South Pasadena Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the setting for low air loss mattress (LAL- mattress designed to prevent and treat pressure ulcer (localized damage to the skin and underlying soft tissue caused by prolonged pressure) for two of three sampled residents (Resident 1 and 2) who are admitted with pressure ulcers(an area of damaged skin and tissue that forms when sustained pressure cuts off blood flow. They commonly develop over bony areas like the heels, ankles, hips, and tailbone in people with limited mobility) were set correctly based on the residents' current weight and in accordance with their individualized care plans. This failure had the potential to cause the residents' existing pressure ulcer to worsen.

Inspectors wroteBased on interview, and record review, the facility failed to implement a comprehensive person-centered care plan for Gastrostomy tube (G-tube, is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) by not having a documented evidence to monitor his G-tube site for one (1) of 2 sampled residents (Resident 2) as indicated on the facility's policy. This deficient practice had the potential for Resident 2 not to receive the proper care and treatment if the medications and nutrition were not administered timely through his G-tube site, which also may result in hospitalization, injury and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary daily needs and care to ensure quality of care was provided, residents' wellbeing was cared for and prevent the possible harm and illness due to Activities of Daily Living (ADL) not being provided for one (1) of two (2) sampled residents (Resident 1). These deficient practices have potentially led to residents do not have quality of life and the harm and illness that might cause due to ADL were not provided. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to document records accurately and completely for one (1) of three (3) sampled residents (Residents 1) in accordance with the facility's policy and procedure (P&P) by failing to ensure oxygen administered to Resident 1 on 2/9/26 was documented on the Medication Administration Record (MAR, a medical record used by healthcare providers to document the administration of a medication or treatment) and on the SBAR Situation, Background, Assessment, Recommendation (SBAR) Communication Form (communication tool that helps provide essential, concise information). This deficient practice can result in a lack of or a delay in communication between the staff and can interrupt provision of care/intervention to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure for Changes in a Resident Condition, by failing to notify the physician on 2/7/2026 for one (1) of three (3) sampled residents (Resident 1) who had a change in condition for altered knee sensation after a witnessed fall on 2/6/2026. This deficient practice had the potential for a result in delayed provision of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Residents 1) were provided necessary treatment and services to prevent formation of and promote healing of pressure injury (pressure ulcers, injury to the skin and underlying tissue resulting from prolonged pressure on the skin) in accordance with the resident's care plan by failing to ensure Resident 1 was repositioned every two hours. This deficient practice had the potential to place Resident 1 at risk for skin integrity complications and to have worsening or recurrence of a pressure injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe environment free of accident hazards by not preventing smoke from entering the facility hallway leading to the front lobby as a result of a burnt Heating, Ventilation, and Air Conditioning unit's (HVAC unit, is a comprehensive system designed to regulate indoor temperature, humidity, and air quality) filter on 1/10/2026. This deficient practice had the potential to place residents, visitors, and staff at risk for smoke inhalation (damage caused to the respiratory system, airways, and lungs by breathing in harmful combustion products [smoke] from fires) which could result in respiratory irritation, including coughing, shortness of breath, and complications such as airway swelling, reduce amount of oxygen to the body, hospitalization, and death.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two sampled residents (Resident 1) received all necessary services including an appointment with his oncologist (a medical professional specializing in the diagnosis, treatment, and prevention of cancer) as prescribed. This failure resulted in Resident 1 not receiving an evaluation and treatment plan for resident's non-Hodgkin lymphoma (NHL, a cancer that affects the lymphatic system [a network of organs, vessels and tissues that moves colorless fluid back to the bloodstream]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure privacy for three (3) of three (3) residents (Residents 1, 2 and 3) as indicated on the facility's policy Resident Dignity and Personal Privacy,. This deficient practice had the potential to violate the residents' right to confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the resident's representative) and privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of three (3) residents (Residents 3) received treatment and care as indicated on the facility's Policy and Procedure (P&P) titled, Changes in Resident Condition when, 1. Licensed Vocational Nurse 2 (LVN 2) did not inform physician immediately and assessed Resident 3's complaint for generalized itching on 9/2/2025.2. Licensed Staff has no documented evidence that Resident 3 was assessed for Skin Evaluation and formulated a Care Plan (CP) specific for generalized itching from 6/6/2025-9/2/2025. These deficient practices had the potential to result in delays in the necessary care and treatment of Resident 3 which could affect the residents' overall wellbeing.

Inspectors wroteBased on interview and record review the facility failed to report an injuries of unknown source for one (1) of two sampled residents (Residents 1) within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB, advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement on 8/14/2025. This deficient practice resulted in a delay of onsite inspection by the Department of Public Health and had the potential to result in inadequate care to residents, unidentified abuse/neglect and continuation of abuse/neglect to the residents in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure Resident 1's phenytoin sodium (a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) was available in stock to be administered on 7/25/2025 at its scheduled time of administration, in accordance with facility's policy and procedure (P&P) titled, Administering Medications, dated 7/2024. 2. Ensure Resident 2's ergocalciferol (also known as vitamin D2 - a vitamin used to treat low levels of vitamin D) was available in stock to be administered on 8/4/2025 at its scheduled time of administration, in accordance with the facility's P&P, titled Administering Medications, dated 7/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent significant medication error (a type of error which causes the resident discomfort or jeopardizes his or her health and safety) for Resident 1 by failing to ensure Resident 1's phenytoin sodium (a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) was available in stock to be administered on 7/25/2025 at its scheduled time of administration, in accordance with facility's policy and procedure (P&P) titled, Administering Medications, dated 7/2024. This deficient practice placed Resident 1 at risk for seizures, falls and other adverse consequences of not getting the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call device (an alerting device for nurses or other nursing personnel to assist a patient when in need) was maintained within easy reach for two (2) of four (4) sampled residents (Resident 76, and Resident 120). This deficient practice had the potential to cause a delay in resident care for Resident 76 and Resident 120's resulting in unmet needs. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its Policy and Procedure (P&P) on intravenous (into the through the vein) therapy for two (2) of three (3) sampled residents (Residents 54 and 58) by failing to ensure: 1. Resident 54's IV tubing (a flexible plastic tube that delivers fluids, medications, and other therapies into the body through a vein) was labeled. This deficient practice had the potential to put Resident 54 at risk of getting a bloodborne (carried by the blood) infection. 2. Resident 58's IV site was monitored every shift as indicated in the resident IV antibiotic (ATB, [medicines that fight bacterial infections]) care plan. This failure had the potential to put Resident 58 at risk for developing an infection and complications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness (food poisoning), by failing to ensure the following:1. Six beef patties that were thawed in the walk-in refrigerator were used within 72 hours or discarded in accordance with the facility policy.2. Kitchen staff wore hairnets and beard restraints (worn by food handlers to avoid getting hair into the food) while preparing food and while dishwashing to prevent loose hair from falling into food or onto surfaces that can come into contact with food.3. Dietary aide used her mouth/teeth to cut the masking tape used to label beverages.4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose garbage (mostly decomposable food waste or yard waste) and refuse (dry material such as glass, paper, cloth or wood that does not readily decompose) by leaving two of four dumpsters (large trash container designed to be emptied into a truck) exposed to the environment and not cover or close completely. This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry disease such as rodents, parasitic worms , or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to the residents and staff of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a coordination of care between the facility and hospice (care designed to give supportive care to people in the final phase if a terminal illness and focus on comfort and quality of life, rather than cure) staff for two of two sampled residents (Resident 14 and Resident 105) in accordance with the physician's order by failing to ensure:1. Resident 14 has a July 2025 Hospice nursing visitation calendar and hospice care in June 2025 was provided as indicated on the physician's order.2. Hospice visits for June 2025 and July 2025 were provided for Resident 105. This deficient practice had the potential for Resident 14 and Resident 105 not to receive the hospice care and services necessary to promote comfort and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections or diseases in the healthcare setting) was followed when medical waste (any waste generated by healthcare activities, ranging from used needles [the pointed hollow end of a syringe[medical device consisting or a hollow tube with a plunger]] and syringes to soiled dressings, body parts, blood, and medical devices) was not disposed safely and appropriately in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to result in the spread of and development of infection through possible cross contamination (passing of bacteria or other harmful substances indirectly from one resident to another through improper disposal of medical waste.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Clean the dryer lint trap for one (1) of four (4) dryers located in the laundry room as indicated in the Facility's Policy and Procedures (P&P). This deficient practice had the potential to cause fire in the facility. 2. Ensure laundry washer temperature was accurately checked on 7/23/2025. This deficient practice had the potential of improper disinfection of residents' clothes. 3. Ensure restroom A and room A were free of urine on the toilet surfaces and floor. This deficient practice had the potential to affect resident's quality of life. 1. During a concurrent observation in the laundry room and interview with Laundry Staff 1 (LS 1) and Infection Prevention Nurse (IPN) on 7/23/2025 at 1:09 PM, 4 dryers were observed in the laundry room. Lint found in the lint traps in 1 dryer (dryer 1). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote dignity and respect for one of 30 sampled residents (Resident 115) when Certified Nurse Assistant 5 (CNA 5) was observed standing above Resident 115's eye level while assisting the resident during mealtime on 7/21/2025. This deficient practice had the potential to affect Resident 115's self-esteem and self-worth and violate the resident's right to be treated with dignity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with a homelike environment for one of one sample resident (Residents 139) for the environment care area by failing to provide bed linen that was damaged with multiple small holes. This deficient practice had the potential to negatively affect the residents' quality of life. During a review of Resident 139's admission Record indicated Resident 139 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), type 2 diabetes mellitus with diabetic chronic kidney disease (a chronic condition that happens when you have persistently high blood sugar levels. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 1) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) by failing to ensure Resident 1's Lorazepam (medication used to treat anxiety [persistent and excessive worry that interferes with daily activities) as needed (PRN) order had a documented rationale for extending the use beyond 14 days in accordance with the facility's policy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for three (3) of 30 residents (Residents 8, 79, and 126) as follows:Resident 79's 1,000 cubic centimeters (cc- a measurement of volume) fluid restriction (limiting the amount of liquids a person consumes each day) as ordered by the physician. Regarding Resident 126's Intravenous (IV) antibiotic (medicines that fight bacterial infections) administration. Regarding Resident 8's use of bolster low air loss mattress. These failures had the potential for Residents 79, 126 and 8 to receive care that is not personalized to meet the specific needs identified above, which could result in decreased quality of care and quality of life. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the bolster (a raised, often inflatable, perimeter around the edges of the mattress that helps prevent patients from rolling out) low air loss mattress (LALM- a specialized medical mattress designed to prevent and treat pressure ulcer [pressure injury- wound that occurs as a result of prolonged pressure on a specific area of the body] by maintaining a cool, dry environment through constant airflow, which helps regulate temperature and moisture) was ordered for one (1) of five (5) sampled residents (Resident 8). This deficient practice had the potential for Resident 8's pressure ulcer to worsen and for the resident to develop new pressure injury. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure one of three sampled residents (Resident 87), received the correct amount of water flush via gastrostomy tube ( GTube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) after medication administration as indicated in the physician's order and care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs). This failure resulted in a decreased amount of water administration for Resident 87, with the potential risk for Resident 87 to experience inadequate hydration and/or clogging of the GTube, causing decreased nutrition and hydration.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor the daily fluid restrictions (limiting the amount of liquids a person consumes each day) of 1000 cubic centimeters (cc- a measurement of volume) for one of five residents (Resident 79) on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) as ordered by the physician. This failure had the potential for Resident 79 to experience complications including fluid overload (having too much fluid in the body) which could negatively affect the resident's overall wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to provide a consistent and accurate account for controlled medications (medications that the use and possession of are controlled by the federal government) through staff documentation for all the controlled medication at shift change. This has the potential for the facility staff to not secure and safeguard controlled medications and not be able to account that the medications were administered to the residents safely and accurately.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Three (3) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error, which yielded a facility medication rate of 12.5% for one (1) of four (4) sampled residents (Resident 87). [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the glucose test strips (small, plastic strips used with a glucose meter to measure the amount of glucose [sugar] in a blood sample) were not expired prior to blood sugar testing for one of two sampled residents (Resident 6) observed during medication administration. This deficient practice had the potential to cause inaccurate test results in the testing of Resident 6's blood sugar, leading to inappropriate and ineffective treatment and management.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain accurate and complete medical records in accordance with the facility's Policy and Procedures (P&P) for two (2) of 30 sampled residents (Resident 58 and Resident 87) when: Resident 58's intravenous (IV, within the vein) therapy medication record was not initialed on 7/14/2025, 7/15/2025, 7/16/2025, 7/17/2025, 7/18/2025, 7/19/2025, 7/20/2025, 7/21/2025, 7/22/2025 and included inaccurate information on 7/22/2025. Inaccurately documenting the administration of water flushes for one of four sampled residents (Resident 87), in the Medication Administration Record (MAR), when the water flushes were not given. These failures had the potential to result in a lack of or delay in the provision of care/interventions for Residents 87 and 58 and inaccurate communication between healthcare providers. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate and up to date staffing information was posted and placed in a visible and prominent place on 7/19/2025 to 7/21/2025. As a result, the total number of staff and the actual hours worked by the staff were not readily accessible to residents and visitors. During an observation on 7/21/2025 at 7:33 AM, the daily staffing information dated 7/18/2025 was observed at the front reception desk near the facility's front entrance area. There was no other updated staff posting found. During an observation on 7/21/2025 at 10:48 AM, the daily staffing information dated 7/18/2025 was still posted at the reception area without any up-to-date staffing information for 7/21/2025. [...]

Inspectors wroteBased on observation, interview and record, the facility failed to provide care in a manner that maintained the resident's dignity and treated the resident with respect for one of two sampled residents (Resident 1'sby failing to ensure Resident 1 was covered with a blanket/ towel when getting out of the shower. This deficient practice violated the resident's right for privacy and had the potential to affect the self-esteem, self-worth, sense of independence and psychosocial well-being (an individual's mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose, all of which are interconnected and influence overall functionality) of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Policy and Procedure (P&P) titled Abuse (misusing something, especially mistreating a person or harming them physically) Investigation and Reporting for one of two sampled residents (Resident 1) by: 1. Failing to report to the State Agency (SA where state law provides for jurisdiction in long-term care facilities), ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities) and local enforcement within 2 hours after Resident 1 reported an allegation of physical abuse to Registered Nurse 1 (RN 1) on 4/22/2025 at 10 AM that Resident 2 jumped on top of Resident 1 and hit Resident 1's head. 2. Failing to separate Resident 1 and 2 immediately after the incident was reported on 4/22/2025 at 10 AM. [...]

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to ensure one (1) of three (3) sampled resident (Resident 2) with a gastrostomy feeding tube (GT- a tube inserted into the stomach to provide nutrition when a person is unable to eat adequately through their mouth) received the GT feeding volume as ordered by the physician. This deficient practice had the potential to result in altered nutritional status, weight loss, not able to promote wound healing and potentially lead to more complications for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was treated with respect and dignity by failing to ensure the television volume was in a comfortable level in Resident 1's room. This deficient practice resulted in a confrontation between Resident 1 and Resident 2 regarding the volume of the television in the room and violated Resident 1's right to be treated with dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of four (4) sampled Residents (Residents 16 and 286) and/or Residents' representatives were informed and provided written information regarding the right to formulate an advance directive (written statement of a resident's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the resident be unable to communicate them to the doctor) in accordance with the facility policy and procedure. This deficient practice had the potential for Residents 16 and 286 or residents' representative to not know their rights and cause conflict in carrying out the Residents' wishes for medical treatment and health care decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure grooming care assistance was provided for two (2) of three (3) sampled residents (Residents 43 and 75) as indicated in the facility policy. This deficient practice had the potential to lead to skin breakdown, poor hygiene, and diminished quality of life for Residents 43 and 75.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent accidents for three (3) of 3 sampled residents (Resident 58,103 and 28) who had history of seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness) by failing to provide padded siderails (a barrier attached to the side of a bed) in accordance with the facility's seizure precaution policy. This deficient practice had the potential for Residents 58,103 and 28 to sustain injuries during a seizure disorder activity.

Inspectors wroteBased on interview and record review the facility failed to provide necessary care and services for two (2) of three (3) sampled residents (Resident 106 and 103) by failing to: 1. Monitor Resident 106's Foley catheter (brand name for urinary indwelling catheter - a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) in accordance with the physician's order. This failure had the potential to place Resident 106 at risk for developing a urinary tract infection (UTI, an infection in any part of the urinary system). 2. Resident 103 suprapubic stoma site (surgically made hole above the pubic area) dressing was not changed daily as ordered. This deficient practice had the potential for Resident 103 to develop an infection at the suprapubic stoma site which could affect the health and well-being of the resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy and procedure regarding oxygen administration for two (2) of 2 residents (Residents 7 and 129) by failing to ensure: 1. Resident 7's oxygen was at the correct ordered setting in accordance with the physician's order. This deficient practice resulted in Resident 7 not receiving the correct ordered amount of oxygen which had the potential to result in complications associated with oxygen therapy. 2. Resident 129's oxygen nasal cannula (NC, a device that delivers extra oxygen through a tube and into your nose) was changed every seven (7) days. Facility also failed to maintain a clean oxygen concentrator (a medical device that gives extra oxygen). These deficient practices had the potential for Resident 129 to develop a respiratory infection and cause complications associated with oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with the facility's policy and procedure by: 1. Facility failed to properly seal a container of chicken soup base and wheat flour. 2. Facility failed to ensure the refrigerator designated for resident's food items brought form outside was kept clean. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, which can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations for resident needs and preferences for two (2) of 26 sampled residents (Residents 124 and 186) in accordance with the facility's policy when: 1. Resident 124's bathroom toilet seat was not at a comfortable and safe height for the resident. This deficient practice had the potential to result in a fall and injury to Resident 124. 2. Resident 186's call light was not within reach. This deficient practice had the potential for Residents 186 not to obtain necessary care and services to meet resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, comfortable, homelike environment for one of seven sampled residents (Resident 58). This deficient practice had the potential to result in the spread of diseases and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop/implement residents' care plan for two (2) of 26 sampled residents (Residents 28 and 103) as indicated in the policy and procedure by failing to: 1. Implement the use of padded side rail for Resident 28 who has a diagnosis of epilepsy (brain disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). This deficient practice had the potential to place the Resident 28 at risk for injuries. 2. Develop a care plan to address the treatment for Resident 103's suprapubic stoma site (surgically made hole above the pubic area). This deficient practice had the potential to increase Resident 103's risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of three (3) sampled resident (Resident 63) was provided a communication board (pre-printed picture board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) with the language the resident was able to understand in accordance with the facility policy. This failure had the potential to result in Residents 63 experiencing a delay in receiving appropriate care and treatment due to the staff not being able to properly communicate with the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for two (2) of five (5) sampled residents (Residents 287 and 46), in accordance with the facility's policy and procedure. This deficient practice had the potential to place Resident 287 to have worsening stage 3 pressure ulcer (full-thickness skin loss in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present) and potential for Resident 46 to develop a pressure ulcer.

Inspectors wroteBased on interview and record review the facility failed to ensure one (1) of three (3) sampled residents (Resident 106) received Restorative Nursing Assistant (RNA, nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible) services as indicated in the physician's order. This failure had the potential to put Resident 106 at risk for decline in physical function and developing contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident received the two (2) liters (unit of volume used for measuring capacity of liquids) of water required to receive daily and to accurately record fluid intake for one (1) of two (2) sampled residents (Resident 112) as indicated in the physician's order and in accordance with the facility's policy. This deficient practice could potentially result to insufficient fluids received daily affecting Resident 112's overall health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physicians order for one (1) of five (5) sampled residents (Resident 124) in accordance with the facility policy by failing to check Resident 124's heart rate prior to administering metoprolol (medication to treat high blood pressure (the force of blood pushing against the walls of your arteries), long term chest pain and heart failure (when the heart muscle does not pump blood as well as it should). This deficient practice had the potential for Resident 124 to experience adverse consequences (undesirable effect) or events such as bradycardia (slow heart rate).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Restorative Nursing Assistant (RNA, nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible) services were documented timely and accurately for one (1) of 26 sampled residents (Resident 106). This failure resulted in the facility not documenting RNA services for Resident 106 timely and accurately as indicated in the facility policy.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 186) had a hospice (a program that gives special care to residents who are near the end of life and have stopped treatment to cure or control their disease) comprehensive assessment for the plan of care to include the frequency of hospice staff visits. This deficient practice had the potential for Resident 186 not to receive the hospice care and services necessary to promote comfort and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were implemented for two (2) of 26 sampled residents (Residents 10 and 57) according to the facility's policy and procedure when: 1. Licensed Vocational Nurse 8 (LVN 8) failed to disinfect (clean with a chemical, in order to destroy bacteria) the shared blood pressure cuff after obtaining Resident 10's blood pressure (pressure of circulating blood against the walls of blood vessels) reading. This deficient practice had the potential to spread infection to other residents in the facility. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident call system (call light- allow resident to communicate when they need assistance) for two (2) of 26 sampled residents (Residents 35 and 119) was functional for Resident 35 and within reach for Resident 119 as indicated in the facility policy. This failure had the potential to put Residents 35 and 119 at risk for experiencing a delay in receiving assistance from facility staff which could lead to a fall or accident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, safe, and sanitary environment when: 1. Food debris were observed under Resident 16's bed. 2. Used syringes were not properly disposed in the sharps container. 3. The rubber covering of two green silicon dumbbells were observed peeling off. These deficient practices had the potential to result in the spread of diseases and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with a safe, clean, comfortable homelike environment for 13 of 15 sampled residents (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, and 15). a. Residents' 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14 and 15 rooms had rodent (small gnawing mammals such as a mouse or rat) droppings. b. Resident 3's room had large clear plastic bag of clothes and hangers on the floor next to resident's bed. These deficient practices resulted in an unsafe and unclean environment with the potential for the spread of infection or accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control protocol. This failure resulted in evidence of an active rodent infestation, including rodent (small gnawing mammals such as a mouse or rat) droppings and nesting materials, in Resident 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, and 15 ' s rooms, 13 out of 15 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation to meet the resident's needs by failing to ensure the resident had a working television and remote control for one of 15 sampled residents (Resident 1). This deficient practice had the potential to negatively impact the psychosocial well-being of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functioning call light for one of 15 sampled residents (Resident 1). This deficient practice had the potential to result in a delay in meeting Resident 1's needs for hydration, pain management, and activities of daily living (ADLs - activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain infection control practices as followed: 1. A staff member did not clean and/or disinfect shared resident equipments, such as a front-wheeled walker (FWW, type of walking aid with a wide base for support) and a cloth gait belt (safety device worn around the waist used to help safely transfer a person from one surface to another) between use with two residents. 2. In the laundry room, the following were observed: a. There was a disposable yellow isolation gown [a type of personal protective equipment (PPE) used to prevent the spread of infection] hanging in the clean PPE donning (putting on) station for re-use. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement safeguards to ensure labels containing resident information were discarded appropriately for two of two sampled residents (Resident 35 and 77). a. Resident 35's Glucerna formula (a total nutritional supplement) container with the resident's information was in the trash bin. b. Resident 77 threw away a sandwich with a label containing the resident's information, the Housekeeper 1 (HK 2) tied the trash bag and placed it in her cart. These deficient practices violated the residents' right to privacy of his/her medical information.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents were provided with a safe, clean, comfortable, and homelike environment for two of four sampled residents' (Residents 97 and 73). Residents 97 and 73's wheelchairs were observed with torn backs and worn arm rest cushions. This deficient practice had the potential to affect the residents' comfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized, comprehensive care plan for one of seven sampled residents (Resident 100), who was on a restorative nursing aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility). Resident 100 did not have a care plan for an RNA program for left upper extremities (LUE, shoulder, elbow, wrist, hand) and left lower extremities (LLE, hip, knee, ankle, foot) for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises and RNA program for right upper extremities (RUE) and right lower extremities (RLE) for active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Licensed Vocational Nurse 6 (LVN 6) flushed with water in between administration of medications via a gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach) during a medication administration to Resident 127. This deficient practice had the potential for the resident to have complications with the G-tube such as obstruction of the tubing and/or drug-to-drug interactions from mixing of drugs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Resident 36 with a communication board to assist the resident with his communication needs. This deficient practice prevented the resident from communicating with the staff and had a potential to delay receiving appropriate care/treatment services that the resident needed.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary treatment and services for one of two residents (Resident 36) to prevent pressure ulcers (PUs, skin breakdown caused from prolonged pressure to the skin) from worsening. The facility failed to turn Resident 36 every two hours and apply pressure relieving device as indicated in the resident's care plan. This deficiency had the potential for the resident to have worsening PUs and/or acquire new PUs.

Inspectors wroteb. During an observation on 7/20/21 at 10:54 a.m., Resident 12 was noted sitting on the bed with bilateral upper side rails up. Left side rail was covered with sheep like wool padding while no pads were noted on the right side rail. Only one floor mat was observed on the left side of the resident's bed. A review of Resident 12's admission Record indicated the facility admitted Resident 12 on 10/16/2020 with diagnosis that included Fall and Fracture (complete or partial break in a bone) part of neck of right femur (bone of the thigh, articulating at the hip and the knee). A review of Resident 12's Minimum Data Set (MDS, a standardized assessment of care screening tool), dated 4/24/2021, indicated the resident had severe impairment in cognitive skills. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 125) was provided with an assessment and education for the resident to disconnect and self-drain his urostomy (an opening in the belly that directs urine away from the bladder) pouch. This deficient practice had the potential for the resident to have urinary infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor blood sugar levels and signs and symptoms of hypoglycemia (when blood sugar levels fall below normal levels) for one of one sampled resident (Resident 56), who received insulin (medication used to control elevated blood sugar levels) injections. This deficient practice had the potential for the resident to receive insulin when the resident's blood sugar levels were low, which could result in the resident's blood sugar levels to become critically low requiring emergency treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label four (4) multi-dose vials (a vial of liquid medication that contained more than one dose for administration) of insulin (medication used to control blood sugar levels) with an open date when it was opened. This deficient practice had the potential to compromise the well-being of the residents by not being able to determine when to discard the medication after removing the seal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in the freezer in accordance to professional standards for food safety. A bag of pork pot stickers was found in the freezer opened and undated. This deficient practice had the potential to cause foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three staff knew how to notify the Quality Assurance Performance Improvement (QAPI) committee of any concerns. This deficient practice had the potential to result in identified problems within the facility would not be resolved.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functioning call light (a button used by a resident to signal his or her need for assistance from staff) for three of 29 sampled resident beds (residents in Rooms 108B, 301A, 301B). This deficient practice had the potential to result in a delay for residents' needs being met and/or injury/harm from falls that may occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment by not keeping the ceiling in some parts of the building free from moisture and water leaks. This deficient practice had the potential to expose the residents, staff, and visitors to accidents that could cause harm or injury.