Sundance Creek Post Acute

Inspectors wroteBased on interview and record review, the facility failed to complete an assessment, care planned a resident-to-resident intimate relationship for two of two residents reviewed (Residents 1 and 2). This failure had the potential to result in unmet psychosocial needs, inadequate monitoring of the relationship, and failure to identify risks requiring interventions to protect resident health, safety, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative of a change in condition (COC) when one of three sampled residents (Resident 1) experienced deterioration of two lower extremity wounds. This failure resulted in the responsible party being unaware of Resident 1's change in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective intervention to prevent resident-to-resident physical altercation for two of three sampled residents (Resident 2 and 3). This failure resulted in Resident 2 sustaining minor injuries from the physical altercation with Resident 3, and putting both residents (Res 2 and 3) and other residents at risk for further [NAME] January 20, 2026, at 8:45 a.m., an unannounced visit was conducted at the facility to investigate an allegation of physical abuse. On January 20, 2026, 9:12 a.m., an interview was conducted with the Director of Nursing (DON). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment for safe self-administration of medication was conducted for two of three residents reviewed for choices (Residents 2 and 146). These failures had the potential for Residents 2 and 146 to self-administer the medications unsafely and without licensed nurse monitoring.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from abuse for one of three residents reviewed for abuse (Resident 127) when the staff member directed inappropriate and derogatory language toward the resident. This failure had the potential to cause psychological harm or emotional harm to Resident 127.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) to the resident or resident representative at the time of transfer to an acute care hospital for one of three residents reviewed for closed records (Resident 1). This failure had the potential for residents and/or their RPs not to be fully informed of their right to request a bed hold or to return to the facility after hospitalization, which could result in an inappropriate discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure incontinence care was provided in a timely manner, consistent with the resident's care needs, for one of one resident reviewed for dignity (Resident 116). This failure had the potential for Resident 116, to be prone to develop urinary tract infection, or increased risk for impaired skin integrity and to prevent her highest psychosocial wellbeing. On September 23, 2025, at 10:30 a.m., during a concurrent observation and interview with Resident 116, Resident 116 was in bed, alert, and interviewable. Resident 116 stated she used her call light during the night shift to request assistance for a brief change. Resident 116 stated, a staff member came in, turned off her call light, and did not return. Resident 116 stated, she again activated her call light, but no staff responded. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician-ordered nutritional interventions were implemented for two of three residents reviewed for nutrition (Residents 63 and 64) when:1. Resident 63 did not receive an ordered extra egg at breakfast; and2. Resident 64 did not receive Boost GC (Boost Glucose Control- blend of protein, carbohydrates and fat to help manage blood sugar levels as part of a balanced diet) as prescribed during medication administration. These failures had the potential to compromise the residents' nutritional status and delay healing in a resident population with identified nutritional risks.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the necessary care and services to maintain a peripheral intravenous (PIV - the administration of fluids, medications directly into a vein) for one of three residents reviewed for parenteral/IV fluids (Resident 95) when: 1. A physician's order was not in place for the PIV.2. PIV site was not documented as assessed and the dressing was not changed per facility policy; and3. A care plan was not initiated to address care and monitoring of the PIVThese failures had the potential to place Residents 95 at risk for infection and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dialysis (a treatment which performs the work of the kidneys when they could no longer function properly) pressure dressing was removed two hours after arrival from dialysis as ordered, for one out of two residents reviewed for dialysis (Resident 148). This failure had the potential for infection and/or clotting to Resident 148's dialysis access site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one oral relief sore throat spray stored in a medication cart was properly labeled. This failure had the potential for the residents to receive unnecessary medications or for medication error to occur.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's food preference was honored for one of three residents reviewed for nutrition (Resident 120). This failure had the potential to result in the resident refusing meals and experiencing decreased nutritional intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician-ordered fortified diet (high calorie, high protein diet) were provided as prescribed for two of eight residents reviewed for nutrition (Residents 98 and 125). This failure had the potential to reduce calorie and protein intake, decrease palatability of meals, and negatively affect nutritional status for these residents, in a facility with a population of 140.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure required personal protective equipment (PPE - specialized clothing or equipment worn by staff to protect themselves and others from exposure to infectious agents) was readily available on the PPE cart for one of one resident reviewed for infection control (Resident 8). This failure increased the risk of transmission of infection to residents and staff.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to make reasonable accommodations to meet the needs and preferences of two residents (Residents A and B) who required Hoyer lift (a mechanical device used to transfer residents who cannot bear weight) for transfers. This failure resulted in delays, missed activities, and disruption of established daily routines for two of three sampled residents (Residents A and B).

Inspectors wroteBased on interview and record review, the facility failed to assess and monitor one of four sampled residents (Resident 1) for signs and symptoms of circulatory insufficiency (decrease blood flow) in the right lower leg after testing positive for deep vein thrombosis (DVT - a blood clot). This failure had the potential to result in staff being unable to detect worsening circulatory insufficiency.

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident's medical records were accurate and complete in accordance with the accepted professional standards and practices, for one of three sampled residents (Resident 1), when the nursing weekly summary and the skin evaluations did not reflect the skin changes from May 21, 2025, to May 31, 2025. These failures could negatively impact patient care and prevent staff or representatives from being aware of the potential changes in the resident's skin condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to report an allegation of physical abuse within two hours to the California Department of Public Health (CDPH), for one of three sampled residents (Resident 1). This failure had the potential to place Resident 1 at continued risk of abuse and negatively impact her emotional and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed for one of three sampled residents (Resident 1), to report Resident 1's total right shoulder prosthesis dislocation [the artificial component of a shoulder replacement entirely come out of their proper position], an injury of unknown source, within 2 hours to California Department of Public Health (CDPH) after the facility was made aware of the injury, for one of three sampled residents (Resident 1). This failure had potential to result in further injury for Resident 1, affecting the resident physical, emotional, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed for one of three sampled residents (Resident 1), to investigate how Resident 1's right shoulder prosthesis became dislocated [the artificial component of a shoulder replacement entirely come out of their proper position]. This failure had potential to result in further harm for Resident 1, affecting the resident physical, emotional, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed for one of three sampled residents (Resident 1) to: 1. Provide the resident and or resident representative a written copy of the transfer or discharge. This failure had the potential to deny the resident the opportunity to understand the reasons for the transfer and the right to appeal, and other pertinent information related to the discharge process; and 2. Ensure a copy of the transfer or discharge notice was sent to the representative of the Office of the State Long-Term Care Ombudsman (LTC Ombudsman - an advocate for residents of nursing homes to protect residents' rights and ensure quality care). This failure had the potential to delay advocacy and oversight of Resident 1's discharge plan, impacting continuity of care and resident rights.

Inspectors wroteBased on interview and record review, the facility failed to provide showers on scheduled shower days and bed baths on non-shower days, for one of three sampled residents (Resident A). This failure had the potential to negatively affect the resident ' s physical, emotional, and social well-being which included skin infections, body odor, and discomfort.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident A) was repositioned and turned every two hours. This failure had resulted in the development of Resident A's pressure ulcer (bed sore).

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of misappropriation of property (a type of financial abuse) to California Department of Public Health (CDPH) within 2 hours after the facility was made aware of the allegation, for one of three sampled residents (Resident 1). This failure had the potential to result in further financial abuse for Resident 1, affecting the resident 's emotional and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of three sampled residents (Resident 1) was monitored after an allegation of financial abuse. This failure had the potential to affect Resident 1 ' s emotional and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when staff was observed not performing hand hygiene upon entry and exit of two transmission-based precaution (TBP - an infection control measure use in healthcare to prevent the spread of infection and diseases) rooms. This failure had the potential to increase the spread of pathogens (germs) and infections by staff to facility residents.

Inspectors wroteBased on interview and record review the facility failed to ensure that the resident and/or the family member (FM) were notified of the grievance investigation findings and result after a complaint, for one of one sampled resident (Resident 1). This failure had the potential for Resident 1's FM to be unaware if the complaint was investigated and addressed, which could lead to ongoing dissatisfaction.

Inspectors wroteBased on interview and record review, the facility failed for one of three residents reviewed for discharges (Resident 1) to provide a complete written notice of transfer/discharge that included the discharge location. This failure had the potential for Resident 1 to experience stress, and confusion due to lack of information about their future living arrangements.

Inspectors wroteBased on interview, and record review the facility failed to ensure a follow-up ophthalmology consult was provided for one of three sampled residents (Resident 1). This failure increased the risk of the resident not receiving the necessary care to address their medical condition and had the potential to result in the progression of resident's altered visual functioning.

Inspectors wrote5. On August 21, 2024, Resident 23's admission RECORD, was reviewed. Resident 23 was admitted to the facility on [DATE], with diagnoses which included end-stage renal disease (ESRD - when the kidneys stop working) on hemodialysis (special procedure done by a trained professional to remove wastes and excess fluids from the body) and fracture (broken bone) on left fibula (long bone in the lower extremity) bone. A review of Resident 23's Order Summary Report, included a physician's order, dated May 6, 2024, indicated to give Tramadol HCL 1 tablet 50 mg by mouth every six hours as needed for moderate to severe pain. A review of Resident 23's Medication Count Sheet, for the month of August 2024, indicated eleven doses of Tramadol HCL 50 mg were signed out by the Licensed Nurse (LN) on the following dates and times: - August 2, 2024, at 9 p.m. - August 6, 2024, at (time illegible). [...]

Inspectors wroteBased on interview and record review the facility, which has more than 120 beds, failed to employ a full-time qualified social worker. This failure had the potential in residents not receiving the necessary treatment and health services provided by a qualified social worker. On August 23, 2024, at 4:30 p.m., the Administrator (ADM) was notified an extended survey would be conducted due to substandard quality of care issues.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) identified concern regarding narcotic (a controlled drug that can cause paralysis or loss of feeling) medication accountability and pain assessment before and after pain medication administration was monitored and evaluated. This failure had the potential for possible diversion of controlled medication and for residents to experience unrelieved and unmanaged pain which could compromise the resident's overall health and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' rights were promoted and respected for six of 11 residents (Residents 23,29, 59, 106, 112 and 126) when: 1. Residents 23, 29, 59, 106 and 126 complained that call lights (devices used by residents to signal a need for assistance from facility staff) were not answered promptly by staff. This failure had the potential for Residents 23, 29, 59, 106 and 126 to not receive timely care, which could lead to falls, injuries, and worsening of residents' condition. 2. Resident 112's lunch meal tray was not served at the same time as another resident's. This failure had the potential to decrease Resident 112's meal intake, which could lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment was conducted for three of eight residents (Resident 49, 101, and 113) reviewed for safe self-administration of medication when: 1. One pink medication pill was found on the overbed table. 2. One opened bottle of 15ml (milliliters - unit of measurement) eyedrops (medication that relieved eye irritation) was found on the overbed table. 3. One opened black bottle of 15,250 MG (milligram - unit of measurement) dietary supplement was found on the overbed table. This failure had the potential for Residents 49, 101, and 113 to receive multiple doses of medication without proper monitoring, which could lead to harmful effects or death.

Inspectors wroteBased on interview, and record review, the facility failed to ensure education and resources for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was provided for 15 of 25 residents (Residents 15, 60, 82, 57, 56, 53, 87, 104, 58, 49, 105, 107, 52, 113, and 101), and or the Resident Representative (RP). This failure had the potential for Residents 15, 60, 82, 57, 56, 53, 87, 104, 58, 49, 105, 107, 52, 113, 101 and the RP not to be educated and informed about AD and the facility unable to know and honor the residents wishes regarding their medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for 20 of 20 residents reviewed for pain (Resident 3, 16, 18, 19, 23, 26, 30, 34, 58, 65, 76, 80, 83, 88, 95, 98, 99, 120, 278, 280): a. A pain assessment was conducted prior to the administration of PRN narcotic pain medication; and b. An evaluation was conducted after the administration of PRN narcotic pain medication. These failures had the potential for Residents 18, 58, 65, 19, 278, 23, 26, 34, 83, 99, 120, 76, 88, 95, 16, 80, 280, 3, 30, and 98, to experience unrelieved and unmanaged pain which could compromise the resident's overall health and wellbeing. In addition, failing to document the residents' pain levels before and after administration of the pain medication could disrupt effective pain management and result in a lack of individualized care. Findings 1. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure Food and Nutrition Service employees were able to carry out their functions safely and effectively when: 1. Several Food and Nutrition Service employees were unable to properly clean used kitchen equipment; This failure had the potential to cause foodborne illness for 128 out of 129 sampled residents who received foods from the kitchen. 2. Two Diet Aide did not know the correct concentration of chlorine (sanitizer) for the dish machine. This failure had the potential to cause a strong chloride odor leading to cross-contamination of clean kitchenware for 128 out of 129 sampled residents who received foods from the kitchen. 3. [NAME] 1 did not follow the recipe for making pureed Bread Stuffing for lunch on 8/20/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy on MEAL SERVICE to provide appetizing food at appropriate temperatures according to residents' preferences for nine of 128 sampled residents (Resident 23, 26, 34, 35, 57, 62, 78, 97 and 426). This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutrition status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Mold, dust and hair were found in the walk-in refrigerator; 2. Calcium buildup was found on hot water spout; 3. Three wet plastic containers were stacked and stored with dried containers; 4. Dust was observed on several pieces of equipment in the kitchen; 5. Rust was found on several pieces of equipment in the kitchen; 6. Two pieces of equipments in the kitchen had chipped paint; and 7. An unsanitary microwave was found in the [NAME] pantry room These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 128 out of 129 residents who received food prepared in the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to provide a homelike environment for one of four residents reviewed for environment (Resident 107) when the resident complained of uncomfortable noise level during sleeping hours. This failure had the potential for Resident 107 to experience lack of sleep, discomfort, and irritability which could affect the resident's overall health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate smoking assessment was conducted for one of one resident reviewed for smoking (Resident 95), who smokes electronic cigarettes (battery powered device that heats liquids into an aerosol that users breathe in). This failure had the potential to result in Resident 95 sustaining an injury associated with the use of electronic cigarettes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one of two residents reviewed for respiratory care (Resident 52) when the physician's order for oxygen therapy was not implemented as ordered. This failure had the potential for Resident 52 to experience oxygen toxicity (harmful effects related to excessive oxygen in the lungs).

Inspectors wroteBased on interview and record review, the facility failed for two of three residents reviewed for dialysis (special procedure done by a trained professional to remove wastes and excess fluids from the body) (Residents 100 and 23) to ensure: 1. Resident 100 was assessed after dialysis; and 2. Resident 23's recommendation to discontinue fluid restriction (limited fluid consumption) was followed. In addition, Resident 23's Intake and Output (I&O) were monitored. These failures had the potential for Residents 100 and 23 to not be monitored which could lead to dialysis complications (e.g. heart failure, fluid overload, bleeding), harm and or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure behavior monitoring was conducted for the use of Olanzapine (used to treat schizophrenia - a condition that affects a person's ability to think, feel. and behave clearly), for one of five residents reviewed for unnecessary medication (Resident 278). This failure to identify and monitor specific behavior manifested had the potential to put Resident 278 at risk of receiving unnecessary medication, which could result in serious harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure discontinued medications were stored properly and not readily available for use when two vials/bottles of Lorazepam (used to treat anxiety [feeling of fear]) and Insulin Lispro Injection (a rapid-acting insulin used to lower blood sugar level) were observed in the medication room refrigerator. This failure had the potential to result in the accidental administration of discontinued medication to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the therapeutic diet order (diet ordered by a physician) and resident preferences were followed for one of 12 residents (Resident 23) when: 1. Resident 23's diet physician order was not implemented and/or provided to the resident. This failure had the potential for Resident 23 to not meet his nutritional needs and not honor his food preferences; and 2. The Registered Dietician's (RD) recommendation to fortify Resident 23's diet was referred to the physician and carried out. This failure had the potential for Resident 23 to have decreased calorie intake and compromise his nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Certified Nursing Assistant (CNA) 4 did not clean and disinfect (use of chemicals to reduce the number of bacteria or virus particles on surfaces) the Hoyer lift (mechanical device use for lifting) before and after resident use. 2. Registered Nurse (RN) 3 did not wear personal protective equipment (PPE - equipment use to protect against infection or illness) when taking care of a resident with Extended Spectrum Beta Lactamase (ESBL - a bacteria resistant to many antibiotics [medication use to treat infections]). These failures had the potential to increase the spread of pathogens (germs) and infections from staff to residents which could lead to illness or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility remained free of pests when house flies were found in the kitchen and East activity room. This failure had the potential to spread bacteria from flies, which could cause illness in a medically vulnerable population of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility policy and procedure for hand hygiene were followed for one of four sampled residents, (Resident 4), when the Treatment Nurse, (TN), did not perform hand hygiene after removing gloves, and before donning a new pair of gloves during wound care. This failure had the potential for contamination of Resident 4's wound.

Inspectors wroteBased on observation and interviews, the facility failed to provide a dedicated dietary manager (DM) to safely and effectively, carry out the functions of the food and nutritional services. This failure had the potential to result in a lack of oversight, leading to poor food safety practices including improper food storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were stored in accordance with the professional standards for food service safety when foods within the refrigerator were missing the use by dates or expiration dates. This failure had the potential that food may be consumed past its safe consumption, leading to foodborne illnesses due to spoilage or contamination.

Inspectors wroteBased on interview and record review, the facility failed to ascertain the current condition of one of three sampled residents (Resident 1), prior to refusing the resident's re-admission to the facility. The resident had been living at the facility for 11 years. This failure increased the potential for prolonged hospital stay and emotional distress to Resident 1 and his family.

Inspectors wroteBased on interview, and record review, the facility failed to ensure information related to facility bed hold (holding or reserving a resident's bed while the resident was absent from the facility during hospitalization or therapeutic leave) was provided to one (Resident 1) of three sampled resident's family member. This failure had resulted in the family member not given the opportunity to ensure a facility bed would remain available for Resident 1's return to receive services needed.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Provide accurate bookkeeping of Resident 1 ' s monthly Room & Board (R&B) charges. 2. Provide a Notice of private pay rate increase, prior to charging a (R&B) daily increase from $280/(per) day to $380/day, for Resident 1. These failures had the potential to result in confusion and overpayment for Resident 1 or Resident 1's representative.

Inspectors wroteBased interview & Record review the facility failed to consistently assess and monitor the changes of one of three sampled residents' (Resident 1) skin body rash. This failure has the potential to result in delayed provision of appropriate treatment which could cause worsening of the skin condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring was done and the physician was notified, for one of five residents reviewed, when Resident 1 was identified with a change of condition on October 25, 2023, at 8:25 a.m. This failure had the potential for Resident 1 to not be adequately monitored and assessed for worsening in his condition and potentially led to Resident 1's transfer to the General Acute Care Hospital (GACH) later in the day.

Inspectors wroteBased on interview and record review, the facility failed to accommodate preferences for certain staff to assist during shower and baths for one of four residents (Resident 1). The facility failure had the potential for the resident to refuse routine personal care which could result in unmet needs.

Inspectors wroteBased on interviews and record review the facility failed to obtain orders from the physician for blood work (labs) and an ultrasound (an x-ray using special medical imaging) for one of three Residents, (Resident 1). This failure had the potential for a delay in care for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall intervention for one of three sampled residents (Residents B), when the resident was left unattended in the doorway. This failure resulted in the resident to fall.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. The ice machine located in the East Wing was not cleaned and sanitized properly per manufacturer's guidance; 2. Several various size of metal pans was stacked and stored wet; 3. Dietary Aide (DA) 2 was not able to perform hand hygiene practices and glove use properly in between dirty and clean areas during the process of machine dishwashing; and 4. Facility had no system in place to review and monitor temperatures of the freezers in the pantries, for the resident's food refrigerators at the East and [NAME] Wings. These failures had the potential to cause food-borne illness in medically vulnerable resident population who consumed food in the facility. The facility census was 96.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care for five of 21 residents reviewed for quality of care (Residents 29, 47, 67 and 69) when: 1. For Resident 47, an assessment and monitoring was not completed when the resident developed skin discolorations to lower extremities; 2. For Resident 67, an assessment and monitoring was not completed when the resident developed skin discolorations to lower extremities; 3. For Resident 69, a reassessment was not conducted to right upper extremity. In addition, an assessment and monitoring was not completed when resident developed edema to the left upper extremity; and 4. For Resident 29, a doctor's appointment was not rescheduled when the appointment was missed on November 23, 2021. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one food service personnel was able to safely and effectively carry out the functions of the food and nutrition services when one Dietary Aide (DA 1) was unable to demonstrate and verbalized the process of manual dishwashing by using three-compartment sink. This failure had the potential to place 96 out of 96 highly susceptible residents who received food from the kitchen at risk for food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified when Resident 88 had an increase in respiratory rate above the baseline (15-20 breaths per minute). This failure had the potential for the resident not to receive the necessary care and treatment resulting in the decline of the resident's condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan on skin issue was reassessed and revised to address the left arm discoloration for one of 21 residents reviewed, (Resident 47). This failure had the potential to result in providing interventions that was ineffective for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meal time assistance was provided for one of three residents reviewed for Activities of Daily Living (ADL) (Resident 95). This failure has the potential to result in a decrease in resident's oral intake which could result in weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide room visits to meet the interests of and support the psychosocial well-being of one of four residents reviewed for activities (Resident 246). This failure had the potential for Resident 246 to not meet her highest physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure the post dialysis assessment was completed after receiving hemodialysis (process of removing waste from the blood with the use of a machine) treatment on November 5, 2021, for one of one resident reviewed for dialysis (Resident 16). This failure has the potential for the facility not to be aware of Resident 16's condition during and after dialysis treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the residents by not having a readily available vial of Lorazepam (medication used to treat anxiety) in the refrigerated eKIT (emergency medication kit) as indicated on the eKIT Content List, located in the medical storage room. This failure had the potential to result in medication not being available for emergency use.

Inspectors wroteBased on interview and record review, the facility's pharmacist failed to provide the monthly medication regimen review timely. This failure had the potential to allow continuation of unnecessary medication regimen for one of five residents reviewed for unnecessary medication (Resident 16). Resident 16 continued to receive daily, two laxative medications (to prevent development of hard to pass stool) and one antidiarrheal (to prevent development of diarrhea), which work to counter each other.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the residents by not labeling the open date sticker on the multi-dose injectable insulin pen (a device used to administer insulin) with the date it was initially opened. This failure had the potential for administering discontinued and below therapuetic concentration of medications to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' medical records were maintained in accordance with the professional standards and practices for two of 21 residents reviewed (Residents 47 and 69), when: 1. The licensed nurses did not document the presence of nephrostomy tube (a tube placed to kidney to drain urine) in the weekly progress notes for Resident 69; 2. Resident 47's skin discoloration on his left arm was not documented under skin observation and weekly progress note. These failures had the potential to result in inaccurate representation of the residents' condition and not reflecting the care and services provided to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices in preventing transmission of COVID-19 (corona virus-illness caused by a virus that can be transmitted from person to person) when: 1. Two visitors (Transport staff) were not screened for their vaccination status prior to entering the facility. 2. One unvaccinated staff was wearing surgical mask and not the N95 respirator (a mask used to filter particles), while working in the facility. These failures had the potential to result in the spread of COVID-19 infection to residents and staff.