Shoreline Care Center

Inspectors wroteBased on interview and record review, the facility failed to follow nursing standards of practice when duplicate medication orders were not clarified with the physician prior to administration for one (1) of two (2) sampled residents (Resident 1). This failure resulted in confusion and a medication error resulting in Resident 1 receiving three (3) extra doses of medication jeopardizing Resident 1's health and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff knocked and announced their presence prior to entering a resident's room for one of six sampled resident (Resident 5). This failure had the potential to negatively impact the residents' dignity and right to privacy, and cause embarrassment, discomfort or loss of respect.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 26) had the Preadmission Screening and Resident Review (PASRR-an evaluation to confirm that an individual has a mental illness) Determination Report recommended specialized services (services that exceed the services ordinarily provided by the nursing facility) for psychotherapy/counseling implemented. This failure had the potential to result in Resident 26 having increased psychiatric symptoms. During a review of the facility's policy and procedure (P&P) titled, PASRR, dated 5/2025, the P&P indicated, It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. Evaluation must be completed by an approved state contractor, and a Determination made by the appropriate MI [mental illness] . state authority. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1. One of four behavior-emotional sampled residents (Resident 51) had a comprehensive care plan (CP) that included an intervention that was not implemented and an intervention that was not supportive of Resident 51's CP goal. This failure resulted in Resident 51's psychosocial needs not being met.2. One of eight Preadmission Screening and Resident Review (PASRR-an evaluation to confirm that an individual has a mental illness) sampled residents (Resident 26) had the PASRR recommendations incorporated into their CP and had interventions (actions to be taken to maintain or improve a goal) that were measurable and clearly identified what was being measured. This failure resulted in Resident 26's psychosocial needs not being met. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 133), had a care plan (CP- an individualized plan for consistently managing a resident's care needs) reviewed and revised by the interdisciplinary team (IDT-a group of medical professionals who work together with the resident to develop a CP) after an assessment of Resident 133's ability to comply with the facility's smoking policy. This failure resulted in Resident 133 storing his smoking material in an unsafe location and becoming belligerent to staff who tried to enforce the smoking policy. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 1/2026, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an appropriate audiology (hearing) referral was implemented for one of 35 sampled residents (Resident 136) with hearing impairment. This failure resulted in a delay in the provision of care, treatment, and services for all residents requiring a referral for care. During a review of the facility's policy and procedure (P&P) titled, Hearing Services, dated 11/2011, the P&P indicated, The resident will be referred as needed for a hearing evaluation. The SSD will keep at least one hearing amplifier available for new residents who are hard of hearing or as a temporary intervention if a resident's hearing aid is missing or lost. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 133), had their smoking privileges restricted when they refused to comply with the facility smoking policy to store their cigarette lighter in a secure box. This failure had the potential to result in avoidable accidents by other residents having access to the lighter. During a review of the facility's policy and procedure (P&P) titled, Smoking Policy, dated [DATE], the P&P indicated, If IDT [interdisciplinary team is a group of medical professionals who work together with the resident to focus on resident-centered care] determines that the resident is unable to safely store their smoking materials or require supervision to smoke safely, smoking products will be kept in a secured cabinet, only accessible to staff. Upon quarterly review by the IDT. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the observance of infection control practices and protocols for one of six sampled residents (Resident 140), when 1. a foley catheter dignity bag (a discreet pouch/bag to keep/hide urine drainage bags for privacy and dignity) was observed in contact with the floor and 2. the facility stored outdated food products in the kitchen refrigerator. These failures had the potential to result in a significant infection control risk such as a catheter associated urinary tract infection (CAUTI) and food-born illness to all residents. 1) During an observation, on 4/21/26, at 9:43 a.m., in room [ROOM NUMBER]A, Resident 140 was lying in bed. The bed was positioned at its lowest setting. Foley catheter urine tubing was observed on the left side of the bed, with the urine collection bag placed inside a dignity bag. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure compliance with required equipment maintenance standards when: 1. Medication refrigerators were not maintained at the proper temperatures and safe dry conditions 2. The kitchen ice machine was not maintained in safe and sanitary working conditionThese failures had the potential to result in compromising the integrity and potency of refrigerated medications and exposing residents to contaminated ice from an improperly maintained ice machine.1. During an observation, on 4/22/26, at 10:15 a.m., in the North Station medication room, the medication refrigerators' thermometer recorded a temperature at 40 degrees Fahrenheit (normal acceptable range +36 to 46 degrees Fahrenheit [2 to 8 degrees Celsius]). [...]

Inspectors wroteBased on interview and record review, the facility failed to adhere to its policy and procedure requiring staff to use English as the primary language of communication, as outlined in the facility's Official language Designation policy. This failure resulted in noncompliance with established administrative standards and oversight practices. These failures have the potential to impede effective communication, compromise residents' rights to receive information in a manner they can understand, and place residents at risk for diminished safety and quality of care. During an interview on 03/25/26 at 2:45 p.m. with the Certified Nursing Assistant (CNA 1) stated, that staff of certain descent were being given preferential treatment at the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to transcribe and implement an x-ray as ordered by the physician in one out of three sampled residents (Resident 1) after Resident 1 sustained a fall. This failure resulted in a delay of treatment and care of a right hip fracture for Resident 1 that went unnoticed and untreated by the facility for 7 days. During a review of Resident 1's admission Record (AR) undated, the AR indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses including Anemia (condition where the body does not have enough healthy red blood cells), Dementia (a progressive state of decline in mental abilities), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and Anxiety (mental health condition characterized by excessive worry, fear, and nervousness). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services provided met professional standards and principles for one of two residents (Resident 1) when mild swelling was observed on Resident 1's left hip five days after the fall incident which was not documented or monitored. This failure had the potential to result in Resident 1's care being compromised without the appropriate nursing follow-up monitoring and documentation in place.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's order to monitor the respiratory rate (RR - the number of breaths per minute) was followed for one of two residents (Resident 1) prior to administration of morphine sulfate (a highly controlled substance given for severe pain). This deficient practice had the potential to cause serious side effects including respiratory depression (slow, shallow, difficulty breathing).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and care-screening tool) accurately reflected the behavior status of one of two sampled residents (Resident 1). This failure had the potential to negatively affect Resident 1's plan of care and delivery of necessary care and services. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted on [DATE], with diagnoses that include Alzheimer's disease (disease characterized by a progressive decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). [...]

Inspectors wroteBased on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) after the resident was transferred to the veteran VA hospital for medication evaluation and adjustment. The facility's failure placed Resident 1 at risk of being admitted to another facility which is far from the wife's residence therefore unable to visit frequently. A complaint was received by the California Department of Public Health (CDPH) on 7/14/25 alleging that Resident 1 had been transferred to an acute care hospital for medication evaluation and adjustment. According to the information provided, a representative of the resident was informed by facility staff that the resident's bed would be held and that the resident would be readmitted to the facility following hospitalization. [...]

Inspectors wroteBased on interview and record review, the facility failed to:1. Ensure two of three sampled residents (Resident 1 and 2) were provided with a written bed-hold notification upon transfer to general acute care hospitals. 2. Ensure Resident 1's wife was provided with the bed hold private payment information before the resident was transferred to the veteran (VA) emergency department (ED). These failures resulted in the residents not having a bed-hold and were at risk of not being able to return to the facility.1. A review of the facility's policy and procedure titled Admission, Transfer, Discharge and Bed-Holds, dated 12/2016, indicated Upon transfer or discharge, a notice of transfer and discharge, as well as the bed-hold notification will be completed and given to the resident at the time of transfer or discharge or as soon as practicable. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 2) was protected from physical and verbal abuse from a fellow resident (Resident 1) who was having undirected behavioral symptoms and outbursts. This facility failure resulted in Resident 2 being slapped by Resident 1 and sustaining bruises (purplish/reddish skin discoloration) to the left arm and hand.

Inspectors wroteBased on observation, interview, and record review, the facility's Interdisciplinary Team (IDT - a group of medical staff that work together to provide care of residents) failed to initiate a Significant Change in Status Assessment (SCSA - a comprehensive assessment) for one of four sampled residents (Resident 1) when: 1. Resident 1 refused to take schizophrenia (mental disorder that affects how a person thinks, feels, and behaves), depression (persistent feelings of sadness that interfere with daily life) and other medications. As a result, Resident 1 developed severe symptoms of distress including psychosis (loss of touched with reality), delusions, hallucinations, and paranoia. 2. Resident 1 showed physical and verbal aggression towards other residents and staff, and refused to follow the facility's smoking rules. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), had their health status accurately documented on the admission Minimum Data Set (MDS: a comprehensive assessment that helps nursing home staff identify health problems and track the improvement or decline of those problems). This failure had the potential to result in an inaccurate plan of care, compromising the resident's quality of life and leading to unmet needs, inappropriate interventions, and negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a plan that includes clear goals to meet a resident's needs) when: 1. Female staff were not consistently assigned to Resident 1 as care planned. This failure had the potential to cause emotional distress and compromise Resident 1's psychosocial well-being. 2. Resident 1's cam boot (foot/ankle brace) was replaced with a non-weight-bearing immobilizer cast (a stiff wrap that keeps an injured area stable) on the left foot with no protocol in place for care. This failure had the potential to result in poor circulatory function and delayed healing of Resident 1's left foot fracture.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control practices in one of two sampled residents (Resident 2) when Resident 2's respiratory care equipment was not stored in a manner to prevent cross-contamination (accidentally transferring harmful bacteria) or labeled/dated. These facility failures had the potential to result in cross-contamination that could negatively impact Resident 2's health and safety and cause preventable HAIs (Healthcare Associated Infections).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's South Side dining room was safe and clean as evidenced by: 1. A wet and dirty plastic container, surrounded by flying insects (fruit flies), was underneath the sink while ten residents were inside the dining room eating lunch. 2. Next to the sink was a trash can surrounded by flying insects (flies). 3. The corner next to the sink was dirty and the walls had food particles adhered to the wall. 4. The sink had been nonfunctional since 6/1/25, was not covered and without any signage indicating the sink was not working. 5. The dining room floor has broken tiles in multiple areas. 6. The dining room had lots of dark stains especially around the corners. [...]

Inspectors wroteBased on interview and record review, the facility failed to report a resident's fall incident with fracture to the Department for one of two residents (Resident 1). Resident 1 experienced an unwitnessed fall, complained of pain on the left hip with an X-ray (process of imaging, using radiation) that indicated an acute fracture. This failure delayed the Department's investigation into the incident and had the potential for Resident 1 and other residents to experience a decline in safety, comfort, and overall well-being.

Inspectors wroteBased on interview and record review, the facility failed to change a hearing aid filter for one of three sampled residents (Resident 1) per instructions from an outside clinic. This failure had the potential for Resident 1's hearing aid to be less effective, potentially impacting Resident 1's ability to hear and communicate.

Inspectors wroteBased on interview and record review, the facility failed to follow its scabies (a contagious skin disease marked by itching and small raised red spots, caused by mites) protocol for one of three sampled Residents (Resident 1). This failure had the potential for scabies to spread throughout the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for the administration of insulin for one of two sampled residents (Resident 1). This facility failure had the potential to expose Resident 1 to unsafe insulin doses, and preventable medication errors.

Inspectors wroteBased on record review and interview, the facility failed to provide quality care for one of two sampled residents (Resident 1) when: 1. Numerous medications were not administered to Resident 1, due to Resident 1 being offsite at a dialysis center. 2. Physical therapy sessions were not provided to Resident 1 as ordered. 3. There was a facility delay following physician orders for Resident 1 to begin weight bearing physical therapy. These facility failures had the potential to result in negative outcomes for Resident 1 and for a delay in care.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of two sampled residents (Resident 1) when an interdisciplinary team (IDT- team members from different discipline with common purpose, to set goals, share responsibilities and make decisions together) admission assessment form was incomplete. This failure had the potential for Resident 1 to have inaccurate and incomplete medical records which could affect the care being provided to them.

Inspectors wroteBased on observation, interview and record review, the facility failed to: Provide adequate supervision for one of two sampled residents (Resident 1) to prevent accidents. Additionally, the facility failed to: -Accurately assessed Resident 1's risk for elopement. -Follow interventions for the administration of anti-anxiety medications. -Call the physician/medical practitioner for change in condition (increased agitation) to seek appropriate care intervention for Resident 1. -Place Resident 1 in a room farther away from the fire exit door which opens to a busy street. These failures resulted in Resident 1 opening an exit door on 2/14/25 between 5:30 a.m. to 5:35 a.m., walked to a busy street, was hit by a moving vehicle, sustained fatal injuries, and was pronounced dead at a local hospital on 2/14/25 at 6:40 a.m.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS) Assessment (an assessment tool) for one of two residents (Resident 1). As a result, the elopement risk assessment did not accurately reflect Resident 1's status.

Inspectors wroteBased on interview and record review, the facility failed to ensure interventions of a behavioral care plan was implemented for one of two residents (Resident 1). This failure resulted in increased behavioral episodes of aggression, anxiety and paranoia (suspiciousness) for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and homelike environment in two shower rooms. These facility failures had the potential to negatively impact residents.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility's kitchen staff failed to maintain clean food preparation equipment, date and label leftovers, thaw raw meat properly, wear gloves when handling ready-to-eat (RTE) food, and ensure hair restraints were worn in the food preparation areas. This deficient practice had the potential to affect all residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to dispose of garbage and refuse properly affecting 3 of 3 dumpsters. Specifically, the trash and recycle dumpster lids were open with overflowing trash piled up over the top of the dumpsters and trash and debris was on the ground surrounding the base of the dumpsters. This had the potential to affect all 171 residents who resided in the facility at the time of the survey.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to protect the residents' right to be free from physical abuse by a resident during 4 (10/28/2024, 12/15/2024, 12/19/2024, and 01/12/2025) of 4 incidents of resident-to-resident abuse involving Resident #118.

Inspectors wroteBased on interview, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, the facility failed to ensure Level I PASRR screenings were accurate and also failed to submit a new Level I PASRR screening after a resident remained in the facility longer than 30 days, during which they were exempt from the requirement. The deficiencies affected 3 (Residents #26, #103, and #129) of 4 residents reviewed for PASRR requirements.

Inspectors wroteBased on observation, interview, and facility document and policy review, the facility failed to serve meals according to the recipes for the planned menu for residents prescribed a pureed diet. Specifically, staff pureed plain beef instead of beef stew, mixed breadcrumbs in water in place of sliced bread to make pureed bread and served applesauce in place of pureed baked apple slices to residents on a pureed diet. This deficient practice had the potential to affect 22 residents who received pureed diets.

Inspectors wroteBased on record review and interview, the facility failed to obtain a physician order, prior to providing one of two sampled residents (Resident 1) with psychological services. This failure had the potential for Resident 1 to receive services not approved by a physician.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician orders for wound care treatment were followed, for one of two sampled Residents (Resident 1). This failure had the potential for Resident 1 to experience complications from worsening pressure ulcers including increased pain and wound infections.

Inspectors wroteBased on interview and record review, the facility failed to reorder medication from the pharmacy according to their policy and procedure, for one of three sampled residents (Resident 1). This failure had the potential to trigger seizures (sudden, uncontrolled burst of electrical activity in brain that can cause temporary changes in behavior, movement, feelings, and level of consciousness) to Resident 1 that can lead to fall or other serious injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a resident room and restroom, in a clean and homelike manner. This failure had the potential to negatively impact residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and revise the care plan for one of three sampled residents (Resident 1) after a verbal altercation with another resident. This failure had the potential to cause psychosocial harm to Resident 1.

Inspectors wroteBased on record review and interview, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1), when Resident 1 eloped (a situation where a resident leaves the facility, without the knowledge of the staff) on two separate occasions. This facility failure had the potential for Resident 1 to suffer negative outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure licensed nurses (LNs) were competent in providing quality of care for two of 2 sampled residents when they failed to: 1. Complete a comprehensive assessment and individualized care plan related to Resident 1's change of condition (COC), did not report to the attending physician after monitoring the COC for possible further instructions and/or orders. 2. Notify the responsible party on an open lesion documented by LN3 on admission. These failures had the potential for delayed identification of change in health status and implementation of needed healthcare interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident rooms in a clean and homelike environment when: 1. Broken floor tiles observed in two resident rooms. 2. An electrical fan was covered in dust/debris. These facility failures had the potential to negatively impact residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a bed remote control and call light in safe operating conditions. These facility failures had the potential for equipment to be unsafe for use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a handrail was in good working order. This facility failure had the potential to place a resident at risk for an avoidable accident.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents and unauthorized personnel had no access to an open, unlocked supply delivery door. This failure had the potential for residents to go out of the facility unnoticed, into a busy street causing safety issues or for an unauthorized person to enter the facility unnoticed, placing the welfare and safety of residents and staff at risk.

Inspectors wroteBased on record review and interview, the facility failed to provide showers for one of two sampled residents (Resident 1) who required assistance with activities of daily living (ADL). This failure resulted in Resident 1's grooming and personal hygiene not maintained and had a potential to affect Resident 1's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two residents (Resident 1) was seen by the physician every 30 days for the first 90 days after admission as stipulated in the regulation. This failure resulted in Resident 1 not able to discuss and not offered to participate in his treatment plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. The temperature was monitored in the dry food storage room; 2. The ice machine's preventative maintenance (PMs) and cleaning schedule was performed and documented according to the manufacturer's instruction for use (MIFU's) manual; 3. The ice machine floor drain was clean, free of debris, and trash. These failures had the potential to place residents at risk for developing foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and homelike environment when: 1. A wall was in a state of disrepair in room six. 2. The floor was in disrepair in room two. 3. Missing section of handrail in the north wing of the facility. 4. Ill fitting closet drawer in room five. 5. Used equipment were stored outside the building of the south wing in view of the residents, staff, and visitors. 6. A toilet seat was in disrepair and peeling paint was on the door jams in room [ROOM NUMBER]. 7. A wall behind the bathroom sink was in disrepair, a faucet knob was not in good working order, limescale buildup was on the faucet, and a vent cover was missing on the bathroom ceiling in room [ROOM NUMBER]. 8. Two rooms with torn loose wall paper, stripped down to the dry wall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. Hand hygiene was not performed in the kitchen. 2. Oxygen tubing and face mask connected to a Nebulizer (breathing treatment machine) was not dated and stored in a plastic bag for one resident (Resident 78). 3. Residents' shared bathrooms (rooms 23, 24 and 25, 26) had unlabeled and uncovered resident supplies, (large basins, bedpan, and emesis basin [small container used to collect vomit]) and were stored on the floor next to the toilet. These facility failures had the potential to result in food borne illness, cross-contamination (the transfer of harmful bacteria) of resident equipment and supplies that could impact residents' health and safety.

Inspectors wroteBased on observation and interview, the facility failed to ensure the indwelling catheter (tube draining urine from bladder) collection bag was covered with a dignity bag (covering for collection bag), for one unsampled resident (Resident 68). This facility failure had the potential for the Resident 68 to be embarrassed and thus, affect their psychosocial well being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident call light (button to press if a resident needs help or assistance) was within reach for two of 32 sampled residents (Resident 13 and Resident 102). This facility failure had the potential for the residents to not be able to call for help or assistance as needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan intervention for oxygen use was being followed for one of 32 sampled residents (Resident 40). This failure had the potential to result in a decline in Resident 40's physical well being.

Inspectors wroteBased on record review and interview, the facility failed to implement Physician's orders for weekly weights and notify the Physician of significant weight loss, for one of 32 sampled residents (Resident 4). This failure had the potential to cause Resident 4 a further decline in health status.

Inspectors wroteBased on observation and interview, the facility failed to ensure the posted nurse staffing information was current. This facility failure had the potential for residents and visitors to not to be aware of the actual nursing hours the facility is providing.

Inspectors wroteBased on record review, and interview, the facility failed to ensure a physician's reason of no action/no change on the pharmacist's recommendation for Cymbalta (medication used to treat depression and anxiety) was documented in the resident's medical record in one of 32 sampled residents (Resident 105). This failure had the potential for over medication and /or ineffective medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 32 sampled residents (Resident 58's) Lorazepam (medication used for anxiety) ordered as needed (PRN) did not exceed 14 days of therapy unless renewed. This facility failure had the potential for Resident 58 to be over medicated or have no assessment for renewal use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a standardized recipe for tuna salad, and no system in place to acknowledge food allergies. This facility failure had the potential to negatively impact the health and safety of residents with known food allergies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's prescribed therapeutic diet order for one of 32 sampled residents (Resident 78) during lunch on 6/16/22. This failure resulted in Resident 78 receiving the wrong prescribed lunch meal and had the potential to result in decreased food intake or unplanned weight loss, further compromising the nutritional and medical status of Resident 78.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST-a care directive during life threatening situations) were reflected as signed and ordered by the attending physician on the resident's electronic medical record (EMR) for one of 32 sampled residents (Resident 28). This failure had the potential to cause a delay or violate resident's rights as to wishes on administering life-sustaining treatments during an emergency.