisher, smoking blanket, or an ash tray. 2. [...]

Inspectors wroteBased on interview and record review the facility failed ensure one of two sampled residents (Resident 1), reviewed for physician orders for a Psychologist (a person who treats mental, emotional and behavioral disorders) evaluation, received appropriate treatment and services. This failure had the potential to cause a deterioration of Resident 1's mental and psychosocial well-being. Findings. A review of the facility's policy titled Provision of Physician Ordered Services dated February 2023, indicated Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations), to the appropriate entity. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to timely administer routine medications to meet the needs of the residents, when one of three residents sampled for timely medication administration (Resident 1) had multiple incidents of routine pain medications being administered from two to six hours late, after the time the medications were ordered to be administered. This failure had the potential to cause Resident 1 to experience increased incidents of general uncontrolled pain issues and negatively impact their physical and emotional health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety and security for: 1. All residents that resided in the facility when five of eight facility entrance doors (Door 1 front door, Door 2 side door, Door 3 laundry hall door, Door 4 back door, Door 5 dining room door) were found to be unlocked during the night and staff were unaware how to lock them. 2. One of one sampled resident (Resident 1) when staff had disarmed, by unplugging, a wanderguard alarm system (a system that alarms and alerts staff when a resident, who was assessed to wander, (attempts to leave the building without staff knowledge or supervision), because the alarm was bothersome to the staff. This disregard for resident safety subjected residents to an unsafe environment which could have had a serious negative impact on their health, safety, and welfare. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to accommodate for one of four sampled residents (Resident 2), who were reviewed for their ability to use the call system (The system that allows residents to notify the staff if they need or want something.), when Resident 2 was paralyzed from the neck down and had a call light that required the use of her hands to operate it. This failure caused Resident 2 to have to yell for help while in her room and made her feel like she was a prisoner.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This failed action had the potential for residents not to be assessed and provided RN services when required.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure that registry Licensed Vocational Nurse (LVN) 1 (a nurse from a registry staffing agency is not a permanent employee of the facility), was oriented to the facility's medication administration system, was accompanied by a Charge Nurse for at least three days to ensure that the facility's established medication administration procedures had been learned, and that LVN 1 followed the five rights of identifying a resident before administering medication (right resident, right medication, right dose, right time and right route (as in by mouth, injection or intravenously), for one of two residents (Resident 1) sampled for medication errors. LNV 1 gave Resident 1 cardiac (heart medications) and blood pressure medications that were prescribed for Resident 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of three sampled residents (Residents 1 and 2) were provided with help to set up their supplies to brush their own teeth when: 1. Resident 1's toothpaste and toothbrush was on her nightstand and she could not reach them. 2. Resident 2's mouthwash and a cup to rinse her mouth were not set up for her to independently use, when she was paralyzed (not able to move), on her right side. This had the potential for Residents 1 and 2 to develop cavities, mouth pain and gum disease and could cause a decline in their ability to perform oral hygiene with minimal staff assistance, and had the potential for all residents who needed help with oral care to have a decline in their oral health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of three sampled Certified Nurse Assistants (CNAs) demonstrated competencies (Centers for Medicare and Medicaid defined competency as a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully), when the Director of Staff Development (DSD) did not evaluate CNA A and CNA B's competencies and skill sets prior to working with residents who lived at the facility. This had the potential to negatively impact resident's physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to that two of three sampled residents (Resident 1 and Resident 2), had accurate and/or complete Activities of Daily Living (ADLs- dressing, grooming, bathing, toileting and hygiene), documentation in their medical record when, both resident's ADL records contained incomplete documentation as to whether or not the residents had received oral care and incontinent (no control over bowel and bladder), care. This failure had the potential for an inaccurate representation of Resident 1 and 2's current status and for changes to go unrecognized, which could negatively impact their continuity of care and health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain medication for one of two sampled residents (Resident 2) when medication prescribed by physician was not available for administration. This failure had the potential to negatively affect Resident 2 ' s health due to multiple sclerosis (MS-a disease of the brain and spinal cord causing weakness, numbness, partial or complete loss of vision, fatigue, memory, mood and cognitive problems).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 1), received treatment and care in accordance with professional standards of practice when Resident 1 experienced symptoms of a urinary tract infection (UTI-an infection of the bladder) and no laboratory test were ordered for eight days. This deficient practice had the potential for Resident 1 to go without laboratory monitoring to detect signs of infection and not to receive appropriate care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residnts' right to be free from deprevation of goods and services for three out of three sampled residents (Resident 1, 3, and 4) when: 1a. The facility had no documented evidence for providing wound care as ordered by the physician for Resident 1. (Refer to F684) 1b. The facility had no documented evidence for providing wound care as ordered by the physician for Resident 3. (Refer to F684) 1c. The facility had no documented evidence for providing wound care as ordered by the physician for Resident 4. (Refer to F684) 2a. The facility ran out of wound care supplies for Resident 1, that were necessary to provide care and physician ordered wound care. (Refer to F684) 2b. The facility ran out of wound care supplies for Resident 3, that were necessary to provide care and physician ordered wound care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify or provide needed wound care and services to three out of three sampled residents (Residents 1, 3, and 4) when: 1. The facility failed to ensure Licensed Nurses (LN) provided Resident 1 with wound assessments (an exam that described the condition of a wound and measurements) that accurately reflected Resident 1's wound condition upon admission to the facility, did not provide Resident 1 with physician ordered wound consult (a doctor that specialized in wound care to exam the wound), did not document physician ordered wound care treatment (care that was ordered to treat the wound), and did not have required wound care supplies. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to report an outbreak of COVID-19 to the California Department of Public Health (CDPH, works to protect the public's health) when six residents and four staff members tested positive for COVID-19. This failure had the potential for the further spread of COVID-19 to other residents.

Inspectors wroteBased on observation, interview, and record review, Licensed Nurse (LN) B failed to explain what nursing services were being provided to one out of two sampled residents (Resident 2) when LN B handed Resident 2 a cup full of medication without explaining what medication was being provided. This failure had the potential to not allow Resident 2 the right to be informed or make an informed decision regarding care and services received by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of one out of three sampled residents (Resident 1) in a timely manner when Resident 1 requested the use of bedrails (metal or plastic bars attached to side of bed) to promote mobility and independence (the ability to turn, reposition, or sit up without the assistance of staff). This failure had the potential for an inability to maintain independence or achieve independent functioning and effect resident well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the privacy curtain track (a metal rail attached to the ceiling that held a moveable curtain that provided residents with privacy) in one out of three observed resident rooms (Resident 1), was in good repair when an approximated two-foot-long section was detached from the ceiling. This had the potential for the privacy curtain to not work properly or to detach further from the ceiling and fall onto Resident 1's bed.

Inspectors wroteBased on observation, interview, and record review, Licensed Nurse (LN) A (an MDS nurse) inaccuratley coded the Minimum Data Set (MDS, a comprehensive assessment tool that helped identify resident care problems) for one out of three sampled residents (Resident 1) when: 1. LN A inaccurately coded the MDS for Section H- Bowel and Bladder for Resident 1, indicating that Resident 1 was incontenent (not having control over bowel and bladder) when Resident 1 was continent (having control over bowel and bladder). 2. LN A inaccurately coded the MDS for Section M- Skin Conditions For Resident 1, indicating that Resident 1 did not have wounds when Resident 1 was admitted with two wounds. This failure had the potential for a decline in Resident 1's wound and bowel and bladder status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of three sampled residents (Resident 1) received wound care treatment and services necessary to avoid a facility aquired pressure ulcer that was not present upon admission. This failure contributed to the development of a Stage 2 pressure injury (CMS defined a Stage 2 Pressure injury as: partial thickness loss of skin presenting as a shallow ulcer with red or pink wound bed, without slough or bruising) to the coccyx (tail bone area).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 1) remained continent of his bowel and bladder when they did not develop an individualized toileting program, gave Resident 1 incontinent briefs (adult diapers) instead of offering toileting, and staff did not provided required assistance for toileting. This resulted in Resident 1 becoming incontinent of his bowel and bladder and put Resident 1 at risk for infections, skin breakdown and a loss of dignity.

Inspectors wroteBased on interview and record review the facility failed to provided one out of three sampled residents (Resident 1) with adequate pain control when: 1. Licensed Nurses (LN) did not recognize that Resident 1's repeated use of PRN (as needed) pain medication indicated the need to assess the current pain medication regimen and consult with the physician regarding scheduled pain medication. 2. Resident 1's pain was not adequately assessed upon admission to the facility when Licensed Nurse(LN) A documented that Resident 1 did not require a pain assessment interview. This failure had the potential for pain to go unrecognized and to cause a decline in physical, mental, psychosocial health, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 3 of 4 sampled residents who were reviewed for timely medication administrations, were given their medications in accordance with the facility's Administering Medication policy when medications were not given within 1 hour before, or within 1 hour after, the time their physician prescribed the medication to be given. (Resident 1, 3, and 4). This caused Residents 1, 3, and 4 unnecessary pain, anxiety, and interrupted their sleep and gave them feelings of being ignored and lowered their self-worth, which negatively impacted their quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure three out of 10 sampled residents, (Resident 1, Resident 5, and Resident 7) resident rights were protected and were treated with respect and dignity when: 1. Licensed Nurse (LN) B was argumentative with Resident 1 while administering medications. 2. Certified Nursing Assistant (CNA) D was rough while providing incontinent care to Resident 5. 3. CNA D was rude and disrespectful when Resident 7 asked for a cup of coffee. This failure had the potential to cause embarrassment as well as depression and did cause a loss of respect and dignity as well as anger.

Inspectors wroteBased on interview, and record review, the facility failed to report three allegations of abuse, to three residents (Resident 1, Resident 5, and Resident 7) out of 10 sampled residents and failed to conduct a thorough investigation and report it within five days, to the California Department of Public Health (CDPH) when: 1. Licensed Nurse (LN) B was argumentative with Resident 1 while administering medications. 2. Certified Nursing Assistant (CNA) D was rough while providing incontinent care to Resident 5. 3. CNA D was rude and disrespectful when Resident 7 asked for a cup of coffee. This failure had the potential to result in abuse to other residents in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to conduct a thorough and immediate investigation of alleged abuse, prevent further potential abuse or mistreatment while the investigation was in progress, and provide complete and thorough documentation for three residents (Resident 1, Resident 5, and Resident 7) out of 10 sampled residents when: 1. Licensed Nurse (LN) B was argumentative with Resident 1 while administering medications. 2. Certified Nursing Assistant (CNA) D was rough while providing incontinent care to Resident 5. 3. CNA D was rude and disrespectful when Resident 7 asked for a cup of coffee. This failure had the potential to result in abuse to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate, assess, and provide wound care treatments for pressure ulcers (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear) for three of three sampled residents (Residents 1, 2, and 3). 1. Resident 1's treatments were not done as ordered by his physician. 2. Resident 2's treatments were not done as ordered by her physician and wound assessments were not done in accordance with facility policy and practice. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide three out of four sampled residents (Residents 4, 5, and 6), medications in accordance with their Medication Administration policy when: 1. Residents 4, 5 and 6 were not given their medications within the time frames allowed, therefore, received them later than they should have. 2. Licensed Nurses (LN) C and LN D had not documented when they administered Resident 6's medications until the end of their shifts, instead of when they were actually given. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide one out of three sampled residents (Resident 3) with the right to be fully informed (having knowledge) of care to be provided and resident rights when the facility did not obtain a Consent to Treatment (a document that was reviewed during the admissions process, that outlined resident rights and described care the resident would receive from the facility). This failure caused Resident 3 and Family Member (FM) 1) to not have knowledge of basic resident rights or care that would be provided.

Inspectors wroteBased on interview and record review, the facility did not follow their Resident Council Meetings (A group of residents who meet monthly to discuss concerns about living in the facility), policy and procedure when, Resident Council Minutes forms were not utilized and there was no documentation that indicated the facility followed up on resident concerns or recommendations. This failure had the potential to negatively impact resident rights and not accurately capture identified resident concerns or recommendations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect two out of four sampled residents (Resident 1 and 2) from abuse when; Certified Nurse Assistant (CNA) B provided care that was rough and painful. This failure had the potential to cause harm and caused Resident 2 to have short term feelings of fear, anger, and helplessness.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of alleged staff to resident abuse to the California Department of Public Health (CDPH) within two hours for one out of three sampled residents (Resident 1) when Resident 1 reported Certified Nurse Assistant (CNA) B was rough during care and caused Resident 1 pain on 1/18/24 and the facility did not report to CDPH until 1/19/24. This failure caused a delay in the investigation process and placed resident's at risk for potential abuse.

Inspectors wroteBased in interview and record review, the facility failed to follow their Abuse policy and procedure (P&P), when an allegation of staff to resident abuse was not thoroughly investigated for one out of three sampled residents (Resident 1). This failure placed residents that lived in the facility at risk for further potential abuse.

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of abuse, to one resident (Resident 7) out of 12 sampled residents and failed to report the abuse within 2 hours, to the California Department of Public Health (CDPH). This failure had the potential to result in abuse to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were ordered, reordered, available, and administered in accordance with their physician ' s orders for 13 out of 31 sampled residents (Resident 2, 4, 10, 12, 13, 19, 22, 24, 25, 28, 31, 37 and Resident 38) when: 1. Resident 2 was not given two doses of Lovenox (a blood thinner) on 12/21/23 and 12/22/23. 2. Resident 4 was not given Lasix (a diuretic medication) and Coreg (a heart medication) on 12/21/23 at 8:00 pm. Resident 4 was not given the following morning medications on 12/22/23 at 08:00 am: Digoxin (a heart medication), Coreg, Lasix, Potassium Bicarbonate (a supplement for high blood pressure), Jardiance (a diabetic medication), Nicotine patch (a tobacco cessation product), Spironolactone (a diuretic medication), and Lisinopril (a medication to treat high blood pressure). 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop a base line care plan within 48 hours for five of five sampled residents (Resident 2, 25, 28, 29, and Resident 30). This failure had the risk to not meet the individual needs of the residents and cause a negative clinical outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 6 of 6 sampled residents (Residents 2, 5, 6, 7, 11 and Resident 39), received assistance with activities of daily living (ADLs, activities related to personal care including bathing/showering, dressing, hygiene, and grooming), to attain or maintain their independence when routine and scheduled showers and nail care were not completed for residents. These failures had the potential to result in residents feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was sufficient staff to meet the needs of the residents when: 1. Showers/Bathing and nail care were not completed as scheduled for December 2023. (Refer to F677) 2. Resident 39 had not received finger nail cleaning and trimming. 3. Certified Nursing Assistants (CNAs) were unable to attend to a resident's (Resident 7) request to go back to bed, because there were not enough CNAs to pass meals trays and help feed residents. These failures had the potential to result in residents feeling ignored and neglected and could negatively impact their ability to attain or maintain their highest practicable level of physical, mental, and psycho-social well-being.

Inspectors wroteDuring observation, interview and record review, the facility failed to ensure that the Licensed Nurses (LNs) were competent and had the skills and knowledge base to provide quality care to the residents and that these competencies and skills were evaluated when: 1. The LNs were not aware of the facility's policies and procedures on how to order and re-order medications and the residents went without medications. Refer to F755 2. The LNs were not aware that Certified Nursing Assistants (CNAs) cannot apply oxygen to residents. Refer to F695 3. LNs did not have their competencies and skills evaluated to determine their knowledge base. These failures had the potential to result in residents receiving substandard quality of care and their needs unmet and result in their inablility to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours per day, 7 days a week. This failure had the potential to adversely affect oversight and direction regarding residents ' quality of care and quality of life directly impacting overall health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their Infection Control Program policies and procedures for controlling and reporting communicable diseases and infections when; 1. Resident 21 was positive for Covid (a serious respiratory infection), and allowed to wander about the facility without a mask. 2. Licensed Nurse (LN) M was positive for Covid before her shift began on 12/16/23, and had symptoms, and worked taking care of residents, and then worked again on 12/19/23. These failures put the residents, staff and families at risk for contracting Covid infections and had the potential to result in serious negative clinical outcomes for this vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of two sampled residents (Resident 1), was seen and evaluated by a Licensed Nurse (LN), upon admission, to ensure that he was being given oxygen in accordance with his physician's orders. This failure had the potential for a negative clinical outcome.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy related to training and screening of newly hired staff. 1. The criminal background search was not done for one of eight newly hired employees. This had the potential that the facility may have hired an employee who had been found guilty of abuse and expose all residents to abuse. 2. The abuse training was not done for four of eight newly hired employees. This had the potential to cause employees not to recognize or report resident abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their established menu and associated recipe, during a breakfast observation on 11/14/19. This failure had the potential to lead to unintentional weight loss, or residents experiencing a decreased level of satisfaction in terms of their expectations for the food being served.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain a clean and orderly environment in the dietary department; when there were multiple areas of peeling paint, and a rusted ceiling vent, above where the clean dishes were stored in the dishwashing area. These failures could lead to the spread of infections, communicable diseases, and food borne illness to all residents who are served out of this kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Follow physician's orders for wound care for two of four sampled residents (Residents 5 and 14). with wounds resulting from pressure and/or shear (a strain in the skin structure produced by pressure, when its layers are laterally shifted in relation to each other); 2. Identify a buttocks shear wound as a pressure related injury, resulting in completing a non-pressure ulcer skin condition record, and omitting documenting of the wound as a stageable pressure injury, (Resident 5) and 3. Complete weekly comparable pressure wound assessments when pressure wound documentation was omitted completely and/ or different staff measured wounds in an inconsistent manner (Resident 5). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient and competent staff when: 1. Five of six confidentially interviewed residents, and Resident 4, reported short staffing causing call light response delays and delays in care when staff were busy, and 2. Current licensed nursing staff (Licensed Vocational Nurses) were not sufficiently trained to consistently identify, document, and measure wounds (refer to F686). These failures had the potential that resident care was delayed or not met, and that wound evaluations were not comparable.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide physician ordered tele-psychiatry consultation services when follow up appointments were not scheduled for one of two sampled residents receiving the services (Resident 11). This failure had the possibility that the expertise of the consulting psychiatrist would not be available for the prescribing physician to consider when prescribing and renewing psychiatric medications.

Inspectors wroteBased on observation, interview, and document review, the facility did not provide 80 square feet per resident, as required by regulation, in 12 resident rooms (Rooms 1, 2, 3, 4, 5, 17, 18, 19, 20, 21, 22, and 23). This had the potential to result in inadequate space for care or services to be provided to residents residing in these rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete an activities assessment and personalized activities care plan for one of 12 residents (Resident 31). This resulted in a delay in recognizing the activity preferences and interests for Resident 31 and had the potential to result in boredom and a psychosocial decline.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper storage of medications when the E-kit (emergency kit that contain frequently used medications that needed to be given right away) was opened with 3 medications removed without notification of the pharmacy for replacement of the drugs. This failure had the potential of drugs not being available for administration to residents during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up on a pharmacy drug regimen review (DRR) recommendation for one of six sampled residents reviewed for unnecessary medication (Resident 11). This failure had the potential that pharmacy recommendations for Gradual Dose Reductions (GDR) were not acted upon and that medications may not be at the lowest dose necessary.

Inspectors wroteBased on interview and record review, the facility failed to comply with its antibiotic stewardship program, when one of two residents (Resident 21) with urinary tract infections (UTIs), during the months of 9/2019 and 10/2019, were treated without associated signs and symptoms. This had the potential to result in unnecessary antibiotic usage and adverse side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to post daily nursing staffing data and retain posted staffing data for 18 months. This failure resulted in staffing data not being available to the facility residents and visitors