Stanley Healthcare Center

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 evening and night shift, who could provide the respiratory services to the residents, in accordance with the residents' plan of care. * For the past year, on the evening and night shift, the facility failed to ensure a staff member was on site at the facility, who could provide respiratory services to the residents with oxygen titration orders. These failures had the potential to result in negative health outcomes for the residents.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen for 27 of 27 residents who consumed food prepared in the kitchen. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * Unlabeled and undated white powder was observed stored inside a plastic measuring cup on the countertop shelf. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for the months of May 2025 through February 2026. The facility conducted surveillance of the resident's infections only when the residents were prescribed antimicrobial medications and/or if the residents were diagnosed with an infection. The facility failed to determine whether the residents who exhibited the signs and symptoms of infection and were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria). The facility failed to include these residents in the facility's infection control surveillance program. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the informed consent was obtained for the use of the bilateral side rails and psychotropic medications for one of five final sampled residents (Residents 6) reviewed for unnecessary medications. * The facility failed to obtain an informed consent for Resident 6's use of the lorazepam (medication to treat anxiety), buspirone (medication to treat anxiety), and bilateral side rail use. In addition, the facility failed to update the informed consent for citalopram (medication to treat depression) when the medication was increased for Resident 6. These failures had the potential for Resident 6 to be unaware of the risks associated with the use of psychotropic medications and bilateral side rails which could negatively affect the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Residents 3) reviewed for unnecessary psychotropic medications was free from unnecessary psychotropic drugs. * The facility failed to monitor Resident 3's orthostatic (a sudden drop in blood pressure upon standing, defined as a reduction of greater than or equal to 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing which may cause dizziness, lightheadedness, and fainting) blood pressure related to the use of the quetiapine (antipsychotic medication). In addition, the facility failed to document what nonpharmacological interventions were attempted when Resident 3 had episodes of bizarre delusions related to the use of the quetiapine medication. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the PASRR Level 1 Screening (identifies if a resident has a suspected mental illness or intellectual/developmental disability or related condition) contained accurate information specific to mental illness, for one of two residents (Resident 4) reviewed for PASRR. *Resident 4 had a diagnosis of bipolar disorder; however, the PASRR Level 1 Screening showed Resident 4 had no diagnosed mental illness. This failure had the potential for Resident 4 not to receive a PASRR Level II Mental Health Evaluation (determines if the resident can benefit from specialized mental health services), which posed the risk for Resident 4 not obtaining recommendations for specialized services to address the resident's mental health needs.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure one of 13 final sampled residents (Resident 8) attained and maintained their highest practicable physical well-being. * The facility failed to apply the foot cradle for Resident 8 in accordance with the physician's order. This failure had the potential for delays in providing the necessary care and services for Resident 8.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the appropriate dialysis (a life-sustaining treatment for kidney failure that filters waste and excess fluids from the blood) care was provided for one of 13 final sampled residents (Residents 8) who was receiving dialysis services. * The facility failed to ensure a dialysis emergency kit was available at the bedside for Resident 8. This failure had the potential for the resident to experience medical complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of four final sampled residents (Residents 2 and 6) reviewed for the use of side rails remained free from the accident hazards associated with the use of the elevated side rails. * The facility failed to ensure the side rails assessment was accurate or completed, and/or the least restrictive measures were provided prior to the use of the side rails for Residents 2 and 6. These failures had the potential to put the residents at risk for entrapment and serious injuries.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the required physician visits were done timely for one of 13 final sampled residents (Resident 15). * The facility failed to ensure Resident 15 was visited by the physician every 60 days. This failure had the potential to result in an undetected decline in medical, health, or psychosocial condition and can lead to a delay in the necessary care, treatment, and services.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the availability of the prescribed medications for one of five sampled residents (Resident 5) reviewed for unnecessary medications. * Resident 5 had a physician's order for Cobenfy (psychotherapeutic medication). The licensed nurse was unable to administer the evening dose of Cobenfy on two consecutive days, due to the unavailability of the medication. This failure posed the risk for inhibiting the therapeutic effects of the medication.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to follow up the MRR recommendation for one of five sampled residents (Resident 6) reviewed for unnecessary medications. * The facility failed to implement the pharmacy recommendations approved by physician to change the ibandronate (medication to prevent bone weakening) administration time for Resident 6. This failure placed Resident 6 at an increased risk for developing preventable adverse effects of the medication.

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 8%. One of three licensed nurses (LVN 2) was found to have made errors during the medication administration to one final sampled resident (Resident 4). * LVN 2 failed to administer the cholecalciferol (supplement) and fluticasone (medication to treat allergies) medications as ordered for Resident 4 due to the unavailability of the medications. These failures had the potential to negatively affect the residents' health conditions and posed the risk of possible complications or delays in interventions.

Inspectors wroteBased on observation, interview, and facility P&P, the facility failed to provide the necessary pharmacy services to ensure the proper storage of medications for one of three medication carts (Medication Cart 1) inspected. * The facility failed to ensure the treatment supplies were stored properly. This failure had the potential to alter the efficacy of the stored treatment supplies and pose the risk of infection to the residents.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in one of one garbage dumpster. This failure had the potential to attract pests and rodents that carry diseases.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately documented for four of 13 final sampled residents (Residents 2, 6, 8, and 11). * The facility failed to ensure the safety assessment for siderails usage for Residents 2, 6, and 11 were accurate in accordance with the physician's orders. * The facility failed to ensure Resident 6's informed consent for buspirone (medication to treat anxiety), and citalopram (medication to treat depression) were maintained in the residents' medical record. * The facility failed to ensure Resident 8's blood pressure access site was accurately documented in the medical record. * The facility failed to ensure Section D of Resident 11's POLST (Physician Orders for Life-Sustaining Treatment) was signed and dated by the physician. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the daily nursing PPD was posted with an accurate information. * The facility failed to update the daily nursing PPD with the correct date, staffing data, and census. This failure had the potential for the residents and visitors to not be informed about the facility's staffing.

Inspectors wroteBased on interview, and facility document review, the facility failed to ensure an employee working as a CNA (a healthcare professional who provides basic resident care and support) at the facility held a valid and up-to-date license and met competency evaluation requirements for training. This failure had the potential to result in an unlicensed CNA providing direct care to the residents without proper the certification and training, and placing the residents' safety at risk.

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 four of four sampled residents (Residents 1, 2, 3 and 4). * The facility failed to ensure Resident 1 had an order to suction secretions. * The facility failed to ensure Resident 2's oxygen nasal cannula was stored in the bag according to the facility's P&P. * The facility failed to ensure Resident 3's nebulizer administration set-up was changed every seven days according to the facility's P&P. * The facility failed to ensure Resident 4's CPAP washable filter, mask, nasal pillows and tubing were cleaned according to the manufacturer's guideline and facility P&P while the resident was in the facility. These failures had the potential to negatively affect the residents' medical conditions. 1. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide written information to the residents about a bed-hold information upon the resident transferring to an acute care hospital for three of three sampled residents (Residents 1, 2, and 3). These failures had the potential for the residents not receiving accurate information to determine if they wanted a bed-hold and to return to the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 2) had the physician's orders for the indwelling urinary catheter use, care, and maintenance. This failure had the potential for the resident to develop indwelling urinary catheter related infection and/or complications.

Inspectors wroteBased on interview and closed medical record review, the facility failed to ensure the annual and discharge return- anticipated MDS assessments were completed within 14 calendar days after the ARD for the annual and discharge return anticipated assessments for one of two sampled residents (Resident 1). This failure had the potential of not identifying each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessments when the health problems had been identified.

Inspectors wroteBased on interview, and medical record review, the facility failed to ensure the medical record was complete and accurately maintained for one of two sampled residents (Resident 2). * Resident 2's physician's order for wound care did not include the location of the wound. This failure had the potential for not providing necessary care and services due to incomplete medical records.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of the diseases and infections for one of two sampled residents (Resident 2). * The facility staff failed to ensure the EBP was maintained for Resident 2 with an indwelling urinary catheter during incontinence care. This failure had the potential to spread infectious organisms to the other residents in the facility.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the microwave utilized to warm up the food was maintained in sanitary condition and free of food residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting board was kept in a sanitary condition and with cleanable surface. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed and implemented as evidenced by: * Residents 2, 6, 9, 18, and 22's physicians were not notified when the residents' infections did not meet the McGeer's criteria. * The facility failed to ensure Resident 627 had contact isolation precautions in place due to the clostridium difficile infection. * The Infection & Control Surveillance Log of Infections for February 2025 was inaccurate. Resident 627's CAI infection was not included in the log. * The blood pressure wrist machine used for the residents did not have a cleanable surface (Velcro with cloth material). * The facility failed to ensure the hospice licensed staff practiced EBP when providing wound care treatment for Resident 20 who was on the EBP. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the services provided met the professional standards of care when LVN 2 failed to properly obtain the blood pressure for one of three residents (final sampled resident, Resident 3) observed for medication administration. This failure had the potential for the residents requiring blood pressure checks to have inaccurate readings.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 8) who had limited mobility and ROM functions received the appropriate treatment and services to maintain or improve their ROM functions and prevent further decline in their ROM functions. This failure had the potential for Resident 8 to experience a decline in her physical abilities.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 3) reviewed for smoking remained free from accident hazards. * The facility failed to ensure Resident 3' smoking assessment was completed upon admission to the facility to determine if the resident was safe to smoke. This failure had the potential for the resident to sustain accidents and/or injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of two final sampled residents (Residents 13 and 17) reviewed for oxygen therapy. * The facility failed to follow the physician's order for Residents 13 and 17's oxygen therapy. This failure had the potential for the residents to not receive the appropriate care and may negatively impact the residents' medical conditions.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure four of 12 final sampled residents reviewed for the side rail use (Residents 1, 12, 13, and 20) remained free from the accident hazards due to the use of side rails. * The facility failed to ensure the Facility Verification of Informed Consent for Resident 13 was accurately completed. The consent form had no physician's signature and date. Furthermore, the facility failed to ensure the physician's order was obtained for the use of the bilateral half side rails for Resident 13. * The facility failed to ensure a care plan was initiated for the use of the bilateral half side rails for Resident 20. * The facility failed to provide the manufacturer's manual for Resident 12's bed to show compatibility for the bed's side rails. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of medications for one of three residents (final sampled resident, Resident 8) observed for medication administration when: * LVN 1 failed to assess Resident 8's bowel status prior to administering a laxative (promotes bowel movements) medication as per the physician's order. This failure had the potential to negatively affect the resident's health conditions that could posed the risk for possible complications.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's identified drug recommendations were addressed for two of 12 final sampled residents (Residents 1 and 17). This failure posed the risk for the residents to have adverse consequences related to their medications.

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 11.11%. Two of two licensed nurses (LVNs 1 and 2) observed during the medication administration were found to have made an errors. * LVN 1 failed to reconstitute the polyethylene glycol medication as per the physician's order for Resident 8. LVN 1 reconstituted the polyethylene glycol medication with five oz of water instead of eight oz of water per the physician's order. * LVN 2 failed to reconstitute the polyethylene glycol medication as per the physician's order for Resident 3. LVN 2 reconstituted the polyethylene glycol medication with five oz of water instead of eight oz of water per the physician's order. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure two of three final sampled residents (Residents 1 and 13) reviewed for hospice services received the necessary care and services. * The facility failed to ensure the hospice visit calendar was available in Resident 1's medical record and provide accurate documentation of the hospice staff visits for Resident 1. The facility also failed to ensure the care plan were updated and available in the resident's medical record. * The facility failed to ensure the hospice visit calendar was available in Resident 13's medical record. Additionally, the facility failed to ensure a care plan was initiated for the hospice services provided for Resident 13. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the QAPI committee developed and implemented action plans to include monitoring the effectiveness of those plans in achieving and sustaining the improvement for a repeated deficient practice cited at F756. This was not in accordance with the facility's POC from the last recertification survey completed on 3/14/24. This failure had the potential to affect the quality of care for all the residents in the facility.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the essential equipment was maintained in safe operating condition. * The facility failed to ensure the quality control record for February and March 2025 reflected on the glucometer with the serial number 1040-4333929. This failure had the potential for the residents requiring glucose checks to have inaccurate readings.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurately completed for four of 12 final sampled residents (Residents 1, 12, 13, and 20). This failure had the potential to negatively impact the residents, resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on the interview, medical record review, and facility P&P review, the facility failed to ensure the POLST was updated and the copy of advance directive form was obtained for one of 12 final sampled residents (Resident 1). This failure had the potential for the resident's decisions regarding their healthcare and treatment not being honored.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to notify the resident and/or their representative of the transfer and reason for the transfer in writing and send a copy of the Notice of Transfer/Discharge to the LTC Ombudsman for two of three closed record sampled residents (Residents 21 and 26). These failures posed the risk for the resident and/or their representative of not knowing about the appeal process and posed the risk of the LTC Ombudsman not being aware of the circumstances of the residents' transfer/discharge should an appeal be filed or requested by the resident or their representatives regarding the transfer.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS for discharge was completed and transmitted for one of 12 sampled residents (Resident 12). This failure had the potential for not having current information in the resident's medical record.

Inspectors wroteBased on interview and medical record review, the facility failed to accurately code the MDS related to RNA services for one of 12 final sampled residents (Resident 10). This failure posed a risk of the resident not receiving an individualized care plan tailored to their specific needs.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the care plan for one of three sampled residents (Resident 1) was revised after Resident 1 had reported an abuse allegation against CNA 1. This failure put Resident 1 at risk of not receiving resident-centered care.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * Time/Temperature Control for Safety (TCS) foods (food that require time and temperature controls to limit the growth of illness causing bacteria) were not accurately monitored to ensure proper cool down process was followed. * The facility failed to ensure the handwashing sink was used for handwashing only. * The facility failed to ensure proper labeling and dating of food in the refrigerator used for resident foods. * The facility failed to ensure the kitchen utensils were clean and stored in sanitary condition. * The facility failed to ensure the cutting boards were kept in sanitary condition. * The facility failed to ensure the kitchen utensils and equipment were kept in good repair. [...]

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to show documentation of Legionella testing protocols. * The facility failed to ensure the personal items and food were not stored in the laundry room with clean linens for the residents. In addition, the facility failed to ensure the laundry soap, fabric softener, and Clorox were stored properly and in clean condition in the laundry room. * The facility failed to ensure CNA 1 performed hand hygiene after assisting Resident 19 with lunch and doffing her gloves. * The facility failed to ensure the urinals, basins, and tubs stored in a shared bathroom shelf were labeled. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review the facility failed to implement their Antibiotic Stewardship Program when the facility failed to conduct an accurate assessment for the McGeer's criteria for one of 14 final sampled residents (Resident 3) and one nonsampled resident (Resident 6). This failure had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antibiotics.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodation to meet the needs for one of 14 final sampled residents (Resident 130) and one nonsampled resident (Resident 25). * The facility failed to ensure the call lights for Residents 25 and 130 were within the resident's reach. This failure had the potential to negatively impact the resident's physical and psychosocial well-being or would result in delayed provision of care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary timely assistance with the execution of an advance directive for healthcare and failed to ensure the POLST and Advance directive acknowledgement form was obtained for two of 14 final sampled residents (Residents 12 and 18). * Resident 18 was admitted to the facility on [DATE] and she informed the facility on 1/16/24, that she wished to execute an advance directive for health care. The facility attempted to contact the Ombudsman on 1/19/24, to schedule a time in which the Ombudsman could sign Resident 18's advance directive; however, the facility failed to follow up with the Ombudsman and Resident 18 had yet to formulate an advance directive. * The facility failed to ensure the POLST and Advance directive acknowledgement form were obtained from Resident 12's responsible party. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to obtain the physician's order for the discharge to home as well as documentation of the physician's notification upon leaving the facility for one of two closed medical records reviewed (Resident 28). This failure had the potential to affect the health and safety of the resident during the transition of care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure ulcers for two of 14 final sampled residents (Residents 16 and 19). * Resident 16 was evaluated to have blanchable redness to his left hip on 1/19/24. Resident 16 developed with DTI on the left hip on 2/11/24. The facility failed to ensure Resident 16's left hip was reassessed per the physician's order. The facility failed to provide the appropriate and necessary services to ensure Resident 16 did not develop a pressure ulcer in the facility. * The facility failed to ensure the LAL mattress setting was consistent with Resident 19's weight. These failures had the potential for the residents to develop the pressure ulcers or worsening of existing pressure ulcers.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 22) and one nonsampled resident (Resident 8) remained free from accident hazards. * The facility failed to ensure CNA 1 locked the wheelchair brakes during a transfer for Resident 22 on 1/23/24, resulting in Resident 22 falling to the ground. * The facility failed to ensure the tab alarm was in place as per the physician's order for Resident 8. These failures had the potential to not prevent further falls for these rresidents.

Inspectors wroteBased on observations, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services related to GT for one of 14 final sampled residents (Resident 23). * The facility failed to ensure Resident 23's HOB was elevated during the enteral feeding to reduce the risk of aspiration. * The facility failed to ensure the licensed staff managed the GT feeding for Resident 23. RNA 1 was observed to turn off the GT feeding to assist with repositioning for Resident 23. These failures posed the risk for complications related to the use of GT for Resident 23.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for four of 14 final sampled residents (Residents 1, 2, 16, and 18). * The facility failed to follow the physician's order for administering the oxygen at 2 LPM instead of 3.5 LPM for Resident 1. * The facility failed to ensure the oxygen tubing was stored and labeled properly for Resident 2. In addition, the facility failed to obtain a physician's order for the oxygen therapy for Resident 2. * The facility failed to ensure the oxygen nebulizer mask and tubing were stored properly and labeled for Resident 16. * Resident 18's nasal cannula was improperly stored. These failures posed the risk for the residents' safety and respiratory related complications including infection.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for one of 14 final sampled residents (Resident 2). * The facility failed to monitor and accurately document Resident 2's fluid intake. * The facility failed to show evidence Resident 2's monthly weight was monitored and recorded. * The facility failed to update Resident 2's comprehensive plan of care to reflect the current dialysis access site. These failures had the potential to result in health complications for Resident 2.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 14 final sampled residents (Residents 1 and 12) remained free from accident hazards related to the use of elevated side rails. * Resident 12 was observed with elevated side rails in place. The facility failed to review the risks and benefits of the side rails with Resident 12 and/or responsible party and failed to obtain the informed consent for the use of the side rails. * Resident 1 was observed in bed with the elevated side rails. However, there was no physician's order, care plan, and informed consent for the use of side rails. These failures had the potential to place the residents at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P, the facility failed to ensure the pharmaceutical services were provided to meet the needs for one of 14 final sampled residents (Resident 2). * The facility failed to administer Sevelamer Carbonate (medication to treat too much phospate in the blood in residents with chronic kidney disease who are on dialysis) with meals as ordered by the physician. * The facility failed to monitor and document the blood pressure prior to administration of Midodrine (medication to increase blood pressure) as ordered by the physician. These failures had the potential to negatively affect the resident's health.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the pharmacy consultant's recommendations were acted upon for one of 14 final sampled (Resident 10). This failure had the potential for the resident not receiving the necessary care and services.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 12) was free from unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure the informed consent was obtained from Resident 12's responsible party for the use of Remeron (an antidepressant drug which can be taken as an appetite stimulant). This failure posed the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of medications in the Medication Cart. The facility failed to ensure treatment supplies were not expired in the Treatment Cart. The Facility failed to ensure the expired hand sanitizer bottles were discarded. * Discontinued prednisone (steroid) tablets were observed in the Medication Cart. * The facility failed to ensure a container of germicidal alcohol wipes was stored separately from the residents' medications. * An unlabeled and unpackaged vial of ipratropium and albuterol (combination medication that relaxes muscles in the airways and increase air flow to the lungs) inhalation solution was observed lying in the Medication Cart. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the pneumococcal vaccine was administered to one of 14 final sampled residents (Resident 17). This failure put Resident 17 at risk for pneumonia.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the essential kitchen equipment was maintained in safe operation condition when the ice machine manufacturer cleaning and sanitizing instructions were not followed. This failure had the potential to result in the equipment to not function in the way it was intended which could affect the health status of the residents.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS discharge assessment was completed for one nonsampled resident (Resident 26). This failure posed the risk for not being able to monitor the resident's decline and progress over time.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan for one of two closed record sampled residents (Resident 27) was initiated upon admission. This failure had the potential for Resident 27 to not receive the necessary care and services in accordance with his care needs.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in one of one garbage dumpsters. This failure had the potential to attract the pest/rodents that carried diseases.