St. Elizabeth Healthcare Center

Inspectors wroteBased on observation, interview, medical record review, facility document review and facility P&P review, the facility failed to ensure three of three sampled residents (Residents 1, 2 and 3) were provided with the necessary care and services. * The facility failed to ensure Resident 1, who was at risk for falls, was supervised while using the restroom resulting in an unwitnessed fall. * The facility failed to ensure the post-fall neurological assessments for Resident 2 were complete. In addition, the facility failed to complete a fall-risk assessment on admission for Resident 2. * The facility failed to ensure the post-fall neurological assessments for Resident 3 were complete. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed. * The RD's facial hair was not covered while inside the kitchen. * The kitchen utensils and equipment were not stored or kept in sanitary conditions. * The meat thawing process was not followed. These failures posed the risk for food borne illnesses in a highly susceptible residents population of 84 facility residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infection. * The facility failed to ensure the transmission based precautions (additional infect control measures used in healthcare settings for the residents with known or suspected infections which can spread beyond standard precautions (minimum infection prevention practices that apply to all resident care, regardless of a resident's suspected or confirmed infection status)) were followed for Resident 63 when CNA 1 failed to sanitize the face shield after she removed the face shield, and before she hung on the hook placed outside the resident's room door in the hallway after she provided care to the resident. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to promote the dignity and respect for two of 19 final sampled residents (Residents 14 and 65) for indwelling urinary catheter (a flexible tube inserted through the urethra (transports urine from the bladder to the outside of the body) or abdominal wall into the bladder to continuously drain urine) use. * Residents 14 and 65's indwelling urinary catheter drainage bags were exposed and not placed inside dignity bags. These failures had the potential to affect the privacy and dignity of the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to determine if bilateral bolster pillows functioned as a physical restraint, for one of two residents reviewed for restraints (Resident 12). * Resident 12 sustained a fall from bed, and the facility implemented bilateral bed bolster (a long, narrow, and firm cushion designed to provide enhanced support, improve spinal alignment, and reduce muscle strain) pillows. Resident 12 stated the bolster pillows prevented him from repositioning himself in bed and they restricted his movement. Resident 12 stated he could not sleep well at night due to the bolster pillows restricting his movement. Resident 12 stated he could not remove the bolster pillows. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the PASRR (Preadmission Screening and Resident Review) Level 1 screening (identifies if a resident has a suspected mental illness or intellectual/developmental disability or related condition) contained accurate information for two of three residents (Residents 7 and 56) reviewed for PASRR. * Resident 7 had a diagnosis of depression and PTSD (Post Traumatic Stress Disorder); however, the PASRR Level 1 screening showed Resident 7 had no diagnosed mental illness. * Resident 56 had a diagnosis of mood disorder and PTSD; however, the PASRR Level 1 screening showed Resident 56 had no diagnosed mental illness. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P, the facility failed to ensure the Plan of Care was revised for one of 19 final sampled residents (Resident 14). * The facility failed to ensure Resident 14's Plan of Care was revised to address the physician's order dated 3/16/26, to change the resident's enteral (a method of delivering nutrients directly into the stomach or small intestine when a person cannot eat or swallow safely) feeding rate and enteral water flush. This failure posed the risk for Resident 14 to not receive the person-centered care and services required to attain or maintain her highest level of physical and mental well-being.

Inspectors wroteBased on observation, interview, medical record review, document review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for one of 19 final sampled residents reviewed with low air loss mattress. * The low air loss mattress setting was not consistent with Resident 11's weight and was on static mode setting. This failure had the potential for the resident to not benefit from the therapy provided from using the low air loss mattress.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate treatment and services for one of 19 final sampled residents (Resident 14) reviewed with enteral (a method of delivering nutrients directly into the stomach or small intestine when a person cannot eat or swallow safely) feeding orders. * The facility failed to ensure Resident 14's enteral feeding was labeled with the resident's name, date, time, and initials by the nurse per facility policy. This failure posed the risk for Resident 14 to potentially affect the resident's clinical condition.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV (intravenous-through the vein) therapy for one of 19 final sampled resident (Resident 63) reviewed with hydration orders. * Resident 63 was not provided with the sodium chloride (a sterile solution used to replenish body water and electrolytes, treat low salt, and provide a vehicle for other medication infusions) 0.9% IV solution 1000 ml as ordered by the physician. This failure posed the risk of Resident 63 not to receive the required treatment in accordance with the resident's plan of care and the physician's order which may potentially affect the resident's clinical condition.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services to two of 19 final sampled residents (Residents 34 and 65) reviewed with oxygen orders. * The facility failed to administer the oxygen as ordered by the physician to Resident 34. Resident 34 had an order for continuous oxygen at 2 LPM (liters per minute); however, it was not administered as ordered. * The facility failed to ensure Resident 65's oxygen tubing was dated. These failures posed the risk of developing complications as result of inadequate oxygen therapy, and had the potential to negatively impact the residents' medical condition.

Inspectors wroteBased on observation, interview, medical record review, facility P&P review, facility document review, and the California Code of Regulations review, the facility failed to ensure a staff member was onsite during the night shift who could provide the respiratory care and services to the residents, in accordance with the residents' plan of care. * For the night shift, the facility failed to ensure a staff member was on site at the facility who could provide the respiratory care and services to the residents with oxygen titration (the process of adjusting a resident's supplemental oxygen flow rate to main the target oxygen saturation levels) orders. This failure had the potential to result in negative health outcomes to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for one of 19 final sampled residents who was receiving dialysis care. * The facility failed to administer Resident 3's medications per the physician's orders when Resident 3 had scheduled dialysis appointments. The medication were as follows: ascorbic acid (dietary supplement), cholecalciferol (a fat-soluble vitamin used to treat or prevent Vitamin D deficiency and support bone health, immune function, and calcium absorption), cyanocobalamin (a synthetic form of vitamin B12 used to support red blood cell production, proper metabolism, and nerve function), furosemide (medication to treat fluid retention), and zinc sulfate (dietary supplement used to treat zinc deficiency). This failure had the potential to negatively impact the resident's health outcomes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain medication was provided for one of five final sampled residents (Resident 63) reviewed for unnecessary medications. * Resident 63 was administered with hydrocodone-acetaminophen {combination medication used to treat severe pain by combining an opioid (hydrocodone) with a non-opioid pain reliever (acetaminophen)} as ordered for severe pain when the resident complained of moderate pain. This failure may have contributed to Resident 63's constipation and potentially affect the resident's clinical condition.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of the medications. * The facility failed to ensure the expired supplies were removed from Treatment Cart A and from the central supply room. * The facility failed to ensure the hydrophilic (water-miscible, topically applied formulations designed to absorb moisture (exudate) while maintaining a moist environment for skin healing) cream and zinc oxide (a topical skin protectant used primarily to treat and prevent diaper rash, minor burns, cuts, and skin irritations by creating a protective, moisture-resistant barrier) cream were not left unattended by the licensed nurse on top of Resident 14's nightstand. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurately maintained for two of 19 final sampled residents (Residents 12 and 21). * The facility failed to ensure Resident 12's H&P examination was uploaded accordingly into the resident's electronic health record. Resident 12's H&P examination was uploaded in Resident 2's electronic health record. * The facility failed to ensure Resident 21's Restraint/Enabling Device/Safety Device Evaluation was accurately completed. These failures had the potential for the residents' care needs not being met as the medical records were inaccurate.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in a safe operating conditions. * The facility failed to ensure the ice machine was cleaned and sanitized as per the manufacturer's instructions. * The facility failed to ensure the glucometers (a device which measures the amount of sugar in the blood) in Medication Carts A and Cart B were calibrated and quality control was performed for two days in October 2025. These failures had the potential for the residents to receive ice from the kitchen not clean for consumption; and had the potential for the residents requiring blood glucose checks to have inaccurate readings.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the care plan interventions for two of eleven sampled residents (Residents 2 and 3). * The facility failed to ensure Residents 2 and 3's care plan interventions to monitor the signs and symptoms of hypoglycemia (low blood glucose) and hyperglycemia (high blood glucose) were implemented. These failures posed the risk of the residents not receiving services that were person-centered to meet the specific needs of each resident.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 6) reviewed for falls remained free from accident hazards. * The facility failed to include a possible cause of injury in the initial investigation statement for a fall. * The facility failed to collaborate with the IDT (Interdisciplinary Team) following Resident 6's change in condition. These failures had the potential for Resident 6 not to receive adequate supervision, assistance, and sustain additional accidents and/or injuries.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement the pharmaceutical procedures when the nursing staff did not ensure an accurate controlled substance accountability for one of three sampled residents (Resident 6) reviewed for medications. * Resident 6's medications were signed out of the CDR (Controlled Drug Record) but not documented as administered on the MAR (Medication Administration Record). This failure had the potential for Resident 6 to be exposed to the medication errors and diversion of the controlled medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs of one of eight sampled residents (Resident 1). *The facility failed to ensure Resident 1 was provided with assistance in a timely manner. The failure had the potential to negatively impact the resident's physical and psychosocial well- being and result in delayed provision of care. Findings Review of the facility's P&P titled Call Light revised 5/2007 showed to answer the call light within a reasonable time and turn off the call light once the request/ need is met. Review of Resident 1's medical record was initiated on 9/8/25. Resident 1 was admitted on to the facility on 7/28/25. Review of Resident 1's H&P examination dated 7/29/25, showed Resident 1 had the capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of three sampled residents (Resident 6) reviewed for unnecessary medications were free from unnecessary medications. * The facility failed to ensure NPI (nonpharmacological intervention) was consistently implemented for Resident 6 prior to administering hydrocodone-acetaminophen (narcotic) 5/325 mg tablet or Ultracet (narcotic) oral tablet 37.5-325 mg medication. This failure had the potential to negatively impact the resident's well being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure two of three sampled residents (Residents 1 and 3) attained and maintained the highest practicable physical well-being. * The facility to ensure Resident 1's nystatin external cream (a medicated cream used to treat fungal or yeast infections of the skin) was administered as per the physician's order. * The facility failed to ensure Resident 3's fluid restriction was followed as per the physician's order. These failures had the potential to negatively affect the residents' health condition and well- being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to administer the parenteral fluids consistent with the professional standards of practice and in accordance with the physician orders when Resident 1's IV fluids was administered at 80 ml per hour, the facility failed to close the clamp and remove the IV container from the IV pole when the infusion was completed. In addition, the facility failed to ensure the IV solution was labeled with the date and time the IV solution was hung. These failures posed the risk for the resident to develop complications related to the use of the peripheral IV catheter.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care and services were provided for two of three sampled residents (Residents 1and 2). * The facility failed to ensure Resident 1's Yankauer suction tubing was stored in a bag. * The facility failed to ensure Resident 2's nebulizer administration set-up was stored in a bag. These failures had the potential for the residents to have respiratory infections and negatively affect the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for two of three sampled residents (Residents 2 and 3) were accurate. * The facility failed to ensure the documentation of the intake monitoring for Resident 2 were accurate. * The facility failed to ensure the documentation of the intake monitoring for Resident 3 were accurate. These failures had the potential for the residents' care needs not being met as their medical information were inaccurate.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 16 final sampled residents (Residents 12 and 40) and one nonsampled resident (Resident 38) were free from the unnecessary restraints. * The facility failed to obtain the order and informed consent, complete the restraint assessment, and develop a care plan problem for the use of Tab alarm prior to applying a Tab alarm for Resident 40's bed and wheelchair. * The facility failed to obatain an informed consent and complete the restraint assessment for the use of pad alarm prior to applying a pad alarm for Resident 38's bed and wheelchair. * The facility failed to obatain an informed consent and complete the restraint assessment for the use of Tab alarm prior to applying a Tab alarm for Resident 12's bed and wheelchair. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered care plans for four of 16 final sampled residents (Residents 2, 22, 49, and 456). * The facility failed to develop a care plan problem to address Resident 22's refusal to shower, turn positions, change diaper, and take medications. * The facility failed to implement the intervention for 1:1 (one staff member to one resident) assistance during meals to address Resident 49's weight loss. * The facility failed to develop a care plan to address the use of oxygen and CPAP for Resident 456. * The facility failed to ensure Resident 2's care plan problem addressing diabetes mellitus included the use of insulin as ordered. These failures placed the residents at risk of not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to follow the professional standards of clinical practice accepted for the administration of GT medications for one of two residents (final sampled resident, Resident 8) observed for medication administration receiving GT medications. * LVN 4 did not flush the GT in between the administering of three of eight medications for Resident 8. This failure had the potential to disrupt the flow of medications and clog the GT affecting the patency and placement of Resident 8's GT.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate services needed to maintain the acceptable parameters of nutritional status were provided for one of one final sampled resident (Resident 49) reviewed for weight loss. * The facility failed to ensure the RD's recommendations on 12/12/24, were followed up with the physician and addressed in the IDT weight variance meeting when Resident 49 had a severe weight loss of 36 lbs in 26 days. This failure had the potential for Resident 49 not to receive the necessary intervention to prevent further weight loss.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 6) reviewed for respiratory care was provided with the appropriate respiratory care when: * The facility failed to ensure the physician's order for CPAP had a schedule when to apply and remove the CPAP for Resident 6. Additionally, Resident 6's medical record did not show the CPAP was applied from 12/9 to 12/11/24. * The facility failed to ensure the physician's order for cleaning and maintenance of Resident 6's CPAP was accurate. The physician's order showed to clean the humidified container but Resident 6's CPAP had no humidified container. These failures had the potential to affect the respiratory health and well-being of Resident 6.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one of 16 final sampled residents (Resident 354). * The facility failed to completely assess Resident 354 for pain prior to administering oxycodone (narcotic analgesic medication). This failure had the potential to cause increased pain and distress to the resident.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services when: * The facility failed to ensure the accurate and complete documentation of the controlled medications administered for one nonsampled resident (Resident 356). * The facility failed to ensure the narcotic sheets had the nurses' initials and signatures for one of two medication carts (Medication Cart 1). * Medication Cart 1 was left unlocked in an area where the residents, other staff, or visitors could access it. These failures had the potential for the medications to be administered in error and opportunities for drug diversion or drug misuse.

Inspectors wroteBased on interview, medical record review, and facility P& P review, the facility failed to ensure two of five final sampled residents (Residents 6 and 49) reviewed for unnecessary medications were free from the unnecessary psychotropic medications. * There were no specific resident-centered goals to monitor for increased appetite for Resident 6's use of mirtazapine (antidepressant medication). * There was no evidence of non-pharmacological interventions for Resident 49's use of escitalopram (antidepressant medication) These failures had the potential to result in unnecessary use of, ineffective and/ or lack of monitoring or interventions for psychotropic medications that could negatively affect Residents 6 and 49's highest practicable mental, physical, and psychosocial well- being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 19.35%. One of three licensed nurses (LVN 4) observed during the medication administration was found to have made errors. * LVN 4 failed to ensure the full dosages for six of eight prescribed medications were administered to Resident 8 as per the physician's orders. This failure had the potential to negatively affect the residents' health.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medications were properly labeled and stored safely. * The facility failed to ensure the single use dressing was discarded after use. * The facility failed to ensure the topical medication was accurately labeled in accordance with currently accepted professional principles, including the expiration date. These failures had the potential to negatively impact the residents' well being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of 16 final sampled residents (Residents 456 and 904) had accurate and complete medical records. * The facility failed to ensure the information on Resident 456's POLST was accurate and updated. * The facility failed to ensure Resident 904's TAR documentation regarding multiple wound treatment orders were completed. These failures had the potential for the residents' health care needs to not be met as the medical record was incomplete and inaccurate.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections. * The facility failed to follow their water management program to regularly test water temperatures as per the facility's P&P. * The facility failed to ensure the staff performed hand hygiene as per the facility's P&P. * The facility failed to ensure the best practice was performed for infection prevention and control when an antibiotic vial was not disinfected prior connecting the intravenous solution to the antibiotic vial. * The facility failed to ensure the staff performed hand hygiene after removing gloves between resident care. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to follow up on the request of the resident to have the bilateral grab bars for one of 16 final sampled resident (Resident 29). This failure had the potential for Resident 29 not to receive care timely.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the privacy was provided for one of three final sampled residents (Resident 8). * The privacy curtain was not pulled completely in Resident 8's room when the licensed nurse administered the medications via GT. This failure had the potential to negatively affect the dignity of the resident and violate the resident's rights to privacy.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the resident's rights to be free from the sexual abuse by a resident for one of three sampled residents (Resident 1). * On 7/28/24, Resident 2 was observed inappropriately touching Resident 1's genitals and making a shaking motion. Resident 1 had severe cognitive impairment and did not have the capacity to consent. This failure had the potential to cause Resident 1 to experience sexual abuse and placed Resident 1 at risk for psychological and emotional harm.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure one of two sampled residents (Resident 1) was provided with the necessary care and services to prevent the development and worsening of pressure injuries. * Resident 1 was evaluated to have a Stage 1 pressure injury to his sacral coccyx on 1/3/24. Resident 1's sacral coccyx pressure injury had advanced to a Stage 2 pressure injury on 1/11/24. On 1/17/24, Resident 1's wound was evaluated by Wound Specialist 1 as an unstageable pressure injury. The facility failed to ensure Resident 1's sacral coccyx unstageable pressure injury was continued to be treated by Wound Specialist 1. This failure posed the risk for Resident 1's pressure injury to deteriorate and develop additional pressure injuries.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to notify the resident's representative regarding the change of condition for one of two sampled residents (Resident 1). This failure posed the risk of violating Resident 1's rights.

Inspectors wroteBased on observation, interview, facility P&P review, and facility pharmacy P&P, the facility failed to ensure the medications and supplies were properly stored. * LVN 1 left MiraLAX (medication for constipation) unattended on the medication cart. * Multiple expired medications and supplies were observed in the central supply room. * Oral and suppository medications were stored next to each other on the same shelf in the central supply room. * Expired wound care supplies were observed in the treatment cart. * Expired IV supplies were observed in the IV cart. * Medication labeled for a resident was opened, used, and stored in the central supply room. * The facility failed to store a bottle of acetaminophen (pain medication) securely and inaccessible by the staff, residents, and visitors. This had the potential for unauthorized access to the medication. [...]

Inspectors wroteBased on observation, interview, facility documents review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the food items in the refrigerator and resident refrigerator were properly labeled. * The facility failed to ensure the resident refrigerator and the bin containing the scoops were clean. * The facility failed to ensure the kitchen utensils were in good repair. * The facility failed to ensure the cutting boards were in sanitary condition. These failures had the potential to expose the residents who consumed food prepared in the kitchen to foodborne illnesses.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections. * The facility failed to ensure Resident 500's family member wore the required personal protective equipment when entering a contact precaution room (Room B). * The facility failed to ensure the infection control practices were maintained in the facility's storage room for cleaning supplies when the personal belongings of staff were stored with the cleaning supplies as per the facility's policy. * The facility failed to ensure the infection control practices were maintained in the facility's laundry room area when a dusty fan and air conditioning unit with dusted air vent were observed in the clean linen area. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of three nonsampled residents (Residents 9, 14, and 399). * The facility failed to ensure Residents 14 and 399's call lights and water pitchers were within their reach. * The facility failed to ensure Resident 9's call light and bed remote control were within her reach. These failures created the potential to negatively impact the residents' psychosocial well-being or result in a delay to provide care.

Inspectors wroteBased on interview and medical record review, the facility failed to clearly identify the current medical intervention status for one of 12 final sampled residents (Resident 20). In addition, a copy of Resident 20's advance directive was not available in the resident's medical record. These failures had the potential to not provide the proper care in accordance with the resident's treatment wishes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the plan of care to reflect the individual care needs for one of 12 final sampled residents (Resident 349). * The established care plan problems did not include the individualized the non-pharmacological interventions to address Resident 349's specific behaviors. This failure posed the risk of not providing the appropriate and individualized care to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of 12 final sampled residents (Resident 7). The facility failed to provide activities for Resident 7 which met her identified interests. This had the potential for Resident 7 to experience feelings of social isolation and frustration.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the physician's order was obtained for a contact precaution for one nonsampled resident (Resident 500). This failure created the risk of not providing the appropriate and consistent care for Resident 500.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 12 final sampled residents (Resident 398) remained free of accident hazards. * The facility failed to provide Resident 398 with the bilateral floor mats and bolster pillow, and failed to keep the bed in the lowest position as per the physician's orders and care plan. This failure had the potential for the resident to fall and sustain injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of one of 12 final sampled resident (Resident 25) and two nonsampled residents (Residents 43 and 44). * The facility failed to provide the pharmaceutical services to assure the accurate acquiring, receiving, dispensing, and administering of medications to meet the needs of Residents 43 and 44. * The facility failed to ensure Resident 25 received the medications via GT and not PO. Resident 25 was on a GT feeding, but the ferrous sulfate and acetaminophen medications were ordered to be given by mouth as per the physician's orders. This had the potential for Resident 25 for aspiration (accidental breathing in of food or fluid into the lungs). These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 349) was free from an unnecessary psychotropic (any drug that affects brain activity) medications. * The facility failed to document the implementation of non-pharmacological interventions for crying and yelling episodes prior to the use of sertraline (antidepressant medication) and ziprasidone (antipsychotic medication) for Resident 349. This failure had the potential for Resident 349 to experience adverse effect or receive unnecessary medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was less than 5%. * The facility's medication error rate was 32.56%. Two of two licensed nurses (LVNs 1 and 2) were found to have made errors during the medication administration for two of 12 final sampled residents (Residents 20 and 41) and two nonsampled residents (Residents 43 and 44). This failure had the potential to negatively affect the residents' well- being.

Inspectors wroteBased on observatioon, interview, medical record review, and facility P&P, the facility failed to ensure two nonsampled residents (Residents 15 and 44) were free from the significant medication errors. * The facility failed to document Resident 15's controlled medication (medications that have some potential for abuse or dependence) administration and follow the physician's orders. * The facility failed to administer Resident 44's carvedilol (medication used to control high blood pressure) during the medication observation. These failures placed Residents 15 and 44 at risk for medical complications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed. * The facility failed to ensure the correct texture of fish and noodles were served. Chopped fish and whole noodles were served instead of ground fish and softly chopped noodles for the residents on the dysphagia mechanical soft diet (diet consists of foods that are moist soft-textured and easily formed into a bolus, meant for people with chewing and swallowing difficulties) as per the facility's menu. This failure had the potential for the residents not receiving the correct food texture and could potentially result to choking.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to inspect the bed frames, mattress, and side rails to identify areas of possible entrapment for three of 12 final sampled residents (Residents 33, 398, and 499). This had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death.

Inspectors wroteBased on observation and interview, the facility failed to ensure the freezer compartment inside the resident refrigerator was free of ice buildup. This had the potential for the refrigerator not being maintained in safe operating condition.