Sherman Oaks Health & Rehab

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach for three of five sampled residents (Residents 5, 57, 31) reviewed under environment task. This deficient practice had the potential to result in a delay in care, and inability to ask for assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one of three sampled residents (Resident 26) reviewed for physical restraints by failing to ensure that Resident 26's use of restraint bed placed against the wall had a current physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), restraint assessment, and a care plan (a document outlining a detailed approach to care customized to an individual resident's [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards by failing to: 1. Ensure residents were not left unattended by staff with the bed in the high / elevated position (a working height (typically that allows caregivers and nurses to perform medical tasks comfortably) for one of six sampled residents (Resident 10) reviewed for Accidents. 2. Ensure the bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was connected and functioning for one of two sampled residents (Resident 49) reviewed for Physical Restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two of two sampled residents (Residents 5 and 38) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq- beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe handling of medications and maintain safe and secure storage by failing to: 1. Label Artificial Tears (eyes drops used to lubricate dry eyes) with the resident's name for two residents (Resident 71 and 40) during the inspection of one of four medication carts (Medication Cart 3/AM) investigated during the Medication Storage and Labeling task. 2. Ensure prepared and unlabeled medications were not stored in the medication cart for two residents (Resident 30 and 19) during the inspection of one of four medication carts (Medication Cart 3/AM) investigated during the Medication Storage and Labeling task. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly document medical records for one (1) of three sampled resident (Resident 8) by failing to accurately document the Metoprolol (a prescription medication that slows down the heart rate and relaxes the blood vessels) in the Medication Administration Record (MAR - a list of scheduled medications and other instructions ordered by the medical director) was held but was documented as given on 6/14/2026, 6/15/2026, and 6/27/2026. These failures had the potential to result in incomplete, inaccurate, or delayed records that could lead to miscommunication between healthcare providers and resident harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the electrical and resident care equipment were in safe operating condition for three of six sampled residents (Residents 38, 53, and 63) reviewed under environmental task by failing to: 1. Ensure Resident 38 and 53 did not have any frayed wires on the residents' bed remote controls (handheld devices that allow residents or caregivers to adjust the position of a motorized medical bed). 2. Ensure Resident 63's bedside electric fan did not have dust build-up on the fan blades and protective grill. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from the use of unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to: 1. Ensure as needed (PRN) lorazepam (a psychotropic medication use to treat feelings of anxiousness) physician orders included a stop date (indicates when medication will no longer be administered or dispensed directed by the prescriber) on 3/12/2026 and 6/22/2026 for one of one sampled residents (Residents 83) reviewed for Hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of two sampled residents (Resident 7) reviewed under pressure ulcer/injury by failing to ensure the facility obtained an order for a right heel protector (devices or covers used to either protect your foot from pain and injury or to safeguard the heels of your shoes from wear and tear) that was applied to the resident's right foot with diabetic ulcer (an open sore or wound on the foot caused by complications from diabetes) and right shin vascular ulcer (a slow-healing open sore on the skin caused by [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received services and assistance for one of two sampled residents (Resident 5) reviewed for urinary catheter (a thin, flexible, hollow tube inserted into the bladder to drain urine (pee) when a person cannot urinate normally) or urinary tract infection (UTI, a common infection that occurs when bacteria enters and multiplies in the urinary system, which includes the kidneys, bladder, and urethra) by failing to ensure Resident 5's urinary catheter was secured on the leg strap (an adjustable fabric band used to secure a urinary catheter and its collection bag directly to the thigh or calf) or stat lock (a specialized, adhesive device used in hospitals to securely hold a catheter tube in place on a patient's skin). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure parenteral fluids (liquids, such as medication or nutrition, that are administered to the body by bypassing the digestive system) were administered consistent with professional standards of practice to one of three sampled residents (Resident 74) reviewed for hydration by failing to ensure Resident 74's peripheral intravenous (IV, within a vein) line (a small, flexible plastic tube [catheter] inserted through the skin into a small vein-usually in the hand, arm, or foot-to deliver fluids and medications directly into the bloodstream) had the time and initials of the licensed nurse who inserted the IV line or changed the IV dressing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for one of one sampled resident (Resident 74) reviewed for respiratory care area by failing to ensure the licensed staff used a humidifier (an attachment for oxygen tanks or oxygen concentrators that adds moisture to the pure oxygen) for Resident 74's 10 liters per minute (LPM, measures the volume of supplemental oxygen flowing into a patient's airways over 60 seconds) oxygen administration via face mask (a plastic device worn over the nose and mouth). The deficient practice had the potential for the resident to develop complications such as sore throat, nasal dryness, and coughing. The lack of moisture may also lead to nosebleeds or cracked, bleeding nasal passages.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order to apply half (1/2) side rails (a half-length bed rail is a safety barrier that covers only the top portion of a bed, typically near the user's torso) for two of two sampled residents (Residents 38 and 63) reviewed for bed rails (metal or plastic bars or guards attached to the sides of a bed to act as a barrier or support). These deficient practices placed the residents at risk for potential accident such as a body part being caught between the rails, falls if a resident attempts to climb over, around, between, or through the rails.

Inspectors wroteBased on observation, interview, and record review the facility failed to account for two (2) doses of controlled substances (CS- medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics, drugs or controlled medication) for Resident 10 and one (1) of five (5) inspected medication carts (Medication Cart 3/AM) reviewed during the Medication Storage and Labeling task. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for one of one sampled resident (Resident 5) reviewed for anticoagulant (blood thinner) use by failing to monitor Resident 5 for adverse effects (any unwanted, unpleasant, or harmful result caused by a medical treatment) such as sign and symptoms of bleeding for the use of Eliquis (a prescription blood thinner). This deficient practice could result in increased risk of a broad range of adverse consequences such as bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 26) was not charged for the loss of dentures when Resident 26 paid $800 for the resident's lost dentures. This failure had potentially violated the right of the resident to have a replacement of lost dentures free of cost.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure:1. Licensed Vocational Nurse (LVN) 3 did not place a fluticasone-salmeterol aerosol inhaler (medication that reduces swelling and inflammation in the lungs) container on a resident's bedside rolling table then back into Medication Cart 1 for one of five sampled residents (Resident 108) during the Medication Administration task. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic (ATB, a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) use protocols and a system to monitor antibiotic use for two of two sampled residents (Residents 5 and 4) reviewed for antibiotic use by failing to ensure: 1. Resident 5's Cefepime (a potent prescription-only antibiotic used by hospitals and clinics to treat severe bacterial infections) and Ampicillin (a widely used, prescription antibiotic designed to treat various infections caused by bacteria) had monitoring for its adverse effects (an unwanted, harmful, or unpleasant physical or mental reaction caused by a medical treatment, such as a medication or surgery). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to ensure staff used one sheet and one chux (an absorbent under pads or bed pads used to protect surfaces from incontinence or spills) or disposable brief between Resident 3 and the Low Air Loss Mattress (LALM - a mattress composed of inflatable air cushions used to relieve pressure on body parts). This deficient practice placed Resident 3 at risk for the development of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free of any significant medication errors on [DATE] in accordance with the prescriber's order and accepted professional standards, when Licensed Vocational Nurse (LVN) 1 prepared and brought an insulin pen (an injection device that looks similar to a writing pen and that contains the insulin medication which lowers blood sugar) to Resident 1's bedside that was labeled with Resident 2's name. This deficient practice resulted in Resident 1 seeing the insulin pen with another resident's name on it and feeling stressed from discovering the medication error.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record of one of four sampled residents (Resident 1) was complete and accurately documented, when Licensed Vocational Nurse (LVN 1) failed to document a medication error that occurred on [DATE] in accordance with the facility's own policies and procedures. This deficient practice resulted in an incomplete medical record for Resident 1 on [DATE].

Inspectors wroteBased on interview and record review, the facility failed to report allegation of visitor-to-resident verbal abuse (the act of harassing, labeling, insulting, scolding, rebuking, or excessive yelling towards an individual) within two hours to the State Survey Agency (the agency that inspects long-term care facilities for the purposes of survey and certification), the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to local law enforcement (LLE - police) as per its policies on abuse for one of three sampled residents (Resident 1). This failure resulted in a delay in the investigation and had the potential to place Resident 1 at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, facility failed to maintain privacy of confidential information when staff left electronic health record (EHR- a digital version of a patient's paper chart) opened and unattended for one of four sampled residents (Resident 4). This deficient practice violated Resident 4's right to privacy and confidentiality of medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure an assistive device was used to prevent accidents for one of four sampled residents (Resident 1) when Resident 1, a resident who was dependent (helper does all the effort) on facility staff for surface-to-surface transfers, was transferred without the use of a mechanical lift (also known as a Hoyer lift, a mechanical device used to lift and/or transfer a person). This deficient practice resulted in Resident 1's transfer to the General Acute Care Hospital (GACH), on 3/31/2025, at 1 p.m., where Resident 1 was diagnosed with a left knee fracture (a break or crack in a bone) of the anterior tibial tuberosity (a bony bump located on the front of your shinbone [tibia], just below the kneecap).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication carts were locked when staff were out of view for two of two medication carts (Medication Cart 1 and Medication Cart 2). This deficient practice had the potential for residents and/or unauthorized personnel to have access to the medications in the medication carts.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of three of four sampled residents (Resident 1, Resident 2, and Resident 3) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Certified Nursing Assistants (CNAs) documented Residents 1, 2, and 3's percentage (% - per one hundred) of food eaten on the correct time. These deficient practices resulted in inaccurate information on Residents 1, 2, and 3's medical records and had the potential for delayed and inaccurate medical interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to ensure Resident 1's low air-loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) was set to appropriate setting per manufacturer's guidelines. This deficient practice had placed Resident 1 at risk for the development of pressure ulcers.

Inspectors wroteBased on interview and record review, the licensed nursing staff failed to ensure the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (psychotropic medication, psychotherapeutic medication - a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) for four of five sampled residents (Residents 96, 89, 48, and 8) reviewed for informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to ensure: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to post the most recent survey results in places that are prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents, family members, and legal representatives of residents. This deficient practice resulted in the residents' and their representative not having access to examine the most recent survey results.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) for two of two sampled residents (Residents 49 and 267) reviewed for restraints by: 1. Failing to complete a restraint assessment, obtain a physician's order, obtain informed consent, and development and implement a care plan prior to application of the bed alarm while in bed for Resident 49. 2. Failing to ensure Resident 267 did not have pillows tucked under the fitted sheet on both sides as observed on 3/13/2025 at 10:11 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received person-centered care by failing to implement the Care Plan (a document outlining a detailed approach to care customized to an individual resident's need) for two (2) of three (3) sampled residents (Resident 42 and 79) reviewed for unnecessary medications (any drug in excess) by failing to: 1a. Monitor the side effects (also known as adverse consequences - unwanted, uncomfortable, or dangerous effects that a drug may have) of clopidogrel (a medication used for paroxysmal atrial fibrillation [irregular and fast heartbeat] that thins the blood) and Eliquis (a medication used for atrial fibrillation that thins the blood) for Resident 42. As a result, Resident 42 did not have monitoring for sign and symptoms of bleeding for the use of clopidogrel and Eliquis between 3/1/2025 and 3/13/2025. 1b. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to three (3) of four sampled residents (Residents 107, 17, and 48) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760.

Inspectors wrote4. During a review of Resident 4's admission Record, the admission Record indicated the facility originally admitted the resident on 1/13/2017 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (HTN-high blood pressure), and type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's Fall Risk Assessment, dated 2/27/2025, the Fall Risk Assessment indicated the resident as high risk for falls and care plan will be developed to reduce falls and injuries. During a review of Resident 4's physician order, dated 2/28/2025, the physician order indicated low bed with bilateral upper siderails up with bilateral floor mats to decrease potential injury due to unpredictable related to dementia. [...]

Inspectors wrote3. During a review of Resident 96's admission Record, the admission Record indicated the facility admitted the resident on 3/6/2024, and readmitted the resident on 2/3/2025, with diagnoses including acute respiratory failure (the lungs are suddenly unable to get enough oxygen into the blood or are struggling to remove carbon dioxide), novel influenza A virus (a new type of flu virus that can infect humans), and pleural effusion (an abnormal buildup of fluid between the lungs and the chest wall, which can make it harder to breathe). During a review of Resident 96's H&P, dated 2/5/2025, the H&P indicated the resident was alert and oriented to person, place, time, and situation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who received hemodialysis (HD, process of removing waste products and excess fluid from the body) received treatment consistent with professional standards of practice for one of one sampled resident (Resident 5) reviewed under the Dialysis care area by failing to ensure licensed nurses performed and documented assessments after Resident 5's hemodialysis sessions. This deficient practice placed the resident at risk for a delay in care and services and a delay in detecting complications resulting from HD.

Inspectors wroteBased on observation, interview, and record review, the facility failed to account for three (3) doses of Controlled Medication (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 5, 97 and 272 in one (1) of four (4) inspected medication carts (Medication Cart Middle Station Morning.) As a result, control and accountability of CMs and availability of medications did not follow state and federal regulations and facility policy and procedures (P&P). [...]

Inspectors wroteBased on interview and record review, the Consultant Pharmacist (CP) failed to report any irregularities in the monthly drug regimen review to the attending physician and director of nursing to two (2) of three (3) sampled residents (Resident 42 and 79) reviewed for unnecessary medication (Resident 42 and 79) use by failing to: 1. Ensure Resident 42 had monitoring for signs and symptoms of bleeding with the use of clopidogrel (a medication used for paroxysmal atrial fibrillation [irregular and fast heartbeat] that thins the blood) and Eliquis (a medication used for atrial fibrillation that thins the blood) 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs (any drug in excess) for three (3) of three (3) sampled residents (Resident 42, 79, and 40) for unnecessary medication review by failing to: 1. Monitor the side effects (also known as adverse consequences - unwanted, uncomfortable, or dangerous effects that a drug may have) of clopidogrel (a medication used for paroxysmal atrial fibrillation [irregular and fast heartbeat] that thins the blood) and Eliquis (a medication used for atrial fibrillation that thins the blood) for Resident 42. As a result, Resident 42 did not have monitoring for sign and symptoms of bleeding for the use of clopidogrel and Eliquis between 3/1/2025 and 3/13/2025. 2. [...]

Inspectors wrote5. During a review of Resident 95's admission Record, the admission Record indicated the facility admitted the resident on 9/4/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), generalized anxiety disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 95's History and Physical (H&P), dated 9/8/2024, the H&P indicated, the resident does not have the capacity to understand and make decisions. During a review of Resident 95's Minimum Data Set (MDS-a resident assessment tool), dated 12/17/2024, the MDS indicated the resident sometimes had the ability to understand others and make self understood. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Four (4) medication errors out of 32 total opportunities contributed to an overall medication error rate of 12.5% affecting two (2) of three (3) residents observed for medication administration (Resident 21 and 77.) The medication errors were as follows: 1. Resident 21: a. Received carvedilol (a medication used to for hypertension [HTN - a condition in which the blood vessels have persistently raised pressure]) at a different time than ordered by Resident 21's physician. b. Received a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) that was different than the one ordered by Resident 21's physician c. [...]

Inspectors wrote2. During a review of Resident 17's admission Record, the admission Record indicated the facility originally admitted the resident on 11/2/2021 and readmitted in the facility on 9/22/2024 with diagnoses including type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), long term use of insulin, and dementia (a progressive state of decline in mental abilities). During a review of Resident 17's History and Physical (H&P) dated 9/25/2024, the H&P indicated Resident 17 did not have the capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise and provide a current staffing plan in the Facility's Assessment (evaluates the resident population and determines what resources are necessary to care for residents competently during both day-to-day operations [including nights and weekends] and emergencies) to meet resident's needs. This deficient practice placed the residents at risk for lack or delay of care and treatment services and resulted in Resident 21 and 77 receiving medications at later time than scheduled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure clean linens were protected from environmental contaminants when 17 of 17 clean linen cart covers were covered with a permeable (can be passed through, especially by liquids or gases)/loosely woven material to cover the linens. This deficient practice had the potential to spread infections and illnesses among residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to provide care in a manner that promoted dignity and respect for one of one sampled resident (Resident 115) when facility staff failed to follow the Do Not Resuscitate (DNR- a written document signed by the patient or their legal representative and the patient's physician, and it is placed in the patient's medical records indicating the resident's wishes of withholding resuscitation efforts) physician order for Resident 115 reviewed under Death care area. This deficient practice violated the rights of the resident to be treated with dignity and respect. Cross-reference:

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (CL, an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for two of six sampled residents (Residents 46 and 107) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers.

Inspectors wroteBased on interview and record review, the facility failed to offer the resident or their resident representative assistance with formulating an Advance Directive (AD - a legal document indicating resident preference on end-of-life treatment decisions) upon admission for two of two sampled residents (Residents 79 and 97) reviewed for advance directive. This deficient practice violated the residents and/or their representatives the right to be fully informed of the option to formulate an AD and had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the residents' personal preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for two (2) of six (6) sampled residents (Residents 79 and 70) reviewed under the environment task by failing to: 1. Ensure Resident 79's floor mat (a cushioned floor pad designed to help prevent injury should a person fall) was free from tears and patched with black tape. 2. Ensure windowsills and baseboards were in good repair and walls were free from red stenciled letters F-L-A-I for one of six sampled residents (Resident 70) reviewed under the Environment task. These deficient practices had the potential to negatively affect the resident's psychosocial wellbeing and make the residents feel uncomfortable in their living space.

Inspectors wroteBased on interview and record review, the facility failed to complete and provide a notice of bed-hold policy and return form (reserving a resident's bed while the resident is absent from the facility) when the resident was transferred to general acute care hospital (GACH) 1 for one of three sampled residents (Resident 33) selected for closed record review. This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility not of the resident's or responsible party's preference.

Inspectors wroteBased on interview and record review, the facility failed to follow the Do Not Resuscitate (DNR- a written document signed by the patient or their legal representative and the patient's physician, and it is placed in the patient's medical records indicating the resident's wishes of withholding resuscitation efforts) physician order for one of one sampled resident (Resident 115) when cardiopulmonary resuscitation (CPR-emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) was administered to Resident 115. This deficient practice violated the resident's preferred treatment wishes. Cross-reference:

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who experienced a significant change of status is comprehensively assessed for one of one sampled resident (Resident 3) reviewed under change of condition by failing to perform a change of condition assessment on 8/25/2024, when the resident was discharged to General Acute Care Hospital (GACH) 2 for abnormal laboratory and elevated white blood cells (WBC, a part of the immune system that protects your body from infection) and blood urea nitrogen (BUN, measures the amount of a waste product called urea nitrogen in your blood, which is a byproduct of protein breakdown, and helps doctors assess kidney function). This deficient practice had the potential to negatively affect the provision of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for two of two sampled residents (Residents 272 and 371) reviewed for urinary catheter or UTI by failing to ensure Residents 272's and 371's urinary catheter tubing did not have a loop while hanging on the side the bed. This deficient practice had the potential for the resident's urine not to flow freely which may lead to development of UTI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions consistent with the resident's assessed needs and goals to maintain acceptable parameters of nutritional for one of four sampled residents (Resident 42) by failing to provide Ensure (a nutritional supplement) to Resident 42 as ordered. This deficient practice had the potential to place Resident 42 at further risk of weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids (are liquids that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice for two (2) of 2 sampled residents (Residents 269 and 15) reviewed during a random observation by: 1. Failing to change the loose and soiled dressing on Resident 269 right upper arm (RUA) peripherally inserted central line catheter (PICC line - a long, thin tube inserted through a vein in the arm and passed through to the larger veins near the heart used for long-term intravenous access) as observed on 3/11/2025 at 9:10 a.m. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the risk of entrapment (an event in which a resident is caught, trapped, or entangled in spaces in or about the bed rail, mattress, or hospital bed frame) from bed rails (a safety device that's installed along one or both sides of a bed to prevent falls) prior to its continued use to one of 2 sampled residents (Resident 88) reviewed for restraints (are any action or procedure that prevents a person's free body movement to a position of choice and/or normal access to the body by the use of any method, attached or adjacent to a person's body that the person cannot control or remove easily) use by failing to assess the resident for risk of entrapment from bed rails quarterly. The deficient practices predisposed residents to bed entrapment and unnecessary restraints.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs were labeled in accordance with currently accepted professional principles to facilitate consideration of precautions and safe administration of medications by failing to ensure intravenous (administered within a vein) meropenem (medication used to treat a wide range of bacterial infections) was labeled with the resident's name for one of two sampled residents (Resident 109) reviewed under the Antibiotic care area. This deficient practice had the potential to result in medication administration to the wrong resident resulting in adverse effects (an undesired and harmful result of a treatment or intervention, such as a medication or surgery) of medication.

Inspectors wroteBased on interview and record review, the facility failed to follow-up with the endocrinologist when Resident 77's hemoglobin A1C (HbA1c-a test that indicates the average level of blood sugar control over the last couple of months, a high number is a sign of poor blood sugar control) test result was reported to the facility for one of five sampled residents (Resident 77) reviewed under Unnecessary Meds, Psychotropic (medications capable of affecting the mind, emotions, and behavior) Meds, and Med Regimen Review Care Area. This deficient practice placed Resident 77 at risk for uncontrolled Hb1A1c levels which could lead to hyperglycemia (high blood sugar), kidney damage, and make the resident susceptible to infections and poor wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper sanitation and food handling practices by failing to ensure a pitcher of cranberry juice stored in the refrigerator in the kitchen was labeled with the date it was poured on the container. These deficient practices had the potential to cause food-borne illnesses (also known as food poisoning, a sickness from eating or drinking contaminated food or beverages, often causing symptoms like nausea, vomiting, and diarrhea).

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records within accepted professional standards for one of eight sampled residents (Resident 17) reviewed for accidents by failing to complete the elopement risk assessment accurately. This deficient practice had the potential to result in inaccurate documentation in the medical record regarding Resident 17's elopement risk status.

Inspectors wroteBased on interview and record review, the facility failed to ensure fairness and integrity of the binding arbitration process (method of resolving disputes outside of court) when one of three sampled residents (Resident 3) reviewed under the Arbitration Agreement (AA - legal document agreeing to arbitration) task, was offered and entered into an AA that failed to provide for the selection of a neutral arbitrator (impartial, or unbiased third-party decision maker) agreed upon by both parties and for the selection of a venue that was convenient to both parties. This deficient practice had the potential to cause psychosocial harm to residents during the binding arbitration process.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care was provided consistently for a resident who was receiving hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) for one of two sampled residents (Resident 95) reviewed under Hospice Care Area by, failing to: 1. Ensure the hospice doctor signed Resident 95's initial Certification of Terminal Illness (CTI-a document in which the physician certifies the patient is terminally ill with a prognosis of six (6) months or less). 2. Ensure Hospice Provider (HP) 1 provided Resident 95's hospice plan of care to the facility upon completion of the recertification of the resident's CTI. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely complete the Minimum Data Set (MDS-a resident assessment tool) Assessment for one of two sampled residents (Resident 16) reviewed under Resident Assessments facility task by, failing to complete Resident 126's MDS Quarterly Assessment timely. This deficient practice had the potential to negatively affect the provision of necessary care and services needed by the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status at the time of the assessment by failing to: 1. Accurately code Resident 2's MDS assessment to reflect the resident's admission date to the facility for one of two sampled residents (Resident 2) reviewed under Resident Assessment facility task. 2. Accurately code Resident 49's MDS assessment to reflect the resident was discharged with return not anticipated on 1/8/2025. This deficient practice had the potential to affect Resident 2 and Resident 49's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the urinary catheters of two of five sampled residents (Resident 2 and Resident 5) were positioned properly to allow unobstructed flow of urine. This deficient practice had the potential to result in Resident 2 and Resident 5 ' s increased risk for infection, injury, and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control procedures for one of five sampled residents (Resident 5) when Licensed Vocational Nurse 1 (LVN 1) failed to wear a disposable isolation gown (protective apparel used to protect healthcare workers and patients from the transfer of microorganisms and body fluids) while repositioning Resident 5 ' s urinary catheter (a flexible tube inserted into the bladder [a hollow, stretchy organ that stores urine] to empty urine). Resident 5 was on Enhanced Standard Precaution (ESP - a resident-centered approach and activity-based approach for preventing multiple drug resistant organisms [MDRO] transmission in skilled nursing facilities [SNF]). This deficient practice had the potential to spread infection to other residents.

Inspectors wroteBased on interview and record review the facility failed to provide prompt efforts to resolve request and grievances on outings voiced by the residents to the facility through the Resident Council Meetings (resident's representative group) for seven of seven resident council group interview attendees during review of resident council facility task. This deficient practice had the potential to result in the residents' grievances to remain unresolved and could lead to increased frustration affecting the residents' overall satisfaction and well-being in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents rights to forms of communication with privacy by failing to ensure mail was delivered on Saturdays for seven of seven residents interviewed during the resident council task. This deficient practice violated the residents' right to receive mail on Saturdays and had the potential to negatively affect the resident's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to post the most recent survey results in a place that is prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents, family members, and legal representatives of residents. This deficient practice resulted in the residents' and their representative not having access to examine the most recent survey results.

Inspectors wroteBased on observation, interview and record review facility failed to maintain privacy of confidential information when a display of multiple appointments along with the resident's date of birth and type of appointment were posted on the wall of the resident's room for one of one random observation (Resident 46). This deficient practice had the potential result in unauthorized exposure of resident's confidential information.

Inspectors wroteBased on interview and record review, the facility staff failed to provide care in accordance with professional standards to two out of five sampled residents (Resident 48 and 91) investigated during review of unnecessary medications by failing to: 1. Ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to Resident 48 and Resident 91. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (breakdown of skin integrity due to pressure) for five (5) out of 5 sampled residents (Resident 51, 303, 38, 7, and 57) investigated during review of pressure ulcers care area by failing to set the low air loss mattress (LALM, designed to distribute the resident's weight over a broad surface area and help prevent skin breakdown) according to the resident's weight. This deficient practice had the potential for the development and worsening of pressure ulcers/injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of five sampled residents (Resident 48 and Resident 91) were free from significant medication errors by failing to: 1. Ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to Resident 48 and Resident 91. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Store and label one inhalation treatment with an open date for Residents 2, in accordance with facility and manufacturer's requirements in one of three inspected medication carts (Medication Cart West.) 2. Store one insulin (a medication used to treat high blood sugar) Novolin R (fast-acting insulin) Flexpen (type of insulin injection device) for Resident 17 and one insulin Lispro (short-acting insulin) Kwikpen (type of insulin injection device) for Resident 46, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart Middle.) 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by: 1. Failing to ensure 13 clear plastic containers of blueberries and one container of strawberries with white patches were discarded timely. 2. Failing to ensure three bottles of spices were labeled when they were opened. These deficient practices had the potential to result in harmful bacteria growth and cross-contamination (the physical movement of transfer of harmful bacteria from one person, object, or place to another) that could lead to foodborne illness (any illness of a toxic or infectious nature contracted through consumption of contaminated water or food) in 92 out of 95 medically compromised residents who receive food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that are complete and accurately documented for one of three (Resident 90) sampled residents investigated during medication regimen review by failing to maintain accurate documentation of Resident 90's Klonopin (a prescription drug used to treat anxiety [persistent and excessive worry that interferes with daily activities]) ordered on 3/1/2024 and 3/4/2024. This deficient practice had the potential to result in the resident's medical record containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's in-service training program by failing to monitor the mandatory in-service (training) attendance, including abuse-related and dementia (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) training, of four of four Certified Nursing Assistants (CNA 1, CNA 2, CNA 3, and CNA 4) investigated under sufficient and competent staffing. This deficient practice had the potential to result in an increased risk of failing to recognize and properly handle instances of abuse or neglect towards residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality by: 1. Failing to ensure Certified Nursing Assistant 2 was not standing over one of one sampled resident (Resident 38) while assisting the resident during a meal during review of dignity care area. 2. Failing to ensure CNA 4 was not standing over one of seven sampled residents (Resident 64) while assisting the resident during a meal during review of dining observation task. This deficient practice had the potential to affect Resident 38 and 64's self-esteem, self-worth, and the residents' sense of independence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (device used to alert nurses and other facility staff to assist a resident in need) within reach of the resident for one of three sampled residents investigated under the environment facility task (Resident 204) when Resident 204's call light was observed on the floor next to the resident's bed. This deficient practice had the potential to result in the resident not being able to call the facility staff for assistance and delay provision of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that is restraint-free as indicated in the facility's policy for one resident (Resident 60) out of one sampled resident investigated during review of physical restraints care area by: 1. Failing to ensure an order was obtained from the physician prior to use of bed pad alarm. 2. Failing to ensure the informed consent was obtained from Resident 60 or responsible party (RP) prior to use of bed pad alarm. 3. Failing to ensure a restraint assessment was completed prior to use of bed pad alarm. These deficient practices placed Resident 60 at risk for unnecessary prolonged use of restraints which can lead to a decline in functioning.

Inspectors wroteBased on interview and record review the facility failed to complete and provide the resident or resident representative the bed hold notification form on 11/22/2023, when the resident was transferred to general acute care hospital 1 (GACH 1), for one out of three sampled residents (Resident 101) selected for closed record review. This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility/acute care hospital not of the resident's or responsible party's preference.

Inspectors wroteBased on interview and record review the facility failed to develop a baseline care plan (initial written guide that organizes information about the resident's care) addressing the use of bed pad alarm for one (1) out of 1 sampled resident (Resident 60) reviewed for use of physical restraints. This deficient practice had the potential for Resident 60 not to receive the appropriate care and treatment specific to her needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for: 1. One of two sampled residents investigated under the communication-sensory care area (Resident 9) when the facility failed to develop interventions in Resident 9's care plan to include the use of a communication board (an assistive visual aid with pictures and words translated into various languages used to facilitate communication between residents and staff). This deficient practice had the potential for the delay of Resident 9's care and communication with staff and visitors. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to review and revise the resident's care plan to reflect the accurate status of the resident for one out of four sampled residents (Resident 38) investigated during review of pressure ulcers/injuries (damage to an area of the skin caused by constant pressure on the area for a long time) by failing to resolve the care plan for actual pressure injury when the resident's pressure injury was resolved on 2/26/2024. The deficient practice had the potential to result in the failure to address a resident's changing needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided a communication device to allow communication between staff and residents for one of two sampled residents investigated under the communication-sensory care area (Resident 9), when Resident 9 was not provided a communication board (an assistive visual aid with pictures and words translated into various languages used to facilitate communication between residents and staff) to communicate with staff and visitors. This deficient practice had the potential to delay Resident 9's care and communication with staff and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive proper assistive devices to maintain vision and hearing abilities by failing to notify the resident's physician of a missed ophthalmology (the branch of medical science dealing with the anatomy, functions and diseases of the eye) appointment and by failing to follow the Ear, Nose, and Throat (ENT) doctor's recommendation for one of three sampled residents (Resident 29) investigated during review of communication and sensory care area. This deficient practice had the potential to result in worsening of the resident's condition and could negatively affect their daily activities and overall well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) for one (Resident 98) out of one sampled resident during a random observation by: 1. Failing to ensure the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) tubing was not touching the floor. 2. Failing to ensure the urinary drainage bag (a bag designed to collect urine from the bladder via a catheter) was not placed on top of the bed. These deficient practices had the potential for Resident 98's urine not to flow freely which may lead to urinary tract infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with necessary respiratory care and services that is in accordance with professional standards of practice to one (1) out of two sampled residents (Resident 50) investigated during review of respiratory care area by: 1. Failing to obtain an order from the physician regarding the use of personal Bilevel positive airway pressure (BiPAP - a machine that delivers pressurized air into the lungs to facilitate breathing via a mask which is worn over the nose and mouth improving the level of oxygen in the blood) from home prior to use. 2. Failing to obtain an order from the physician regarding monitoring of setting and maintenance for the use of BiPAP. 3. Failing to complete an assessment prior to use the BiPAP machine. [...]

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services accurately and safely to one out of one sampled resident (Resident 48) investigated during review of pharmacy services by failing to clarify an order of prednisone (a drug used to reduce inflammation and lower the body's immune system) prior to administration of the medication to Resident 48. The deficient practice had resulted to administering an incorrect dose of prednisone for two days, placing the resident at risk for medical complications. Cross refereance to F658 and F760.

Inspectors wroteBased on interview and record review, the facility failed to act upon the recommendations of the consultant pharmacist and review a resident's medical record for one of one sampled residents investigated under the antibiotic (medication that inhibits the growth or destroys microorganisms) use care area (Resident 80) when the facility failed to obtain a stop date from the physician for Resident 80's erythromycin (a type of antibiotic) ophthalmic (relating to the eye and its diseases) ointment and review the medication during the February 2024 medication regimen review (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from unnecessary drugs for one of one sampled resident (Resident 80) investigated under the antibiotic (medication that inhibits the growth or destroys microorganisms) use care area when Resident 80 was administered erythromycin (a type of antibiotic) ophthalmic (relating to the eye and its diseases) ointment without a stop date. This deficient practice had the potential for Resident 80 to develop antibiotic resistance (when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them) and decrease the efficacy (the ability to produce a desired or intended result) of antibiotics prescribed in the future.

Inspectors wroteBased on interview and record review, the facility failed to incorporate resident's food preferences for one of three sampled residents (Resident 57) being investigated under food preferences by failing to serve prune juice on his breakfast tray on 3/19/2024. This deficient practice denied Resident 57 of his right for food preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of seven sampled residents (Resident 12) investigated under the infection control care area when Housekeeper (HK) 1 was observed cleaning Resident 12's bathroom without wearing the appropriate personal protective equipment (PPE - protective clothing used to protect the wearer's body from infection), when Resident 12 was placed under enhanced standard precautions (ESP - a resident-centered and activity-based approach for preventing multi drug resistant organism transmission in skilled nursing facilities). [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Antibiotic Stewardship Program ([ASP]-a set of commitments and actions designed to improve the use of antibiotics [a medication used to treat bacterial infections]) for one of three sampled residents investigated under the medication administration care area (Resident 54) and for one of seven sampled residents investigated under the infection control care area (Resident 80) when the facility failed to follow its Antibiotic Stewardship policy and procedure (P&P) for Resident 54's Bactrim (an antibiotic used for urinary tract infection [UTI - an infection in the system of organs that makes urine]) order and Resident 80's erythromycin (a type of antibiotic) order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post daily staffing information that included the total number of Certified Nursing Assistants (CNA) and their actual hours worked for three of three sampled dates (3/18/2024, 3/19/2024, and 3/20/2024) during review of sufficient and competent staff facility task. This deficient practice resulted in residents, visitors, and facility staff not knowing how many staff were available to provide care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2), who was dependent on staff for transfers and was a fall risk, was provided a safe environment and assistance to prevent accidents and injury. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was free from unnecessary physical restraint (a strap or other thing that holds a person in place) by: 1. Failing to obtain a physician order for the use of four side rails. 2. Failing to obtain an informed consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) on the use of four side rails. 3. Failing to monitor Resident 3 on the use of four side rails. 4. Failing to create a care plan to address the use of four side rails. These deficient practices resulted to unnecessary restraint and placed Resident 3 at risk of entrapment and injury.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1). On 9/24/2023 and 9/29/2023, nurses did not document indication of oxygen use as per physician ' s order. This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1 ' s medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a floor mat near the bed to prevent injuries from a potential fall as indicated in the care plan for one of three sampled residents (Resident 1) who has a history of multiple falls including the recent fall on 11/23/23 at the facility. This deficient practice had the potential to have an injury from fall from Resident 1's bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control program for two out of three sampled residents (Resident 4 and Resident 5) by: 1. Failing to ensure Licensed Vocational Nurse 1 (LVN 1) wore fit-tested (a test protocol conducted to verify that a respirator is both comfortable and provides the wearer with the expected protection) N95 respirator (a respiratory protective device/mask designed to achieve a very close facial fit) while assisting Resident 4. 2. Failing to ensure Certified Nursing Assistant 5 (CNA 5) wore N95 respirator covering both her nose and mouth while assisting Resident 4. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to hold (suspend the medication administration under specific conditions) the administration of nifedipine, metoprolol, and hydralazine (these medications are used to treat high blood pressure [BP - pressure circulating blood against the wall of the blood vessels]) as per physician ' s orders when the resident ' s systolic blood pressure (SBP - pressure in the arteries when the heart beats) was below 110 for one of three sampled residents (Resident 4). This deficient practice had the potential to result in further drop in Resident 4 ' s blood pressure.