Southland

Inspectors wroteBased on observation, and interview, the facility failed to ensure a mattress placed on the floor next to one of three sampled resident's (Resident 1) bed was not damaged. This deficient practice resulted in a visibly damaged mattress placed on the floor next to Resident 1's bed and had the potential for harm to Resident 1 and to affect his sense of dignity.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure sufficient staff were available to provide care and ensure four out of eight sampled residents' (Residents 35, 60, 63, and 123) needs were met as evidenced by 1. Resident 35 had not been showered for several weeks, and 2. Call lights (device that allows residents to request assistance from nursing staff) for Residents 60, 63, and 123, were not answered in a timely manner. These failures had the potential to resulted in a delay in care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 104 out of 112 total residents in the facility by not:A. Ensuring Foods were dated, labeled, and discarded before the used by date (expiration dates). B. Ensuring the proper level of the concentration of the Quaternary Ammonium (a type of chemical that is used to kill bacteria, viruses, and mold) in sanitization bucket was monitored and maintained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed infection control practices for four of thirty sampled residents (Resident 5, 89, 154, and 157) when:Certified Nurse Assistant (CNA) 2 failed to wear proper PPE prior to performing Foley catheter care for Resident 5. Laundry staff (LS) 1 failed to perform hand hygiene before and after distributing linens to Resident 89, 154 and 157. This failure has the potential to result in cross contamination, transmission of infectious organisms, healthcare-associated infections, and overall compromise of resident safety and sanitary conditions to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident's privacy and dignity for one of one sample resident (Resident 1) while Resident 1 was urinating. This failure has the potential to result in compromised the resident's dignity and privacy, embarrassment and unwanted expose to others while urinating.

Inspectors wroteBased on interview and record review the facility failed to ensure two of six sampled residents' (Resident 7 and 60) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for a psychotropic drug (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was obtained prior to administration. These deficient practices violated Resident 7 and 60's rights to receive advanced information of risks and benefits of proposed care, treatment, treatment alterative, and choose the alterative of choice which includes information for administration of psychotropic drugs.

Inspectors wroteBased on interview and record review the facility failed to meet the needs for four of eight sample residents (Residents 35, 60, 63, and 123). Resident 35 had not been showered for two weeks, and the call lights (device that allows residents to request assistance from nursing staff) for Residents 60, 63, and 123, were not answered in a timely manner. These deficient practices resulted in delays of care and services, which could negatively impact resident outcomes.

Inspectors wroteBased on observation, interview and record review:a) The facility failed to discuss and provide written information on the formulation of advanced directives (a legal document indicating a resident preference about end-of-life treatment decisions) for one of one residents (Resident 125) reviewed.b) The facility failed to ensure that advanced directives for two of three residents (Resident 101 and 132) sampled were included in their respective electronic and physical medical records. These deficient practices infringed on residents' right to be fully informed of their options regarding advanced directives and created a potential for care that conflicts with their expressed wishes.a. [...]

Inspectors wroteBased on interview and record review the facility the facility failed to:a. To define and monitor resident specific, measurable target behaviors related to use of Depakote for one of five residents sampled for unnecessary medications (Resident 7).b. To ensure there were regular Interdisciplinary Team Conferences to assess for continued need/justification and possible gradual dose reduction (stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of psychotropic medications (medications can alter brain chemistry, impact body functions, and modify a person's thoughts, moods, feelings, awareness, and perceptions) for two out of two residents (Resident 60 and 101) as indicated in facility policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow through and accurately assess with the Preadmission Screening and Resident Review (PASARR- a comprehensive evaluation that ensures people who have been diagnosed with serious mental illness, intellectual, and/or developmental disabilities are able to live in the most independent settings while receiving the recommended care and interventions to improve their quality of life) level I and level II evaluation for one of five sampled residents (Resident 2) to determine the facility's ability to provide the special needs of the residents. This failure had the potential to result in Resident 2 being at risk of not receiving the necessary care and services Resident 2 needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a person-centered care plan was implemented for two of four sampled residents (Resident 13 and Resident 111) when:Resident 13 needed additional time for dental services and refused to comply with dental personnel during the dental visits. Resident 111 received wound treatment on the left knee incision after surgery. These deficient practices had the potential to negatively affect the quality of life and wellbeing for Resident 13 and Resident 111 and personalized goals and interventions for continued care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper urinary indwelling catheter care for one of one sampled resident, (Resident 80) by failing to:1.) Ensure the indwelling catheter (a soft, thin tube that goes into your bladder so urine can drain out and into a bag outside your body) drainage bag was off from the floor.2.) Ensure the indwelling catheter drainage bag was below the bladder level during the care. This failure had the potential to cause urine backflow into the resident's bladder, increasing the risk for urinary tract infections (UTI- an infection the bladder/urinary tract) and indwelling catheter-related complications.

Inspectors wroteBased on observation, interview and record review the facility failed to:a. Ensure one of four residents received the correct dose of their pain medication (Resident 53). b. Ensure an emergency kit ([E-kit] receptacle that includes medications that need to be administered when pharmacy services are not available) was replaced after being used for Resident 4. These failures have the potential to result in medication errors. [...]

Inspectors wroteBased on interview and record review, the facility failed to address the consultant pharmacist's recommendations to clarify the behavior manifestation for Seroquel [ a prescription medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)] on 3/6/2026 and to consider a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) for Depakote (a prescription medication used to treat bipolar disorder) on 4/19/2026 during the Medication Regimen Review (MRR - a monthly report from the consultant pharmacist identifying any medication irregularities in a resident's current medication regimen) for one of five resident (Resident 7). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of one resident's (Resident 84) Ativan (a class IV medication for anxiety [mental health condition characterized by pervasive worry and fear affecting daily life]) was properly stored. The medication was not in a locked container. The failure had potential to result in drug diversion (illegal transfer of prescription medications).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills such as :A. [NAME] (CK) 1 failed to follow the meal ticket for Resident 67 during the trayline (an assembly line system used in nursing homes and institutional food services to prepare and assemble patient or resident meal trays). B. [NAME] (CK) 2 and Dietary Supervisor (DS) failed to verbalize substitute fortified food items for cheese for Resident 67. These failures had potential to result in Resident 67 not receiving fortified diets as prescribed and Resident 67's food preference was not honored to prevent weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food brought by visitors was properly monitored, stored, and supervised according to the physician's prescribed diet order for one of one two sampled residents (Resident 36). This failure has the potential to result in poor diabetic control, aspiration risk, exposure to unsanitary food conditions, and pest contamination, which could negatively affect resident's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for one of two sample resident (Resident 80) when the molding located at the head of Resident 80's bed was damaged. This failure has the potential to result in injury and compromised infection control to the residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain a sanitary, pest-free environment for one of nine sampled residents (Resident 105) when Family Member 1 (FM 1) discovered rodent droppings in Resident 105's laundry hamper while sorting through Resident 105's laundry. This deficient practice resulted in a damaged shirt and had the potential to result in negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Inventory list (Resident's Clothing and Possessions form) for one of four sampled residents (Resident 1) was created during the admission of Resident 1 to the facility. This deficient practice resulted in the clothing and/or other possessions for Resident 1 not being documented on admission to the facility. This deficient practice had the potential for Resident 1 to have no recourse to recovery clothing or other possessions that could be lost.

Inspectors wroteBased on interview, and record review, the facility failed to report an injury of unknown origin for one of four sampled residents (Resident 1) when Resident 1 experienced right hip pain and an X-ray (a medical test that takes black and white pictures of the inside of the body) indicated Resident 1 sustained a dislocation (a traumatic injury where the ends of two connected bones are forced out of their normal positions) to her right hip. This deficient practice resulted in the California Department of Public Health (CDPH) not being aware of Resident 1's injury causing a delay in their investigation. This deficient practice had the potential for pertinent information to be lost and/or forgotten.

Inspectors wroteBased on interview, and record review, the facility failed to thoroughly investigate an injury of unknown origin for one of four sampled residents (Resident 1) when Resident 1 experienced right hip pain and an x-ray (a medical test that take black and white pictures of the inside of the body) indicated Resident 1 sustained a dislocation (a traumatic injury where the ends of two connected bones are forced out of their normal positions) to her right hip. This deficient practice resulted in the facility's inability to determine how the injury occurred and had the potential for abuse and/or neglect to go unrecognized.

Inspectors wroteBased on interview and record review, the facility failed to ensure a duplicate blood drawn was not conducted on one sampled resident (Resident 1) on 1/12/2026 when the order to obtain labs had already been completed on 12/26/2026. This deficient practice resulted in an unnecessary and duplicated blood draw on Resident 1 without an order from the physician to obtain blood work on 1/12/2026. This deficient practice had the potential to cause anemia, physical injury, and lack of physician oversight.

Inspectors wroteBased on observation. interview and record review, the facility failed to Implement the facilities procedures and policy (P&P) titled Infection Prevention and Control plan revised 5/2023, indicating standard and transmission-based precautions would be followed to prevent the spread of infections by failing to ensure visitors and staff use Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when indicated. These failures had the potential to result in compromised infection control measures resulting in the spread of Covid-19 (a highly contagious respiratory infection caused) infection among residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure they reported an allegation of resident to resident abuse within two hours of being made aware of the allegation for two of two sampled residents (Resident 1 and Resident 2). This deficient practice resulted in the inability for the California Department of Public Health (CDPH) to conduct an immediate investigation of the abuse allegation and had the potential for information to be lost and/or forgotten.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility conducted an investigation for two of two sampled residents (Resident 1 and Resident 2) when they were made aware of a physical altercation between the two residents on 10/24/2025. This deficient practice resulted in not determining what the problems were between Resident 1 and Resident. This deficient practice had the potential for an ongoing situation between the two residents to escalate due to no attempted determination of events or resolution of the situation.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) by failing to notify the physician and responsible party regarding Resident 1's Computed Tomography (CT- a medical imaging procedure that uses X-rays to create detailed cross-sectional images of the body) scan result which indicated multiple kidney stones (hard objects made of minerals and salts in urine lodged in the kidney, very painful). This failure resulted in a delay in care and treatment to prevent urinary tract infection (UTI- an infection in the bladder/urinary tract) and abdominal pain. [...]

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure effective pain management measures for one of three sampled resident (Resident 1), by failing to ensure Resident 1 had pain medication for moderate pain (pain scale [a tool used to assess pain intensity, with a scale of 0 to 10, where 0 represents no pain and 10 represents the worst pain imaginable] level of 4-7) and routine and breakthrough pain (a transient exacerbation of pain that occurs in individuals who are already experiencing chronic pain). This failure had the potential to result in social isolation and worsening of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). [...]

Inspectors wroteBased on interview and record review the facility's Quality Assessment and Assurance (QAA) Committee, thereby affecting 114 of 114 residents, failed to identify and implement corrective action to systemic problems identified: a. Ensure infection control program was implemented to mitigate the Coronavirus disease (Covid-19 - contagious disease) outbreak. b. Ensure dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents were assessed before departing for dialysis and after residents returned from outpatient dialysis. c. Ensure all allegations of abuse were prevented, reported, and investigated. The deficient practices placed the residents at risk for not receiving the quality treatment necessary to adequately meet their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures on 3 of 5 sampled residents Resident 7, 8, 268 and 7 by failing to: a. Ensure Certified Nursing Assistant 5 (CNA 5) wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while addressing Resident 8's pain concerns which required direct contact with Resident 8 who was on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). b. Ensure Restorative Nursing Aide 1 (RNA 1) and Restorative Nursing Aide 2 (RNA 2) wore isolation gowns while providing RNA exercises to Resident 8 who was on EBP precautions. c. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a pest-free environment when a cockroach appeared in one of one sample resident's room (Resident 48's) . This failure had the potential to compromise the provision of a clean and homelike environment to residents.

Inspectors wroteBased on observation, interview, and record reviews the facility failed to ensure five of ten sampled residents (Resident 36, 42, 76, and 98) were treated with dignity and respect when the facility failed to ensure: a) Resident 98's foley catheter bag (medical device that helps drain urine from the bladder) was covered with a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag, so it is not visible). b) Resident 42 was groomed and was not wearing a hospital gown. c) Resident 76's teeth were cleaned, and clothes were not soiled with feces. d) Resident 36 had a dignified dining experience. e) Resident 33 was assisted to the toilet and not instructed to defecate or void in the adult disposable underwear. These deficient practices resulted in residents not treated with dignity and respect and does not promote enhancement of quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of three sampled resident's (Resident 30 ) would not be allowed to keep medications at the bedside without a physician's order and without being assessed to determine if the resident is capable to self-administer her own medications . This deficient practice had a potential for resident to over or under medicate herself which can lead to further complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of four sampled residents (Residents 8 and 58) call lights (device that allows residents to request assistance from nursing staff) were accessible and within reach. This deficient practice resulted in a delay of care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two sampled residents (Resident 76) family member (FM) 2's grievance (complaints regarding treatment, care, management of funds, lost clothing, or violation of rights) involving an unidentified Certified Nurse Aide (CNA) was addressed, investigated, and resolved in a timely manner. This deficient practice placed Resident 76's at risk for mistreatment can negatively affect Resident 76.

Inspectors wroteBased on interview and record review the facility did not protect one of three sampled residents (Resident 76) from abuse when the facility failed to: a) Ensure Resident 167, who was only wearing a hospital gown and adult disposable underwear, did not enter Resident 76's room and kiss Resident 76 in the arm without Resident 76's consent on 2/23/2025 at around 7:30 a.m. b) Ensure Resident 76 was assessed, monitored and provided with emotional support after allegations of abuse were made on 2/23/2025 that Resident 167 entered Resident 76's room and kissed Resident 76's arm without Resident 76's consent. [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse to the California Department of Public Health (CDPH) within the regulated time frame of two hours. a) The facility failed to report to CDPH when an allegation of abuse was made on 11/15/2024 by Family Member (FM)2 that an unidentified Certified Nurse Assistant (CNA) took Resident 76's cell phone, closed Resident 76's door, and turned the television on loud and Resident 76 felt isolated. b) The facility failed to report to CDPH when an allegation of abuse was made, about an incident that occured on 2/23/2025, by FM 2 that a male resident (Resident 167), without pants on, entered Resident 76's room and allegedly kissed Resident 76's arm without Resident 76's consent. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and submit the investigation report of all allegations of abuse to the California Department of Public Health (CDPH) within five days of the incident. a) The facility failed to thoroughly investigate and submit investigative reports to CDPH when an allegation of abuse was made on 11/15/2024 by Family Member (FM)2 that an unidentified Certified Nurse Assistant (CNA), unidentified, took Resident 76's cell phone, closed Resident 76's door, and turned the television on loud and Resident 76 felt isolated. [...]

Inspectors wroteBased on interview and record review the facility did not develop and implement a comprehensive person-centered care plan for two of four sampled residents (Resident 23 and 74) when the facility failed to: 1. Develop a care plan and interventions to improve, prevent, and limit a decline in range of motion (ROM - the extent and direction of movement at a joint or series of joints) for Resident 23 who was identified as having left upper extremity ROM limitations. 2. [...]

Inspectors wroteBased on observation, interview, and record reviews the facility failed to ensure one of three sampled resident (Resident 42) was groomed and was not wearing a hospital gown and one of three resident's (Resident 76) teeth were brushed at least twice a day. This deficient practices resulted in residents' poor hygiene which can increase the risk of poor physical and mental wellness.

Inspectors wroteBased on observation, interview and record review the facility did not provide quality care and services for five out of eight residents (Resident 23, 51, and 74) when:. a. The facility failed to ensure Resident 51's self-administration of insulin (hormone produced by the pancreas that regulates blood sugar levels) via an insulin pump (a small, wearable device that delivers rapid-acting insulin continuously, mimicking the function of a healthy pancreas (organ that produces hormones which regulate blood sugar levels), and allowing individuals with diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) to manage their blood glucose levels more effectively than with injections) was monitored per facility's policy and procedure, titled Self-Administration of Medications dated 5/2019 which indicated nursing would be responsible for recording [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatments and services to one of eleven sampled residents (Resident 23) to improve, prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) by failing to: 1. Provide ROM services to improve, maintain, and prevent a decline of Resident 23's left shoulder 2. Ensure Resident 23's Joint Mobility Assessments (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 7/4/2024 and 10/4/2024, included the assessment of Resident 23's left shoulder ROM These deficient practices had the potential to cause Resident 23 to have a decline in ROM leading to contracture (loss of motion of a joint associated with stiffness and joint deformity) and have a decline in physical functioning such as the ability to eat, dress, and walk.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 98) who had a foley catheter (device that drains urine into a collection bag) was monitored and assessed for signs and symptoms of a urinary tract infection. The deficient practices had the potential to result in a urinary tract infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of four hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents (Resident 58,98, and 103) received dialysis care and services based on professional standards. The facility failed to: a. Ensure Resident 51 received HD as scheduled on Tuesday, Thursday, and Saturday. b. Ensure Resident 58 had a dressing on the site of the dialysis catheter (medical device used to do HD). c. Ensure Resident 98 was assessed prior to sending Resident 98 to HD after Resident 98 returned from the dialysis center. d. Ensure Resident 103 had equipment and supplies necessary to manage emergencies such as bleeding at the bedside. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide 1 (RNA 1) and Restorative Nursing Aide 2 (RNA 2) were competent in locating personal protective equipment (PPE, equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) for one of eleven sampled residents (Resident 8) who was on EBP precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection among the residents and staff members.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent (%) during medication pass for two of four sampled residents (Residents 68 and 90) by failing to: a. Administer Resident 90's Vitamin B12 (a vitamin used to treat low level of vitamin B12 and help with red blood cell formation) and Vitamin B1 (a vitamin used to treat low level of vitamin B1) in accordance with physician orders. b. Clarify Resident 68's MiraLAX ([generic name - polyethylene glycol], a medication used to treat constipation) order before administration and failed to administer MiraLAX in accordance with medication label and manufacturer specifications. These deficient practices of medication administration error rate of 11.54 percent (%) exceeded the five (5) percent (%) threshold.

Inspectors wroteBased on interview and record review, the facility failed to administer two of three residents' (Resident 58 and 76) medication as ordered. The facility failed to administer Resident 58's Eliquis (medication used to treat and prevent blood clots) twice a day and Resident 76's Levothyroxine Sodium Oral Tablet (medication to treat hypothyroidism - condition in which the thyroid gland doesn't produce enough thyroid hormone) once a day in the morning. This deficient practice had the potential to result in decreased efficacy of medication treatment which can negatively impact the residents' health and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and label medications in accordance with manufacturer specifications and professional principles in two of three medication carts (Station 1 Medication Cart 2 and Station 3 Medication Cart 3A) and two of two medication rooms (Station 1 Medication Room Refrigerator and Station 2 Medication Room Refrigerator) by failing to: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. dispose of expired Italian dressing, barbeque and caramel sauce. b. properly stores and label coffee creamers and a peanut butter sandwich in the resident's food refrigerator per facility policy. These deficient practices placed the residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records for one of eleven sampled residents (Resident 23) were accurately documented and readily accessible by failing to: 1. Ensure Resident 23's Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 1/5/2025, was accurately completed to indicate the severity of range of motion (ROM, full movement potential of a joint) loss of Resident 23's left shoulder. 2. Ensure Resident 23's Orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) Consultation Progress Note, dated 4/3/2024, was readily accessible. These deficient practices had the potential to delay and negatively affect the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship program policy for two of three sampled residents (Resident 53 and 106) by not completing the Mc Geer's Criteria (criteria used to determine appropriate use of antibiotics). This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification.

Inspectors wroteBased on observation, interview, and record review the facility failed to document education provided regarding the benefits and risks of immunization and administration of the influenza (Flu-a contagious respiratory illness) and pneumonia (PNA -an infection of the lungs ) vaccinations (medication to prevent a particular disease) for three of 21 sampled residents ( Resident 11, 75 and 93) . This deficient practice had a potential for residents to who are unvaccinated with influenza, pneumonia and no record of being vaccinated.

Inspectors wroteBased on observation, interview, and record review the facility failed to document education provided regarding the benefits and risks of immunization and administration of Covid-19 (an infectious respiratory illness) for two of three sampled residents ( 11 and 74) This deficient practice had a potential for residents to become unvaccinated with Covid and no record of being vaccinated.

Inspectors wroteBased on interview and record review, the facility failed to involve one of three sampled resident's (Resident 76) in an Interdisciplinary Team (IDT-team of health care professionals that work together toward and prioritize the resident 's needs) care conference. This deficient practice violated Resident 76's rights to be informed and the right to participate in resident's plan of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to account for one of two resident's (Resident 76) personal belongings. This deficient practice violated Resident 76's rights to retain and use personal possessions and resulted in missing belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Case Manager (CM) reported one of eleven sampled resident's (Resident 23) continuous refusals for Orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) follow up appointments to the physician. This deficient practice resulted in Resident 23 not receiving necessary treatment and services to improve left arm range of motion (ROM, full movement potential of a joint), unnecessary weightbearing restrictions (guidance from a physician limiting the amount of weight a person can put through a specific arm and/or leg after surgery) of the left arm, a delay of therapy and restorative services, and had the potential to result in a decline in Resident 23's overall mobility and physical functioning.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one sampled resident (Resident 76) with a colostomy (surgery to create an opening for the colon through the belly) received the correct colostomy bag (pouch that attaches to the stoma [small opening in the abdomen] to collect the waste). This deficient practice resulted in Resident 76's colostomy to leak which had a negative impact in the resident's physical and mental wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clarify and administer medications in accordance with physician orders and manufacturer specifications for two of four sampled residents (Residents 90 and 68) by failing to: 1. Administer Resident 90's Vitamin B12 (a vitamin used to treat low level of vitamin B12 and help with red blood cell formation) and Vitamin B1 (a vitamin used to treat low level of vitamin B1) in accordance with physician orders. This deficient practice failed to provide medications in accordance with the physician's orders or professional standards of practice that can increase the risk to result in medical complications due to choking, constipation and nerve dysfunction for Residents 68 and 90.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two sampled residents (Resident 76) was not in Resident 76's room while workers (unnamed) were sanding and painting a patch on the wall. This deficient practice had the potential to result in an unsafe environment which can negatively affect Resident 76.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident, who had diagnosis of type 2 diabetes [a disorder characterized by difficulty in blood sugar control and poor wound healing]) and was receiving blood sugar lowering medication, had blood sugar monitoring to ensure the effectiveness of Empagliflozin (medication to lower blood sugar) and to prevent the resident from having hyperglycemia (level of glucose (blood sugar) in the blood is abnormally high) leading to diabetic ketoacidosis (life-threatening complication of diabetes that occurs when the blood sugar levels are too high and untreated for a prolonged length of time) for one of 3 sampled residents (Resident 1). The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents ' ordered medications were available for administration and were administered to residents as prescribed by the physician for one of three sampled residents (Resident 1). The facility failed to: A. Ensure Resident 1, who had a history of Coronary Artery Disease ( CAD-disease in which there is a narrowing or blockage of the blood vessels that carry blood and oxygen [gas needed for survival] to the heart) , received Ticagrelor (medication used for the prevention of stroke [blood flow to the brain is interrupted] , heart attack [blood flow to heart interrupted]) as directed by the physician. B.Ensure Resident 1 ' s physician care team was notified when Ticagrelor was not available for administration. These deficient practices resulted in; 1. [...]

Inspectors wroteBased on interview and record review the facility's Quality Assessment and Assurance (QAA- committees established for the purpose of improving the safety and quality of health services) and Quality Assurance Performance Improvement (QAPI- approach to maintaining and improving safety and quality in nursing homes ) committee failed to establish monitoring systems such as fedback to ensure the corrective actions implemented to address the deficiencies of the recent abbreviated survey conducted on 9/30/2024 were maintained. These deficient practices placed the facility residents at risk for not receiving appropriate care needs and services to adequately afford their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tanks were safely stored in the oxygen storage room for one of three sampled residents (Resident 1). This deficient practice had the potential to place the resident at risk for injury due to a fire hazard.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN 1) had the competency skills to care for two of three sampled residents (Residents 1 and 2) by failing to: 1. Provide Cyclosporine Ophthalmic Emulsion 0.05% ([eye drops] medication used to increase tear production in people with dry eyes) to Resident 1 according to the facility ' s policy and procedure (P&P) titled, Medication Administration. 2. Notify Resident 2 ' s physician when Resident 2 had a change of condition (COC) and required oxygen through a non-rebreather mask (a mask that delivers a high concentration of oxygen to a patient in an emergency). 3. Document Resident 2 ' s COC in the medical record. These deficient practices resulted in: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Care Plan was developed for one sampled resident (Resident 1), who had dry eyes. This failure resulted in Resident 1 not receiving Lubricant PM Ophthalmic ointment (an eye lubricant for the temporary relief of burning, irritation, and discomfort due to dryness of the eye) in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents ' ordered medications were available for administration and were administered to residents as prescribed by the physician for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 received Lubricant PM Ophthalmic Ointment (an eye lubricant for the temporary relief of burning, irritation, and discomfort due to dryness of the eye) one strip in both eyes at bedtime as ordered for dry eyes. 2. Ensure the licensed nurses followed-up with the pharmacy when Resident 1 ' s medication was not available for administration. This deficient practice resulted in Resident 1 not receiving her prescribed medication as ordered and resulted in Resident 1 having dry eyes and eye pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a history of dementia (impaired ability to remember, think, make decisions that interferes with everyday activities) received necessary behavioral health care and services. The facility failed to A. Provide psychiatric (medical specialty that addresses the diagnosis and treatment of a mental illness) follow up after Resident 1 demonstrated increased aggressive behaviors and a change of behaviors was reflected in Resident 1's Minimum Data Set assessment ([MDS] a standardized assessment and care-screening tool) dated 3/4/2024 and progress notes. B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2) fingernails were kept clean and neat. This deficient practice resulted in a black/brown substance being observed underneath Resident 1 ' s fingernails and Resident 2 ' s right hand fingernails and had the potential to cause infections to Resident ' s 1 and 2 and to have feelings of low self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident, who was riding in the facility's van while sitting in a wheelchair, had a shoulder seat belt strap on to secure upper body for one of 23 sampled residents (Resident 32). This deficient practice resulted in Resident 32 thrown forward with a wheelchair landing on top of the resident when Driver 1 abruptly stops the vehicle on a yellow light. Resident 32 was admitted to general acute care hospital (GACH) on 3/19/2024 and hospitalized for six days with multiple fractures (broken bone) including fracture to both arms, both legs and neck. On 3/27/2024 Resident 32 was sent back to GACH for anxiety ( a feeling of worry, nervousness, or unease) related to the accident on 3/19/2024.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of two sampled residents (Resident 70 and 75) are treated with respect and dignity by failing to feed the resident at eye level. This deficient practice has the potential to affect resident's sense of self-worth and self-esteem. a. During a review of Resident 70's admission Record indicated Resident 70 was admitted on [DATE] with diagnoses including cerebral palsy (condition that affect movement and posture often before birth) schizoaffective disorder (a combined disorder that causes hallucinations and mood), major depressive disorder (decreased or loss of interest in pleasurable activities), anxiety disorder (feelings of worry or fear), dysphagia (difficulty swallowing),muscle weakness, and down syndrome (wide range of developmental delays and physical disabilities caused by a genetic disorder). [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately assess and follow through with the Preadmission Screening and Resident Review ([PASARR]- a comprehensive evaluation that ensures people who have been diagnosed with serious mental illness, intellectual, and/or developmental disabilities are able to live in the most independent settings while receiving the recommended care and interventions to improve their quality of life) Level I for three of six sampled residents (Resident 45, 21, and 40) to determine the facility's ability to provide the special need of the resident. This deficient practice placed Resident 45, 21, and 40 at risk of not receiving necessary care and services needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of 23 sampled residents (Resident 40 and 79) received restorative nurse aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) (restorative nurse aide) services and treatment to prevent the further decrease in range of motion [ROM, full movement potential of a joint (where two bones meet)] and contractures (chronic joint stiffness associated with joint deformities and pain). This failure resulted in Resident 40 and 79 not receiving the needed RNA services placing Resident 40 and 79 at risk for further decline in the range of motion and at risk for developing contractures.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to label medications with open date and discard medications after 28 days for four out of 20 sampled residents (Resident 41,75,77 and 169). This deficient practice had the potential for Resident 41, 75, 77 and 169 medications to lose effectiveness and or therapeutic effect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe proper storage of medications by: 1. Failing to ensure open date label on Tuberculin test solution (solution used to aid in the detection of with tuberculosis [lung infection]) and Influenza (respiratory illness) vaccine (medication used to stimulate the body's response against diseases) five (5) milliliter (ml-unit of measurement) multi-dose vial 9 contain more than one dose of medication). 2. Failing to ensure open date label on insulin (medication allows your body to use glucose for energy) multi-dose vial for Resident 99. 3. Failing to ensure open date label on morphine sulfate solution (medication for moderate to seven pain) for Resident 22. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as: 1. Two (2) of 2 staff were not following the manufacturer's guidelines of the test strip when checking the concentration of the Quat Sanitizer (a chemical use for disinfection) solution used in the two (2) compartment sink and sanitation of food preparation surfaces. This failure had a potential to result to potential cross-contamination (a transfer of bacteria from one object to another), ineffective dish machine, and unsanitized dishes that could lead to food borne illness (an illness caused by contaminated food and beverages) in 107 of 108 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu for 53 out of 108 residents on Regular texture diet (diet that has no restriction in texture and consistency) by not following the portion for beef barbeque based on the facility's menu spread sheet. This deficient practice had the potential to cause unintended (not done on purpose) weight gain.

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 when: 1. Refrigerator gaskets (a piece of rubber used for sealing) were torn. 2. Equipment Cleanliness A. Dirt debris in the refrigerator bottom shelves and gaskets. B. Over the counter pill was found on the floor of the walk-in-refrigerator. C. Storage rack of condiments had dust and oil buildup. D. Dusty/Sticky knife storage box. E Rusty carts and refrigerator shelves. F. Hot water dispenser had a hard water buildup. G. Cambro containers had white sticker sticky residue. H. Plate warmers had food and dirt debris. 3. Cross-contamination A. Scoop was found inside the oatmeal container. B. Scoop handle was not stored in one direction. C. Bottom portion of the preparation table was cracked and had white and black residue. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not covering the one (1) of three (3) dumpster (a large trash container designed to be emptied into a truck) for unknown amount of time. This deficient practice had a potential to attract flies, insects, cats, and other animals to the dumpster area placing 107 of 108 facility residents getting food from the kitchen cross-contamination (a transfer of harmful bacteria from one place to another).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident call light was within reach for one of three sampled resident (Resident 1) meeting reasonable accommodation or resident needs by: This deficient practice resulted in Resident 1 unable to call facility staff for help when needed and may lead to feelings of low self-esteem.

Inspectors wroteDuring observation, interview, and record review, the facility failed to implement comprehensive plan of care for three of six sampled residents when: 1. Resident 61 who was assessed for high risk for falls had a rectangle wooden piece of wood on the floor next to the bed on the left side. This deficient practice had the potential to result in injury related to fall. 2. Residents 27 and 71 have cigarettes and smoking paraphernalia stored on the bedside table. This deficient practice had the potential to result in an accidental fire.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 40) Depakote (medication used to treat certain mental conditions) level was measured per psychiatric nurse practitioner (a nurse who has advanced clinical education and training) order. This deficient practice resulted in Resident 40 not having her Depakote levels checked, while continuing to use the medication, which could potentially lead to toxic levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove old oxygen tubing and kept the tubing off the floor for one of one sampled resident (Resident 13). This deficient practice had the potential to spread respiratory infection or other diseases to Resident 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for two of three sampled residents (Resident 72 and 90) when: 1. The gate that led to the outside of the facility was opened during smoking times for Resident 72. This deficient practice had the potential elopement risks for Resident 72. 2. Oxygen concentrator (a medical device that gives you extra oxygen) was not turned off when not in use. This deficient practice had the potential to cause the oxygen concentrator cause fire, placing the residents' safety in jeopardy.

Inspectors wroteBased on observation and interview, the facility failed to implement its Infection Prevention and Control Program by failing to: 1. Ensure Certified Nurse Assistant (CNA 1) wore a face shield (a type of personal protective equipment [PPE, protective equipment designed to protect the wearer from injury or the spread of infection or illness]) which is worn for protection of the facial area including the eyes, nose, and mouth from splashes, sprays and spatter of body fluids) and N95 respirator mask (a mask designed to achieve a very close facial fit and very efficient filtration of airborne particles) while providing care to one of three sampled residents (Resident 1) who tested positive for COVID-19 (a contagious and potentially severe respiratory illness) and who was on contact (intended to prevent transmission of germs which are spread by direct or indirect contact with a person or the [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 1) who had a fall from bed in the facility on 12/23/2023: a. had a physician's order for a mattress on the floor next to Resident 1's bed b. fall care plan was implemented, and the facility followed the nursing interventions. These deficient practices placed Resident 1 in danger of sustaining another fall in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two sampled residents (Resident 1) responsible party's (RP1) grievance (complaints regarding treatment, care, management of funds, lost clothing, or violation of rights) involving Certified Nurse Aide (CNA) 1 was addressed without with fear of discrimination or reprisal (negative actions, retaliation). RP 1 filed a grievance regarding quality-of-care concerns for Resident 1, and the grievance was investigated by the Director of Staff Development (DSD- licensed nurse who oversees the training and scheduling of CNAs) who was CNA 1's family member. This deficient practice resulted in RP1 and Resident 1's anxiety and worry that CNA 1 and the DSD would retaliate against Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure a certified nursing assistant (CNA 1) did not provide perineal care (washing the genital [reproductive organs located on the outside of the body] and rectal [area where a person holds stool before excreting it from the body] areas of the body) by himself without the assistance of another staff to a resident who required a two-persons physical assistance with toileting and personal hygiene for one of two sampled residents (Resident 1). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was created for one of two sampled residents (Resident 1), whose Minimum Data Set ([MDS] a standardized assessment and care screening tool) assessment indicated Resident 1 required a two-person physical assist with toileting and personal hygiene. This deficient practice resulted in the care needs of Resident 1 being unknown to staff and contributing to Resident 1 falling from the bed and sustaining an inner lower lip laceration (a deep cut or tear in the skin or flesh) with a potential for Resident 1 to sustain more serious consequences such as a brain injury, fractures (a partial or complete break in the bone) and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of three sample residents (Resident 1) was treated with respect and dignity by failing to dress Resident 1 in his own clothes before discharge. This deficient practice has the potential to affect resident 1 ' s sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice infection control measures to prevent a scabies (a contagious skin condition caused by tiny insects called mites which infest and irritate the skin causing intense itching, red patches, and inflammation [the immune system's response to harmful stimuli]) outbreak (two or more clinically suspect or confirmed cases of scabies identified in patients/residents, healthcare workers, volunteers and/or visitors during a six week time period) for seven of 12 sampled residents (Resident 2, 3, 4, 5, 6, 7, and 8). By failing to: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed ensure one of 12 sampled residents (Resident 1) fingernails were kept clean and neat. This deficient practice resulted in a black/brown substance being observed underneath Resident 1's fingernails and had the potential to cause infections and for Resident 1 to have feelings of low self-worth and self-esteem.