Studio City Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the Lead Respiratory Therapist (Lead RT) maintain accurate and complete record for three of three sampled staff (Registered Nurse 1 [RN 1], Respiratory Therapist 1 [RT 1] and RT 2), by failing:1. To ensure the Lead RT documented and completed RN 1, RT 1 and RT 2's Ventilator and Nebulizer Key Competency Checklist to indicate if the three staff (RN 1, RT 1 and RT 2) were able to demonstrate proper knowledge, use and application of ventilator (a medical device to help support or replace breathing) and handheld nebulizer (HHN- a small machine that turns liquid medicine into a mist that can be easily inhaled).2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) by failing to develop a care plan for tracheostomy tube (a surgically created hole [stoma] in the neck leading directly into the windpipe [trachea] to provide an airway, often using a tube to help with breathing) change after admission on [DATE]. This failure had potential for delays in the delivery of necessary care and services to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had history of acute and chronic respiratory failure (acute failure happens suddenly [minutes/hours] and is a life-threatening emergency, while chronic failure develops gradually over time due to ongoing lung damage), with tracheostomy (a surgically created opening [stoma] in the front of the neck leading into the trachea [windpipe] to assist with breathing) and dependent on ventilator (a medical device to help support or replace breathing), was provided with respiratory care consistent with professional standards of practice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control measures for one of three sampled residents (Resident 2) by failing to ensure Registered Nurse 3 (RN 3) wore gown when suctioning Resident 2 who had a tracheostomy tube and on Enhance Barrier Precaution (EBP- infection control measures for high-risk residents, to reduce the spread of multidrug-resistant organism [MDRO- Bacteria that resist treatment with more than one antibiotic]). This failure had the potential for cross contamination (unintentional transfer of bacteria or germs or other contaminant from one surface to another) and spread infections and illnesses to residents, and staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) was maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure licensed nurses documented the level of care provided to Resident 1 while the resident was in the facility. Resident 1's vital signs (essential, objective measurements of basic body functions, used to evaluate physical health, indicate disease, and monitor recovery) were not documented in the resident's medical records during a change of condition (COC) on 2/26/2026. This deficient practice resulted in incomplete information on Resident 1's medical records and had the potential for delayed medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of three sampled residents (Resident 1) when the facility failed to administer amoxicillin-potassium clavulanate (a prescription combination antibiotic used to treat various bacterial infections, such as sinusitis, pneumonia, ear infections, and urinary tract infections). This deficient practice had the potential to negatively affect Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with acceptable professional standards and practices for one of three sampled residents (Resident 1) when the facility failed to accurately document in the Resident 1's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). This deficient practice resulted in inaccurate documentation of Resident 3's records.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of four sampled residents (Resident 3) when the facility failed to accurately document Resident 3's diagnosis. This deficient practice resulted in inaccurate documentation in Resident 3's records.

Inspectors wroteBased on observation, interview, and record review the facility failed to: A. Ensure one of four sampled residents (Resident 10) who had intact skin upon admission on [DATE], was assessed as at risk for developing pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence), required assistance with turning while in bed and in a chair, and was incontinent of bowel and bladder (having no or insufficient voluntary control over urination or defecation) did not develop pressure ulcers while in the facility and received appropriate treatment and services to maintain skin integrity (the condition of the skin being intact, healthy and free from damage) by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition for three of three sampled residents (Residents 67, 96, and 13) reviewed for informed consents (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to ensure: 1. Resident 67's Lorazepam (slowing activity in the brain to allow for relaxation) and Quetiapine (used to treat certain mental health conditions) informed consents indicated the name of the medication, dosage, and frequency of intake. 2. Resident 96's had an informed consent for Remeron (is a type of antidepressant medication used primarily to treat major depressive disorder in adults). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the pad call light (a specialty alerting device that have ultra-sensitive touch surface for patients with limited mobility for nurses or other nursing personnel to assist a patient when in need) was within reach for three (3) of six (6) sampled residents (Residents 41, 148, and 158) reviewed under the environment task. This deficient practice had the potential to result in a delay of care and services and possible injury to residents when they are unable to call for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for five of seven sampled residents (Residents 76, 6, 148, 51, and 79) reviewed for physical restraints care area by failing to: 1. Ensure Resident 76's use of tab alarm (a simple device designed to alert staff when a resident attempts to get out of bed or a chair without assistance) was assessed quarterly for appropriateness of use per facility policy and procedure. 2. Ensure Resident 6 did not have rolled pillows tucked under the resident's fitted sheet on both sides. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's drug regimen was free from unnecessary drugs for three of five sampled residents (Resident 125, 148, and 15) reviewed for unnecessary medications by failing to ensure: 1. Resident 125's Xanax 0.25 milligram (mg, a unit of weight) tablet every six (6) hours as needed for anxiety (a feeling of worry, nervousness, or unease, typically about an event or something with an uncertain outcome) had a 14-day stop date. This deficient practice had the potential to result in use of unnecessary psychotropic drugs (medications that affect your brain and change how you think, feel, and behave) for Resident 125, and can lead to side effect and adverse consequence (refers to the negative or harmful results that follow from a particular action or event) such as a decline in quality of life and functional capacity. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) by failing to: 1. Develop and implement a CP for the use of a Geri chair (a type of adjustable, reclining wheelchair that may prevent a resident from rising independently) for one of six sampled residents (Resident 79) reviewed during the Physical Restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) care area. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses provided care in accordance with professional standards to three of three sampled residents (Residents 4, 13, and 35) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites for Residents 4, 13, and 35. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of seven sampled residents (Residents 33 and 112) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that is free from accident hazards over which the facility has control for six of seven sampled residents (Residents 66, 158, 124, 112, 40, and 125) investigated under the Accidents care area by: 1. Failing to ensure Resident 66's bed lock (a mechanism that prevents a hospital bed from rolling or having its position adjusted) was engaged while the resident was in bed. 2. Failing to ensure Resident 158's bed was at the lowest position. 3. Failing to ensure there were no furniture or equipment on top of Residents 40's floor mats (a cushioned floor pad designed to help prevent injury should a person fall). 4. Failing to ensure there were no furniture or equipment on top of Residents 125's floor mats. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six of seven sampled residents (Residents 11, 51, 41, 168, 4, 125, and 155) reviewed under the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain) and urinary tract infection (UTI, a common infection that occurs when bacteria enters and multiplies in the urinary system, which includes the kidneys, bladder, and urethra) care area received appropriate treatment and services to prevent UTIs by: 1. Failing to ensure Resident 11, 51, 41, 168, and 4's catheter tubing did not have dependent loops or kinks (incorrect positioning of the catheter tubing that forms a U-shaped loop or low point that traps urine and creates back pressure). These deficient practices increased the risk of urine to backflow into the bladder which may lead to the development of a UTI. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by failing to: Rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites for three of three sampled residents (Residents 4, 13, and 35) reviewed for insulin. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption was followed for one of one sampled resident refrigerator by failing to: 1. Ensure Certified Nursing Assistant (CNA) 4 informed Resident 82 that the facility had refrigerator designated for residents' food brought from home. 2. Ensure the facility's resident refrigerator was within acceptable temperature range per facility's policy and procedure for refrigerator at 40 degrees Fahrenheit (F, a scale for measuring temperature) or below and freezer at 0 degrees F or below. 3. Ensure expired whole milk yoghurt (6 packs), with expiration date of 7/23/2025 was discarded. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the binding arbitration agreement (a resident waives the right to sue the nursing home in court, and instead agrees to have any future disputes handled by a private arbitrator) indicated the resident or anyone else (e.g., resident's representative) were allowed to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman for three of three sampled residents (Residents 30, 85, and 101) reviewed for Arbitration Facility Task. The deficient practice had the potential for residents to be unaware of their rights pertaining to the Arbitration Agreement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) oxygen tubing (flexible, hallow tube that connects the air compressor of a nebulizer to the medication cup) was not left on the floor for one of six of sampled residents reviewed during the Respiratory care area (Resident 35) and one of three sampled residents (Resident 16) reviewed during the Nutrition care area. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure self-administration of a Breo (a medication used to treat breathing problems) inhaler was evaluated and considered safe by the interdisciplinary team (IDT - a multi-discipline group of healthcare professionals involved in periodically meeting and planning care for individual residents) for one of four resident's observed for medication administration (Resident 48.) The deficient practice of allowing Resident 48 to self-administer medication without an IDT evaluation for safety increased the risk that she may have administered the wrong dose of Breo due to poor technique possibly resulting in medical complications resulting in hospitalization or death.

Inspectors wroteBased on interview and record review, the facility: 1. Failed to ensure resident's medical records were updated to show documented evidence that advance directives (AD - a legal document indicating resident preference on end-of-life treatment decisions) were discussed with one (1) of four (4) sampled residents (Resident 32). This deficient practice violated the resident`s rights and/or representative's right to be fully informed of the option to formulate their advanced directives. 2. Failed to ensure that a current copy of resident's advance directive (a legal document indicating resident preference on end-of-life treatment decisions) was in the resident's medical record for one of four sampled residents (Resident 4). The deficient practice had the potential to violate the resident's right to self-determination when the resident is incapacitated to make decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for one of five sampled residents (Resident 71) investigated under the facility environment task. This deficient practice had the potential to negatively affect Resident 71's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for one of four sampled residents (Resident 16) reviewed during the Pressure Ulcer / Injuries (PU/PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) care area by failing to obtain physician orders prior to administering a wound care treatment for a newly identified skin issue. This deficient practice had the potential for Resident 16 to experience adverse (unwanted, unintended result) reactions or a delay in wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required colostomy (an opening [stoma] on your abdomen [belly] that connects your colon [large intestine] to the outside of your body) received care consistent with professional standards of practice for one of one resident (Resident 155) reviewed for colostomy care by failing to empty a full colostomy bag (s a small pouch worn on the outside of the abdomen to collect stool after a surgical procedure called a colostomy) when the resident already have been complaining that it was full since shift change in the morning. This deficient practice had predisposed the resident to discomfort, skin excoriation (a scrape or scratch to the skin), and had the potential for the bag to become dislodged, resulting in leakage of the fecal contents onto the resident`s body and bed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for two (2) of six (6) sampled residents (Residents 6 and 169) reviewed for respiratory care by: 1. Failing to ensure Resident 6's oxygen tubing was changed timely per facility policy and procedure (P&P). This deficient practice placed the resident at risk for acquiring respiratory infections. 2. Failing to ensure Resident 169's oxygen therapy (a treatment that provides extra oxygen to breathe in) via nasal cannula (NC, a simple, two-pronged device that delivers extra oxygen to the nose) was applied in the resident's nostrils. This deficient practice had the potential for the resident to develop complications such as shortness of breath, desaturation (low levels of oxygen in the blood), and respiratory infections.

Inspectors wroteBased on interview and record review, the facility failed to provide pain management for one of four sampled residents (Resident 10) reviewed for pressure ulcer/injuries (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) before providing wound treatment as ordered by the physician. This deficient practice had the potential to result in increased pain and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Treatment Nurse (TN) 1 demonstrated clinical competency and skills to care for residents at risk for pressure ulcers / injuries (PU / PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) reviewed under the Sufficient and Competent Nurse Staffing task. This deficient practice resulted in TN 1 failing to provide the necessary care to Resident 10 to prevent the development of PUs, when on 8/12/2025, Resident 10 was identified with a sacral (tailbone) stage three PU (full-thickness skin loss that extends through the skin into deeper tissue and fat but do not reach muscle, tendon or bone) and a left buttock stage two PU (partial thickness loss of skin, presenting as a shallow open sore or wound).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for one dose of tramadol (a controlled medication used to treat pain) 50 milligrams (mg - a unit of measure for mass) affecting Resident 112 in one of five inspected medication carts (Station 3 Cart). This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations (medications with a high risk for diversion) and the risk that Resident 112 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one used single-dose vial of testosterone injection (a medication used to supplement testosterone) was discarded after use affecting Resident 170 in one of five inspected medication carts (Station 4 Cart.) This deficient practice of failing to discard used single-dose vial of testosterone increased the risk that Resident 170 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications such as infection resulting in hospitalization or death.

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 the facility failed to label one opened bag of mini tortillas with an opened date. This deficient practice had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were maintained in accordance with professional standards that are complete and accurately documented when the facility failed to: Ensure Resident 15's Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) Progress Note dated 8/1/2025 was not signed by an occupational therapist (OT, rehabilitative professional that provides services to increase and/or maintain a person's capability to participate in everyday life activities). This failure had the potential for incomplete and inaccurate medical documentation.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in long-term care facilities to ensure that antibiotics are used only when necessary and appropriate [means prescribing the right drug at the right dose at the right time for the right duration]) program and infection prevention and control program for one of one sampled resident (Resident 6) by: 1. Failing to complete the Surveillance Data Collection Form (a checklist used in nursing homes to help healthcare workers identify if a resident actually has a significant infection, rather than just having symptoms) for Respiratory Infections that the resident met the criteria for the use of antibiotic. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and resident care equipment in safe operating condition for two of six sampled residents (Residents 44 and 92) reviewed under the environment task by failing to ensure the residents' bed controller (device used to change the height and angle of the bed) cord did not have frayed or exposed wires. This deficient practice had the potential to place the residents at risk of incurring injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure five of 33 sampled residents received an accurate Minimum Data Set (MDS - a comprehensive resident assessment tool) by failing to: 1. Complete assessment Section I (active diagnoses), by failing to include diagnoses of mood disorder (a mental illness characterized by having rapid changes in mood from depression to mania) per information in the medical record for two of five residents sampled for unnecessary medications (Resident 15 and 107). 2. Accurately code Section O for therapy (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) minutes and days provided for one of six sampled residents (Resident 32). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of 65 resident rooms (room [ROOM NUMBER]) accommodated no more than four residents per room. room [ROOM NUMBER] measured 418.5 square feet (sq. ft. - a unit of area measurement) and had five beds inside the room. This deficient practice had the potential to result in inadequate usable living space for the residents and working space for the healthcare staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft. - unit of area measurement) per resident in multiple resident bedrooms for three out of 65 resident rooms (rooms [ROOM NUMBER]). room [ROOM NUMBER] had four beds and measured 290.93 sq. ft., room [ROOM NUMBER] had three beds and measured 215.2 sq.ft., and room [ROOM NUMBER] had three beds and measured 213.58 sq. ft. This deficient practice had the potential to result in inadequate useable living space for the residents and inadequate working space for healthcare staff.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for three of three sampled residents (Residents 1, 2, and 3) by failing to ensure a care plan was develop on residents ' potential exposure to scabies (a skin condition caused by tiny mites that burrow [a hole or tunnel] under the skin, leading to intense itching and a rash which is contagious [disease that they can pass to other people] and can spread through prolonged skin-to-skin contact). This deficient practice had the potential for delayed provision of necessary care and services and spread of scabies among residents.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of four sampled residents (Resident 1 and 2) by: 1. Failing to ensure Resident 1 ' s physician order was followed for oxycodone (medication used to treat pain) for severe pain level between seven to ten. 2. Failing to ensure Resident 2 ' s physician order was followed to hold diltiazem (medication used to treat high blood pressure) for systolic blood pressure (sbp - the top number in a blood pressure reading, indicating the pressure in your arteries when your heart beats) below 110. This failure had the potential to result in medication error and can cause hypotension (low blood pressure).

Inspectors wroteBased on interview and record review, the facility failed to ensure three of four sampled residents (Residents 1, 2, and 3) who had no scabies (a parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash) was not given Elimite (medication used to treat scabies) cream. This failure had the potential to result in Residents 1, 2, and 3 to receive unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to implement infection control measures for three of four sampled residents (Resident 1, 2, and 3) by. 1. Failing to ensure Resident 1 was placed on contact isolation after physician ordered skin scraping (a medical procedure where a sample of skin cells is collected by gently scraping the surface of the skin with a sterile blade) to test for presence of scabies (a contagious skin condition caused by microscopic [so small as to visible only with microscope] mites [tiny bugs] burrowing [made a hole] into the skin). 2. Failed to ensure skin monitoring was done and documented in Residents 1, 2, and 3 ' s medical records after physician ordered the monitoring on 2/18/2025. These failures had the potential for the spread of scabies among residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2), who was on a self-release belt restraint (a device, often used in healthcare settings, designed to secure a patient to a bed or chair while still allowing them to move or sit up), was free from unnecessary physical restraint (a strap or other thing that holds a person in place) when on 4/2/2025 at 8:56 a.m., Resident 2's lap was observed covered with a white blanket covering his lower abdomen to his knees with edges wrapped around to his (Resident 2) sides and secured to Resident 2's wheelchair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident received care consistent with professional standards of practice to prevent pressure ulcer (a localized injury to the skin and or underlying tissue usually over a bone prominence as a result of pressure or pressure in combination with shear [occur between the internal body structures and skin tissues typically moving in opposite directions and may lead to deep tissue injury]) for one of three sampled residents (Resident 5) by failing to ensure no excessive padding was placed over the low air loss mattress (LALM-a mattress designed to distribute the patient's body weight over a broad surface area to prevent skin breakdown and treat pressure ulcers) as indicated in the manufacturer ' s manual and facility ' s policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Attending Physician (AP) was notified timely for one of four sampled residents (Resident 1). This deficient practice resulted in a delay of obtaining appropriate instructions from the physician for proper management.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of four sampled residents (Resident 1). This deficient practices had the potential to cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Resident 3, Resident 4, and Resident 5) were provided a safe and homelike environment. The facility failed to: 1. Ensure the facility temperature was between 71 degrees Fahrenheit (°F, unit of measurement for temperature) to 81°F as indicated in the facility's policy and procedure (PnP). 2. Ensure safe and clean shower rooms were provided for the residents. These deficient practices had the potential to cause serious medical problems and altered comfort level. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) on 9/15/2024 when Resident 2 punched Resident 1 on the face. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained swelling on the left side of his face and right side of his face, and purple discoloration (change in natural skin color) to the right eye and left eye. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of three residents (Resident 35 and 144) reviewed during the Environment task and for two of four sampled residents (Residents 104 and 134) observed during a random observation. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to ask assistance from facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) for four of six sampled residents (Resident 6,126, 9, and 467) investigated during review of the physical restraints care area and one of one sampled resident (Resident 30) investigated during random observation when the facility failed to: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for: 1. Two of six sampled residents (Resident 9 and 126) for placement of bed against the wall as a physical restraint (the use of a manual hold to restrict freedom of movement of all or part of a person's body, or to restrict normal access to the person's body) during review of physical restraints. 2. One of six sampled residents (Resident 467) for using all four side rails up during review of physical restraints. 3. One out of six sampled residents (Resident 116) addressing use of urinary catheters (a flexible tube used to empty the bladder and collect urine in a drainage bag). 4. One of six sampled residents (Resident 30) for using pillows tucked under a fitted sheet during review of physical restraints care area. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards: 1. For five of seven sampled residents (Resident 12, 38, 56, 116 125, and 49) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites. 2. For one of one sampled resident (Resident 38) investigated during review of anticoagulant use by failing to rotate enoxaparin (medication to prevent and treat blood clots) subcutaneous injection sites. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (the breakdown of skin integrity due to pressure) for two of four sampled residents (Residents 67 and 469) investigated during review of pressure injury by failing to: 1. Ensure Resident 67's low air loss mattress' (LALM, designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) power was turned on. 2. Ensure Resident 469's LALM was set according to the resident's weight. The deficient practices had the potential for the development and worsening of the resident's pressure ulcers/injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatments and services to minimize decline in joint range of motion (ROM, full movement potential of a joint) and mobility for three of five sampled residents (Residents 6, 138, and 125) who had limited ROM by failing to: 1. Provide Resident 6 with a right knee splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) during Restorative Nursing Aide Program (RNA, nursing aide program that help residents to maintain their function and joint mobility) seven (7) times a week as ordered and report to nursing when Resident 6 did not complete range of motion exercises or wear the right knee splint. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's environment was free of accident hazards for four out of four sampled residents (Residents 74, 73, 30, and 19) by failing to ensure: 1. Resident 74's oxygen concentrator (a medical device that separates nitrogen from the air so that 95% of pure oxygen can be breathed in) was not placed on top of the fall mat (safety features that are placed on the floor along the side of the bed in the home or next to a hospital bed). The deficient practice lessened the effectiveness of the fall mat to prevent falls with injury by placing a heavy equipment and furniture on top of the fall mat, decreasing its effectiveness to lessen the impact of a fall due to permanent dented mat surface and potential of the residents hitting the hard surfaces of the heavy equipment and furniture. 2. [...]

Inspectors wroteb. During a review of Resident 158's admission Record, the admission Record indicated the facility admitted the resident on 6/28/2024, with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection), acute kidney failure (a sudden and often reversible reduction in kidney function), and artificial opening of urinary tract (a urostomy is a stoma, or opening, in the abdomen that connects the urinary tract to allow urine to drain freely from the body). During a review of Resident 158's History and Physical (H&P), dated 6/28/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and record review the facility failed to: 1. Account for five doses of Controlled Medications (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 30, 42, 60, 123, and 317 in one of five inspected medication carts (Medication Cart Station 1) 2. Document and dispose (remove or destroy) an Ativan (a CM) vial for Resident 143 in the presence of two witnesses, in one of three inspected medication rooms (Medication Room Subacute.) As a result, control and accountability of CMs did not follow state and federal regulations and facility policy and procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 31 total opportunities contributed to an overall medication error rate of 6.45% affecting one of four residents observed for medication administration (Resident 56.) The medication errors were as follows: 1. Resident 56 did not receive docusate (a medication used for bowel [intestine] management) as ordered by Resident 56's physician, and 2. Resident 56 received metformin (a medication used to treat high blood sugar levels) at a different time than ordered by Resident 56's physician. [...]

Inspectors wroted.1. During a review of Resident 12's admission Record (a document containing demographic and diagnostic information,) dated 8/22/24, it indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus 2 ([DM2] - a condition where there is high blood sugar levels.) During a review of Resident 12's Order Summary Report, dated 8/22/24, it indicated Resident 12 was prescribed Lantus (long-acting insulin) to inject 20 units ([un] - a measure of dosage for insulin) SQ at bedtime for DM rotate sites, starting 2/21/24. During a review of Resident 12's Medication Administration Record ([MAR] - a record of mediations administered to residents), for August 2024, the MAR indicated Resident 12 was prescribed Lantus 20 un SQ to give at bedtime for DM rotate sites, at 9 PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Remove and discard from use one open lorazepam (a controlled substance [CS]- medications which have potential for abuse and may also lead to physical or psychological dependence that is used for anxiety and agitation) vial for Resident 28, in accordance with manufacturer's requirements and facility policy and procedures, in two of two inspected medication rooms (Medication Room Station 3.) 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor, appearance, and temperature when a. one of three sampled residents (Resident 128) investigated under the food care area when Resident 128 was served food that did not appear attractive to the resident on 8/20/2024. b. Italian herb vegetables were mushy and overcooked. Red and green salad and peach crisp looked saggy (wet and soft). c. Red and green salad was at 54 degrees Fahrenheit ([°F] a scale of temperature). These deficient practices resulted in Resident 128 not eating their meal and placed 20 of 44 facility residents on regular consistency texture (texture with no restriction) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate food preferences and provide appealing options of similar nutritive value to residents who choose not to eat food that is initially served for two of sixteen sampled residents (Resident 122 and 84) reviewed during the Dining task by failing to: a. Ensure Resident 122 was offered a food substitute after verbalizing that they did not like the meat provided with lunch. b. Ensure Resident 84 did not receive pasta with lunch when Resident 84 had a dislike of pasta. This deficient practice had the potential to result in further weight loss in Resident 122 and not respect Resident 84's wishes.

Inspectors wroted. During concurrent observation of the mixer and interview with DD on 8/21/2024 at 9:11 a.m. the mixer had dry food buildup and residue. DD stated they used the mixer to make pudding and cake and it was last used on 8/19/2024, Monday. DD stated mixer must be cleaned every after use. DD stated the inside parts of the mixer had dust and dry food buildup and it was not acceptable because it was risky for the residents for cross-contamination. DD stated they used to cover the mixer with plastic when not in used and after cleaning, but they did not do it anymore due to humidity build up. A review of the facility's P&P titled Sanitizing Equipment and Surfaces dated 4/17/2024 indicated Sanitizing solution will be used to sanitize equipment and surfaces after each use or as often as needed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have a policy regarding the use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption when the policy did not include the facility's responsibility for storing food brought in by family and other visitors as it indicated The facility cannot store outside food. This deficient practice had the potential to cause a decrease food intake resulting to unintentional (without trying) weight loss, frustrations, and psychosocial harm to 117 of 161 facility residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Occupational Therapy Assistant (COTA 1) had an active California occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) license to perform occupational therapy treatments at the facility. COTA 1's California Board of Occupational Therapy license expired [DATE] and COTA 1 continued to perform occupational therapy treatments at the facility as of [DATE]. This deficient practice resulted in an unlicensed COTA performing occupational therapy treatment for at least three months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate and complete clinical records in accordance with accepted professional standards and practices for four of 21 sampled residents (Residents 122, 125, 138, and 6) when: a. Certified Nursing Assistant 5 (CNA 5) did not accurately document the percentage (%, a unit of measurement) of Resident 122's meal intake. b. [...]

Inspectors wrote6. During a review of Resident 121's admission Record, the admission record indicated the facility originally admitted Resident 121 on 12/3/2021 and readmitted the resident on 6/16/2022 with diagnoses including, but not limited to, benign prostatic hyperplasia without lower urinary tract symptoms (enlargement of the prostate [gland surrounding the neck of the bladder] that can lead to difficulty in urination) and obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered into the digestive system as a liquid) for two (2) out of 2 sampled residents (Residents 30 and 367) investigated under the tube feeding care area by failing to ensure Registered Nurse 6 (RN 6) obtained a physician's order for a tube feeding replacement when Jevity 1.2 (a high-protein, fiber-fortified formula that provides complete, balanced nutrition for long- or short-term tube feeding) was unavailable for immediate use by the resident. This deficient practice had the potential to place Residents 30 and 367 at risk for complications of enteral feeding such as diarrhea (loose, watery stools) or vomiting which may lead to dehydration (loss or removal of water).

Inspectors wroteBased on observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice for one (1) out of 1 sampled resident (Resident 104) during random observation of residents with intravenous (IV) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) by: 1. Failing to indicate the insertion date and the licensed nurse's initials on the peripheral intravenous line (PIV - a soft, flexible tube placed inside a vein, usually in the hand or arm to give a person medicine or fluids) dressing. 2. Failing to place a sterile injection cap over the injection port of the PIV line. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive the necessary respiratory care and services that is in accordance with professional standards of practice by failing to place a fenestrated gauze (a type of wound care product that has cuts, or fenestrations, cut through the entire thickness of the material to allow exudate to drain from a wound) under the flange (is the part of the tracheostomy tube [a metal or plastic tube placed in surgically created opening in the windpipe to keep it open] that extends from the outer part of the tracheostomy [an opening surgically created through the neck into the windpipe] and has holes to attach the tracheostomy tube tie) around the tracheostomy opening for two out of three sampled resident (Residents 468 and 112) investigated during review of respiratory care area The deficient practice had a [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Consultant Pharmacist's (CP) recommendation for June 2024 Medication Regimen Review ([MRR] - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) note was reviewed, addressed or carried out as per facility policy and procedure for one of five sampled residents (Resident 56). The deficient practice increased the risk of receiving medication that was not optimal for Resident 56's medical condition, that would not maintain the resident's highest level of physical, mental and psychosocial well-being and/or increase the risk of side effects (a type of adverse effects [unwanted, uncomfortable, or dangerous effects that a drug may have]) from the medication therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Residents 126) was free from unnecessary medications by not implementing adequate monitoring for Melatonin (a medication used to regulate circadian rhythm [body's sleep and wake cycle]). As a result, Resident 126 was not monitored for hours of sleep and for the effectiveness and side effects (also known as adverse effects - unwanted, uncomfortable, or dangerous effects that a drug may have) of Melatonin since 7/8/24. This deficient practice had the potential to cause Resident 126 to receive suboptimal (less than the highest standard or quality) care, and inability to assess the effectiveness of Melatonin for sleep, leading to the use of unnecessary medications causing potential side effects and negatively impacting their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meals at regular times comparable to normal mealtimes in the community for one of 16 sampled residents (Resident 162) investigated under the dining observation care area when Resident 162 was served his lunch tray after the facility's scheduled lunch time. This deficient practice had the potential to affect the temperature of the food served and negatively affect the resident's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program (measures to eradicate and contain common household pests [e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice, and rats]) so that the facility is free of pests and rodents for one of three sampled residents (Resident 162) investigated under the environment care area when ants were observed inside Resident 162's room. This deficient practice had the potential to negatively affect the resident's psychosocial wellbeing and promote the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a standardized assessment and care screening tool) Assessments dated 10/16/2023, 1/16/2024, and 4/17/2024 for one (1) out of 1 sampled resident (Resident 111) investigated during a review of behavioral-emotional care area by failing to code the resident's diagnosis of Post-Traumatic Stress Disorder (PTSD - a condition that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event) in the MDS. This deficient practice had the potential to negatively affect Resident 111's plan of care and delivery of necessary care and services while in the facility.

Inspectors wroteBased on observations. interviews, and record review, the facility failed to ensure that one of 65 resident rooms (room [ROOM NUMBER]) accommodated no more than four residents per room. room [ROOM NUMBER] measured 419.06 square feet and had five beds inside the room. This deficient practice had the potential to result in inadequate usable living space for the residents and working space for the healthcare staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. - unit of measurement) per resident in multiple resident bedrooms for the three out of 65 resident rooms (rooms [ROOM NUMBER]). room [ROOM NUMBER] had 4 beds inside the room. room [ROOM NUMBER] and 23 had 3 beds inside the room. This deficient practice had the potential to result in inadequate useable living space for all the residents and inadequate working space for the health caregivers.

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to application of a self-released seat belt for one of three sampled residents (Resident 1). This deficient practice violated the resident's right to be informed of and participate in the resident's treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient ' s body that he or she cannot easily remove that restricts freedom of movement or normal access to one ' s body) to one of three sampled residents (Resident 1) by failing to obtain an informed consent from Resident 1 ' s representative prior to application of a restraint (self-release seat belt). This deficient practice had the potential to result in the restriction of residents ' freedom of movement, a decline in physical functioning, psychosocial harm, and physical harm. [...]

Inspectors wroteBased on interview and record review, the facility failed develop a comprehensive person-centered care plan for one of three sampled residents (Resident 1) for the use of self-release seat belt. This deficient practice had the potential to negatively affect the resident's physical wellbeing and inhibit Resident 1's freedom of movement and activity.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Change of Condition (COC - a major decline in a resident ' s status), and notify the physician for one of five sampled residents (Resident 1) who had a significant COC that started on [DATE] at 4 a.m. On [DATE], at 4 a.m., Resident 1 ' s tracheal tube (trach tube, a two-inch-to three-inch-long curved metal or plastic tube placed in a surgically created opening [tracheostomy] in the windpipe to keep it open) was partially (not completely) displaced (removed from the usual or proper place). Respiratory Therapist 2 (RT 2) was unable to replace the tracheal tube with the same size (7.5 millimeter (mm, one thousandth of a meter) but was able to replace the tracheal tube with a smaller-sized tube (6 mm). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received tracheostomy (an opening surgically created through the neck into the trachea to allow air to fill the lungs) care when on [DATE] at 4 a.m., Resident 1 ' s tracheal tube (trach tube, a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining an open airway) was partially (not completely) displaced (removed from the usual or proper place). Respiratory Therapist 2 (RT 2) was unable to replace the tracheal tube with the same size (7.5 millimeter [mm, a metric unit of length equal to one thousandth of a meter]) but was able to replace it (the trach tube) with a smaller-sized tube (6 mm) and RT 2 noted Resident 1 had bilateral (both lungs) diminished (decreased) breath sound and minimal airflow from airway. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the daily staffing information accurately in the sub-acute unit on 5/14/2024. The posted daily staffing information posted was for 5/15/2024. This deficient practice had the potential to result in residents, visitors, and facility staff not knowing how many staff were available to provide care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for four of 12 facility staff (Activity Assistant 1 [AA 1], Business Office Assistant [BOA], Certified Nursing Assistant 1 [CNA 1], and Housekeeping 3 [HKP 3]), by failing to ensure AA 1, BOA, CNA 1, and HKP 3 wore the N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly. This deficient practice placed other residents and staff at risk for exposure and contracting COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive the necessary care based on the assessed individual needs to prevent accidents and minimize injuries for one of the three sampled residents (Residents 1). The facility failed to ensure Resident 1 was provided postural support while sitting in the wheelchair due to abnormalities of gait and mobility. As a result, on 10/7/2023 at 1:55 p.m., Resident 1 fell out of the wheelchair hitting the floor face first. Resident 1 sustained facial lacerations (a cut or tear in the soft tissue of the face). Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where resident was diagnosed with nasal (nose) bone fractures (broken bones) and facial laceration (a skin wound or cut) repair.

Inspectors wroteBased on interview and record review, the facility failed to provide the requested medical records to the legal representative of one of three sampled residents (Resident 1). The facility received the request to release Resident 1 ' s medical records on 9/6/2023. This deficient practice violated Resident 1 ' s rights to secure personal medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents on invasive mechanical ventilators (a lifesaving intervention for patients with respiratory failure) were provided good mucosal (relating to the thin skin inside the mouth) care to the lips and the nasal (relating to the nose) passages to three of three sampled residents (Residents 2, 3, and 4). This deficient practice had the potential for residents on invasive mechanical ventilators to have dry and cracked lips and nasal passages.

Inspectors wroteBased on observation, interview and record review, the facility failed to anchor (to secure) the urinary indwelling catheter (a thin, hollow tube inserted through the urethra [the tube that lets urine leave your bladder and your body] into the urinary bladder to collect and drain urine) on the leg of a resident to prevent tugging and pulling of the urinary catheter to one of four sampled residents (Resident 3). The deficient practice had the potential for Resident 3 ' s catheter to tug and pull causing trauma to the urinary meatus [duct that transmits urine from the bladder to the exterior of the body during urination] that could lead to infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the intravenous (IV, within a vein) tubing set were affixed with the date, time and initials of the licensed nurse who initiated the IV fluid therapy (is a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) to one of four sampled residents (Resident 2). The deficient practice had the potential for prolonged IV set use predisposing Resident 2 to infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program to two of four sampled residents (Residents 2 and 3) by failing to ensure oxygen tubing (used for oxygen delivery during at-home oxygen therapy or in-clinic procedures) were labeled with a date. The deficient practice had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of infection among residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices to four out of six sampled residents (Residents 2, 8, 9, and 10) by: 1. Failing to ensure Certified Nursing Assistant 1 (CNA 1) removed used protective gown before walking in the hallway. 2. Failing to ensure Licensed Vocational Nurse 2 (LVN 2) performed hand hygiene before donning (put on) gloves and wear a protective gown before touching the urine drainage dignity cover of Resident 2 who was on enhanced standard precaution (an infection control intervention designed to reduce transmission [transfer] of multidrug-resistant organisms [MDRO- bacteria that have become resistant to certain antibiotics that can no longer be used to control or kill the bacteria]). 3. [...]

Inspectors wroteBased on observation, interview and record review, Licensed Vocational Nurse 5 (LVN 5) failed to protect the resident's rights of four out of four sampled residents (Residents 9, 11, 12, and 13) by: 1. Leaving the laptop opened to Resident 11 ' s Medical Record unattended facing the hallway with the picture of the resident and medical information showing. 2. Leaving a handwritten physician order for Resident 13 and barcode stickers for medications with Resident 9 and Resident 12's names on a legal-sized (8.5 inch x 14 inch in measurement) white paper on top of the medication cart. These deficient practices violated the resident's right to privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was posted and placed in a visible and prominent place daily. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors.

Inspectors wroteb. On 11/16/2021 at 12:46 p.m. during dining observation, observed Certified Nurse Assistant 5 (CNA 5) enter a person under investigation's (PUI - resident with risk factors for a specific infectious disease) room, wearing face shield and surgical mask. On 11/16/2021 at 01:14 p.m. during an interview with CNA 5, CNA 5 stated he did not put a gown when entering the PUI room. CNA 5 stated when entering the PUI room he should be wearing gloves, gown, N95 (a mask containing multiple layers of protective fabric that they can capture up to 95% of bacteria and viruses and provide good protection against infection), and face shield. CNA 5 stated when he entered the PUI room, he was wearing a surgical mask but should have been wearing an N95. CNA 5 stated N95 provides a better protection than the surgical mask. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhance a resident's dignity when Certified Nurses Assistants (CNA 1 and 3) were standing over the residents while assisting them to eat, for two of two sampled residents (Residents 43 and 101), investigated for dignity. These deficient practices had the potential to affect the residents' sense of self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call light was within reach for one of one sampled resident (Resident 163) investigated under the Environmental task. This deficient practice has the potential to result in Resident 163 not being able to call for facility staff assistance.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse and follow facility's abuse protocol, for one of one sampled resident (Resident 132). This deficient practice had the potential to place Resident 132 at risk for further verbal abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- as assessment and care screening tool) accurately reflected the resident's discharge status for a resident that left against medical advice for one resident (Resident 173) investigated for closed record review. This deficient practice had the potential to inaccurately reflect the plan of care for residents

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an activities care plan for Resident 27. This deficient practice had the potential to result in inconsistent implementation of the care approaches that may lead to a delay in delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement an activities program designed specifically to the needs of the individual residents, for one of two sampled residents (Resident 168). This deficient practice had the potential for a decreased quality of life and meaningless purpose in the facility for Resident 168.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an element of the care plan for a resident with a pressure ulcer (injury to skin and underlying tissue due to prolonged pressure over a bony structure) by failing to reposition as scheduled, for one of eight sampled residents (Resident 140), investigated for pressure ulcers/injury. This deficient practice had the potential to result in the development of worsening and newly acquired pressure ulcers for Resident 140.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a tab alarm (sensor that alerts caregivers if a resident is getting up from bed or chair) was placed while resident was in bed per physician order for one of two sampled residents (Resident 127). This deficient practice placed Resident 127 at risk for falls and serious injuries that include possible fracture (break in the bone) and bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for the care of gastrostomy tube (g-tube - tube placed into stomach for nutritional support and administering medications) by: 1. Failing to ensure Resident 105's gastrostomy tube insertion site was covered with dry dressing as ordered for one of two sampled residents (Resident 105). 2. Failing to use an abdominal binder (wide compression belt that encircles the abdomen) as ordered for one of two sampled residents (Resident 105). These deficient practices had the potential for contaminating Resident 105's g-tube insertion site and increasing the resident's risk for infection; and also had the potential for Resident 105, who has a history of pulling out his gastrostomy tube, to pull out his g-tube again and increase the risk for injury to the g-tube site.

Inspectors wroteBased on observation, interview, and record review, facility failed to meet professional standards of quality for two of two sampled residents (Residents 148 and 107) by failing to administer blood pressure medication according to parameters (limit or range) set by physician. These deficient practices have the potential to result in Resident 148 and 107 in unintended complications related to the management of blood pressure such as hypotension (abnormally low blood pressure and can lead to falls).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that one of 65 resident rooms (room [ROOM NUMBER]) accommodated no more than four residents per room. room [ROOM NUMBER] measured 480 square feet and had five (5) beds inside the room. This deficient practice had the potential to result in inadequate usable living space for the residents and working space for the healthcare staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. - unit of measurement) per resident in multiple resident bedrooms for the nine out of 65 resident rooms (Rooms 5, 7, 9, 11, 19, 22, 23, 24, 29). room [ROOM NUMBER] had five beds inside the room. room [ROOM NUMBER] had 4 beds inside the room. room [ROOM NUMBER], 7, 9, 11, 22, 23, 24 had 3 beds inside the room. This deficient practice had the potential to result in inadequate useable living space for all the residents and working space for the health caregivers.