Sunland Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Residents 4) was provided with information regarding the resident's Medi-Cal (the state's Medicaid program) share of cost (the amount of money a beneficiary must pay on medical expenses each month before Medi-Cal begins covering eligible services) in a timely manner. This deficient practice had the potential to result in negatively affect the resident's ability to make informed financial decisions.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (at type of abuse that uses language) for two of four sampled residents (Resident 1 and Resident 2), when on 5/4/2026, in the dining room, Resident 1 stated offensive language toward Resident 2 and Resident 2 responded by stating offensive language back to Resident 1. This deficient practice resulted in Resident 1 and Resident 2 being subjected to verbal abuse while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure that a Significant Change in Status Minimum Data Set (MDS- a resident assessment tool) assessment was completed for one of five residents (Resident 5) when the resident had a significant decline in two areas (skin condition and functional status) from baseline, as compared to the most recent comprehensive assessment, and did not return to baseline within two weeks. This deficient practice had the potential to negatively impact the provision of necessary care and services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation in the residents' clinical records for two of five sampled residents (Resident 4 and Resident 5), in accordance with accepted medical and professional standards and consistent with the care provided. This deficient practice had the potential to negatively affect the plan of care and the delivery of necessary care and services for these residents. a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received their mail unopened, in accordance with the facility's policy on Resident Rights. This deficient practice resulted in the violation of Resident 1's right to receive mail unopened.

Inspectors wroteBased on interview and record review the facility failed to implement the facility's discharge planning process policy by failing to document the resident's discharge needs and discharge plan for one of three sampled residents (Resident 2). This deficient practice had the potential to delay Resident 2's discharge to the community and placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) addressing a resident's discharge plan for one of three sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.

Inspectors wroteBased on interview and record review the facility failed to provide resident-centered care and services, for one of three sampled residents (Resident 1) by failing to ensure that a required 72-hour neurological assessment (neuro check - an evaluation of neurological [relating to the nerves or the nervous system, which includes the brain, spinal cord, and peripheral nerves that control body functions, movement, and sensation] status) was accurately completed following Resident 1's unwitnessed fall on 12/28/2025. This deficient practice had the potential to cause confusion in the care and services provided to Resident 1 and placed the resident at risk of not receiving appropriate care due to inaccurate or incomplete medical information. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that pain medication was administered in accordance with the physician's orders based on the documented pain scale for one of three sampled residents (Resident 1). This deficient practice had the potential to result in inadequate pain management for Resident 1. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/28/2020 with diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm), muscle weakness, and non-displaced fracture of medial malleolus of right tibia (a crack in the bony bump on the inner side of the right ankle, where the broken pieces remain properly aligned). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: Record the medication refrigerator temperatures containing vaccines twice a day from [DATE] to [DATE], in one (1) of three (3) inspected medication rooms (Medication Room Station 2.) 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain residents' privacy of confidential information when Licensed Vocational Nurse 3 (LVN 3) stepped away and left the computer on the medication cart in Station 3 unlocked and unattended. This deficient practice had the potential to violate the right to privacy of all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for three of five sampled residents (Residents 61, 17, and 76) when: 1. Resident 61's tray table was not kept clean and free of clutter during mealtime. This deficient practice had the potential to negatively impact Resident 61's quality of life, and placing Resident 61 at risk for not properly eating during mealtimes. 2. An alarm located near Resident 17 and Resident 76s' rooms activated each time a staff member exited and entered through the smoking patio gate. This deficient practice denied Residents 17 and 76 the right to a comfortable, homelike environment and had the potential to negatively impact their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) that meets the care/services based on the resident's individual assessed needs for three of 23 sampled residents (Resident 76, 81 and 85) by failing to: 1. Ensure safety and supervision during smoking were addressed in Resident 76's and 85's care plans. This deficient practice had the potential to place the residents at risk for smoking-related injuries. 2. Ensure Resident 81's prescribed Klonopin (an antianxiety medication) black box warning (the strongest safety alert for prescription drugs) was addressed in Resident 81's care plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment that is free from accident hazards to four of eight sampled residents (Resident 12, 61, 76 and 85) by failing to: 1. Ensure Resident 12's fall risk assessment was accurate to reflect Resident 12's risk of falling. 2. Ensure disinfectant wipes container was not left open, unattended and within reach at the top of Resident 61's tray table. 3. Ensure Resident 76 and 85 did not possess a lighter and cigarette as indicated in the facility policy titled, Smoking Policy. 4. Ensure Resident 76 and 85's The Safe Smoking Evaluation specify whether both residents were independent smokers or supervised smokers, as indicated in the facility policy titled, Smoking Policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 25 total opportunities contributed to an overall medication error rate of 12% affecting three (3) of five (5) residents observed for medication administration (Resident 37, 70, and 101.) The medication errors were as follows: Resident 37 received aspirin (a medication used for cerebrovascular accidents ([CVA] - an interruption in the flow of blood to cells in the brain] by thinning the blood,) prophylaxis ([PPX] - action taken to prevent disease,) at a different time than ordered by Resident 37's physician. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the prescribing provider obtained informed consent from a resident's responsible party for the use of a physical restraint (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 i.e. [wander guard], a bracelet that a resident wears that alarms when he attempts to exit the facility) for one of one of one resident investigated for the use of restraints. This deficient practice had the potential for the responsible party to not be informed regarding decisions that may affect Resident 47's health conditions.

Inspectors wroteBased on interview and record review the facility failed to implement the facility's policy and procedure titled Advance Directives, for two of three residents (Resident 3 and Resident 2) reviewed under the Advance Directive Care area by failing to:1. Maintain a copy of Resident 3's Advance Directive in the resident's medical record. 2. Ensure that Resident 1 was provided written information concerning the resident's right to prepare an Advance Directive. These deficient practices had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment and had the potential to cause conflict with Resident 3 and 2's wishes regarding their medical care.

Inspectors wroteBased on observation, interview, and record review the facility failed to inform a resident's responsible party (one who makes medical decisions for a resident who is unable to make their own decisions), that the resident was place on one-to-one monitoring (when one staff stays with a resident at all times to ensure the safety of the resident), for one (Resident 47) of seven residents reviewed under the care area of accidents. This deficient practice had the potential to violate Resident 47's representative's right to be informed of the treatment and services provided to Resident 47.

Inspectors wroteBased on interview and record review, the facility failed to provide in writing the completed Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, a notification to the resident or responsible party [RP] of the potential liability charges for services not covered when the resident was discharged from Medicare Part A services [Medicare that helps pay inpatient care in a hospital, critical access hospital or a skilled nursing facility] with benefit days remaining) for one (Resident 43) of three sampled residents reviewed during the Beneficiary Notification task. This deficient practice had the potential to result in Resident 43 or their representative not being able to exercise their rights to be informed in advance of financial responsibilities, request an expedited review upon appeal, or determine in advance the course of their care.

Inspectors wroteBased on interview and record review the facility failed to follow its policy and procedure (P&P) on physical restraint to ensure residents were free from any 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) by failing to ensure there was documentation supporting the use of the wander guard (a bracelet that a resident wears that alarms when he attempts to exit the facility) for one of one of one resident investigated for the use of restraints. This deficient practice had the potential to result in psychological harm for Resident 47.

Inspectors wroteBased on interview and record review, the facility failed to Involve the resident`s representative or responsible party (RP) during the Interdisciplinary (IDT- a collaborative approach where healthcare professionals from various disciplines work together to provide comprehensive patient care) Care Plan (a structured document that outlines a patient's healthcare needs, goals, and the nursing interventions required to achieve those goals) meeting (quarterly and annually) for one of seven residents (Resident 47) reviewed under the accidents care area. This deficient practice had the potential to result in Resident 47 receiving inadequate care and supervision at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure residents receive care in accordance with professional standards of practice by failing to rotate insulin injection sites to one of two residents (Resident 6) reviewed under the insulin care area. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs) to Resident 6.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate care and services to maintain acceptable parameters of nutritional status for one of four sampled residents (Resident 9) reviewed under the nutrition care area by failing to notify the kitchen staff of the new physician's order for a large portion breakfast for Resident 9. This deficient practice had the potential to place Resident 9 at risk for weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary respiratory care consistent with professional standards of practice for one of one resident (Resident 91) reviewed under respiratory care area by failing to ensure Resident 91 received oxygen as ordered by the physician. This deficient practice had the potential to cause Resident 91 shortness of breath that could lead to hypoxemia (a low level of oxygen in the blood.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure the concentration of the quaternary ammonium sanitizing solution (common, effective chemical used in disinfectants for hard surfaces, killing germs like bacteria or viruses) used to clean kitchen surfaces was maintained at 200 parts per million (ppm- a unit used to express the concentration of a substance in a solution or mixture) to ensure effectiveness of the solution. This failure had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) in food preparation surfaces that could lead to foodborne illnesses (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for 102 of 108 medically compromised residents who receive food and ice from the kitchen. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the pneumococcal vaccine (prevents infection from pneumonia [infection that infects one of both lungs]) was offered to one of seven sampled residents (Resident 58) per the facility's policy. This deficient practice placed Resident 58 at a higher risk of acquiring and transmitting pneumonia to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Coronavirus Disease (COVID-19, a severe respiratory illness caused by virus and transmitted from person to person) vaccination was administered after a resident's representative gave consent (agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) to be vaccinated for one of seven sampled residents (Resident 14). This deficient practice placed Resident 14 at a higher risk of acquiring (to get) and transmitting (pass on) the COVID-19 virus to other residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) was involved in determining and assessing whether the self-administration of medications was clinically appropriate for one of five sampled residents (Resident 4) who was not assessed for self-administration of the medications stored at the resident's bedside. This deficient practice had the potential to result in Resident 4 unsafely administering medications and unsafely accessing medications stored at bedside.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) for one of five sampled residents (Resident 5) addressing Resident 5's behavior of spitting. This deficient practice had the potential to result in failure to deliver the necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and Individual Count Sheet Record (accountability record of medications that are considered to have a strong potential for abuse) coincided per facility policy for one of three sampled residents (Resident 6). This deficient practice had the potential for medication errors and drug diversion (illegal distribution or abuse of prescription drug).

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for one of three sampled residents (Resident 6) by failing to ensure a discontinued bottle of lorazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) was kept safe, secured, and accounted for. This deficient practice resulted in Resident 6's bottle of lorazepam to go unaccounted and had the potential to result in undetected diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 7) with meals that accommodated their food preferences and failed to implement their food preference policy by failing to update food preferences during the quarterly review. This deficient practice resulted in Resident 7's food preferences not being honored and had the potential to result in decreased meal intake which could lead to weight loss and malnutrition (lack of sufficient nutrients in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure clear storage cups of gelatin were dated and labeled according to the facility's policy. This deficient practice had the potential to place 109 out of 116 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 3) had a functioning call light (a device used by a resident to signal his/her need for assistance from staff). This deficient practice had the potential to result in a delay in meeting the residents' needs for assistance which could have left the resident feeling isolated and at an increased risk for falls or accidents.

Inspectors wroteBased on interview and record review, the facility failed to permit one of three sampled residents (Resident 1) to return to the facility after Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) for psychiatric (the branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) evaluation. This deficient practice subjected Resident 1 to an unnecessary prolonged hospitalization, violated Resident 1's rights to return to their facility, and has the potential to result in Resident 1's displacement in an unfamiliar facility requiring adjusting to new surroundings. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's responsible party with a notice for bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) prior to transferring to General Acute Care Hospital 1 (GACH 1) for one of three sampled residents (Resident 1). This deficient practice had the potential to deprive the resident and/or the resident's responsible party the right to be informed of their rights regarding bed holds. [...]

Inspectors wroteBased on 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 six sampled residents (Resident 1) when on 4/19/2025, Resident 2 hit Resident 1 ' s face several times with a fist (a person ' s hand when the fingers are bent in toward the palm and held there tightly). This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident ' s physician regarding an increase in episodes of yelling after discontinuing Seroquel (antipsychotic, a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) for one of six sampled residents (Resident 1). This deficient practice had the potential to result in worsening symptoms and negatively affect the delivery of care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) within two (2) hours of the incident for one of six sampled residents (Resident 1). This deficient practice resulted in a delay in an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse.

Inspectors wroteBased on interview and record review, the facility failed to monitor and provide ongoing assessment of a resident ' s behavioral health needs, as to whether the interventions are improving and stabilizing the resident ' s status or causing adverse consequences after discontinuing Seroquel (antipsychotic, a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) for one of six sampled residents (Resident 1). This deficient practice had the potential to negatively affect Resident 1 ' s psychosocial (the mental, emotional, social, and spiritual aspects of a person ' s life) well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) by failing to ensure Resident 1's physician order for trazadone (medication used to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest]) PRN (as needed) had a duration. This deficient practice had the potential to result in the use of unnecessary medication and adverse reaction (undesired harmful effect resulting from a medication or other intervention) or impairment in the resident's mental or physical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable environment by failing to: 1. Ensure that the facility ' s roof was free from cracks, holes and other damage that allowed water from rain to penetrate through and drip into the space between the roof and ceiling, and the ceiling structure inside the building did not become damaged from rainwater leaking in through holes, cracks, and other damage to the roof affecting five residents (Resident 2, 3, 4, 7, and 8), staff, and visitors. 2. Maintain the ceiling structure in the resident ' s rooms (the shared room for Resident 5 and 6) and the kitchen free from cracks and holes. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan (a document that summarizes a resident's needs, goals, and care/treatment) to indicate resident-centered interventions for the use of a mechanical lift machine (a device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) for one of eight sampled residents (Resident 1). This deficient practice had the potential to affect the provision of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provided two-person physical assistance when using a mechanical lift machine (a device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) to transfer the resident from the bed to wheelchair for one of eight sampled residents (Resident 1). This deficient practice had a potential for the resident to experience discomfort during transfer by a mechanical lift and may lead to accident such as a fall and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of three sampled residents (Resident 2). This deficient practice had the potential to delay the provision of care and services for the resident and their needs not being met.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an allegation of resident abuse (when staff intentionally prevents a resident from having contact with friends, family, or others) by facility staff was reported to the State Survey Agency (SSA) immediately, but no later than two hours after the allegation was made for one of three sampled residents. This deficient practice had the potential to result in a delay in the abuse allegation investigation.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control practices by failing to ensure a resident's urinal bottle (also known as urine bottle, a container used to collect urine) was labeled with the resident name and room number for one of six sampled residents (Resident 6). This deficient practice had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents.

Inspectors wroteBased on interview and record review the facility failed to protect the right of one of nine sampled residents (Resident 2) by failing to ensure Resident 2 and or Resident 2's Responsible Party (RP) were informed of Resident 2's laboratory result drawn on 8/7/2024. This deficient practice violated the Resident 2's right to be informed of his health status including his medical condition, care and treatment received while in the facility.

Inspectors wroteBased on interview and record review the facility failed to obtain a physician order for Thyroid Stimulating Hormone (TSH- a laboratory test that measures the amount of TSH in the blood to convey how well a person's thyroid gland [a butterfly-shaped organ in the neck that produces hormones that regulate metabolism, growth, and other bodily functions] functions) to be done on 8/7/2024 for one of nine sampled residents (Resident 2). This deficient practice resulted had the potential to cause injury or harm to Resident 2 due to laboratory test being drawn on 8/7/2024 without a physician order.

Inspectors wroteBased on interview, and record review, facility staff (Registered Nurse 3 [RN 3]) failed to monitor and provide peripheral (away from the center of the body) intravenous (IV- into a vein) line care to one of one sampled resident (Resident 65) on 10/6/2024, when Resident 65 complained of pain to the IV site on the left forearm. This deficient practice resulted in RN 3 continuing to use Resident 65's IV site on the left forearm on 10/6/2024 to administer IV medication further causing Resident 65 to experience untreated pain to the IV site.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) was set correctly for one of one sampled resident (Resident 41). This deficient practice had the potential to increase the resident's risk of skin breakdown. 2. Ensure a resident's deep tissue injury (DTI, a form of pressure ulcer usually presenting with intact skin that is red or purple in color) pressure ulcer on the left and right heels were measured for approximately six weeks for one of two sampled residents (Resident 93). This deficient practice had the potential to not know if Resident 93's DTI was healing or not.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 63) was assessed for pain per shift as ordered by the physician. This deficient practice had the potential for Resident 63 to experience undetected pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 13) received their trazadone (medication used to treat major depressive disorder [mood disorder that causes a persistent feeling of sadness and loss of interest]) as ordered by the physician. This had the potential for Resident 13 to not receive adequate sleep and to suffer depression.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses monitored for side effects while a resident received apixaban (an anticoagulant- medications that prevent and treat blood clots [gel-like clumps of blood] in the heart and blood vessels) for one of three sampled residents (Resident 101). This deficient practice had the potential to result in Resident 101 experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the anticoagulant including bleeding from the gums or nose, having blood in the stool, and unusual bruising.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses monitored for changes in behavior and side effects while a resident received Seroquel (antipsychotic, a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]), for one of five sampled residents (Resident 101). This deficient practice had the potential to lead to Resident 101 to have unnoticed changes in behavior and experience adverse side effects (undesired harmful effect resulting from a medication or other intervention) including tardive dyskinesia (a movement disorder which causes involuntary and repetitive movements, including those of the face, mouth, tongue, arms, or legs) and cognitive impairment (decreased mental status [ability to understand and make decisions]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure five of seven sampled residents (Resident 37, Resident 43, Resident 63, Resident 65, and Resident 81) were placed on enhance barrier precautions (EBP-a method of using personal protective equipment [PPE - equipment designed to protect the wearer from injury or the spread of illness or infection such as gloves and gowns] to reduce the spread of pathogens between residents in skilled nursing facilities). This deficient practice had the potential to increase the risk of spreading infection to other residents. 2. Ensure an employee was wearing a hairnet while in the kitchen and handling food and two employees were not wearing dangly jewelry and watches while cooking and handling food. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a facility staff member provided privacy while doing a blood sugar level check (procedure to check the amount of sugar in the blood) and administered medications for one of three residents (Resident 99). This deficient practice violated the resident's right to privacy which had the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents' rooms (Resident 45) was within a comfortable temperature range of 71 degrees Fahrenheit (F, unit of temperature) to 81 F. This deficient practice placed Resident 45 at risk for being in an uncomfortable environment due to the temperature being less than 71 F.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of one sampled resident's (Resident 65's) representative (RR 1) was invited and participated in Interdisciplinary Team (IDT - a group of professionals with different areas of expertise who work together to achieve a common goal for the resident) care plan meetings (a written document that summarizes a resident's needs, goals, and care/treatment). This deficient practice denied Resident 65 and RR 1's involvement in planning interventions related to the resident's recent weight loss. 2. Ensure the hospice (program that provides care and support for people who are nearing the end of their life and have stopped treatment to cure or control their disease) care provider was invited and included in the development of one of one resident's (Resident 24) care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for one of two sampled resident (Resident 203) by failing to follow the facility's policy and procedure when performing a fingerstick (a procedure in which a finger is pricked with a lancet [a small needle] to draw a tiny drop of blood for testing) to check Resident 203's blood sugar level. This deficient practice had the potential for Resident 203 to have an inaccurate blood sugar test result and not receive the correct amount of insulin glargine (an injection that treats diabetes mellitus [DM - a disorder characterized by difficulty in blood sugar control and poor wound healing]) ordered by the physician, and possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who required assistance with nail trimming was provided care and services to maintain good personal hygiene for one of one sampled resident (Resident 24). This deficient practice had the potential to result in a negative impact on the resident's self- esteem due to an unkempt appearance.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of one sampled resident (Resident 65) by not clarifying the rate of two intravenous (IV - medication that is given into a vein) medications. This deficient practice had the potential for Resident 65 to receive a medication error and harm to the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure that a 24-inch television was bolted or anchored on the television stand for one of three residents (Resident 8). This deficient practice had the potential for the television to fall over and cause injury to the resident. 2. Ensure a resident's medication was not left unattended at the bedside for one of three sampled residents (Resident 83). This deficient practice had the potential for other residents to enter the room and take another resident's medication and could experience adverse side effects (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain the weight of one of one sampled resident (Resident 65) according to the facility's policy and procedure (P&P). This deficient practice had the potential for a delay in care and services and undetected weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care services consistent with professional standards of practice by failing to ensure that a resident received continuous oxygen per the physician's order for one of two sampled residents (Resident 203). This deficient practice had the potential to result in complications from receiving more oxygen than required and can negatively impact Resident 203's well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from significant medication error by failing to administer an intravenous (IV - medication through a vein) medication at a rate (how much and how fast) prescribed by the physician to one of one sampled resident (Resident 65). This deficient practice had the potential to cause an adverse reaction (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a multi-dose vial (contain more than one dose of medication) of Aplisol (used in a skin test to help diagnose tuberculosis [TB, a contagious bacterial infection that can affect the lungs and other parts of the body)] infection) found in one of three medication rooms (Medication Room A), was labeled with an open date. This deficient practice had the potential for the multi-dose of Aplisol to become expired and loss its potency and had the potential for it to be administered to multiple residents and lead to an inaccurate test result.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the facility's kitchen by failing to: 1. Ensure a scooper was not left inside of a large container of cornstarch. 2. Ensure an unpackaged container of lentils was not left open to air. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) for 104 of 109 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate records in accordance with accepted professional standards for two of three sampled residents (Resident 1 and Resident 3) by failing to maintain accurate information regarding shower/bed bath in the Certified Nursing Assistant Flowsheet (CNA Flowsheet- a chart used to keep track of information about resident's daily care). This deficient practice had the potential to result in the confusion of delivery of care and services to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an informed consent (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) was obtained from a resident and/or the resident's responsible party (person, usually a family member who makes medical decisions for a resident) for one of three sampled residents (Resident 3) regarding the use of a psychotropic medication (medication capable of affecting the mind, emotions, and behavior). This deficient practice had the potential for the resident and/or the resident's responsible party to not be informed on medication therapy decisions that may affect a resident's health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach for one of three sampled residents (Resident 1). This deficient practice had the potential to delay the provision of services and the resident's needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services for one of three sampled residents (Resident 3) by failing to: 1. Ensure the facility provided transportation for the ophthalmology (branch of medicine concerned with the diagnosis and treatment of disorders of the eye) appointments for Resident 3 on 9/18/2024. 2. Ensure Licensed Vocational Nurse 1 (LVN 1) documented Resident 3's missed ophthalmology appointments. 3. Ensure Resident 3's physician was notified that Resident 3's transportation did not occur per facility's policy. These deficient practices resulted in a delay in care and services and had the potential to place the resident at risk for further progression of vision impairment.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation staff to resident physical abuse (deliberately aggressive or violent behavior by one person toward another that results in bodily injury) towards one of 11 sampled residents (Resident 2) made on 7/22/2024 by Resident 1. This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift was posted daily as indicated in the facility's policy and procedure (P&P) on Posting Direct Care Daily Staffing Numbers. This deficient practice resulted in the residents and visitors being unaware of the total number of staff and the actual hours worked by the staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan (a document a designed to facilitate communication among members of the care team that the summarizes a resident's health conditions, specific care needs, and current treatments) and implement care plan interventions for two of seven sampled residents (Resident 2 and 3) by failing to: 1. Ensure a comprehensive person-centered care plan to accommodate Resident 3's food preference was developed and implemented. 2. Ensure a comprehensive person-centered care plan to address Registered Dietician 1 (RD 1) nutritional care planning recommendation to promote Resident 2's wound healing was developed and implemented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate a resident's food preference of no milk or dairy products with meals for one of two sampled residents (Resident 3). This deficient practice had the potential to result in decreased meal intake which can then lead to weight loss.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that are complete and accurately documented for one of seven sampled residents (Resident 1). This deficient practice resulted in incomplete and inaccurate resident medical care information for Resident 1 and had the potential to result in confusion with the care and services for Resident 1 which could place the resident at risk for not receiving appropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure Licensed Vocational Nurse 1 (LVN) 1 performed hand hygiene (washing of hands with water and soap or applying an alcohol-based hand rubs) for three of five sampled residents (Resident 2, Resident 3, Resident 4) on 5/30/2024 during wound care treatment. This deficient practice had the potential to spread the infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of five sampled residents (Resident 1) by failing to ensure licensed nurse signed the Treatment Administration Record (TAR - a report detailing wound care treatment provided to the resident by a healthcare professional) for Resident 1 on 5/30/2024. This deficient practice had the potential to result in confusion regarding Resident 1 ' s condition and what care and services were provided to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1 having long and untrimmed fingernails that had the potential to result in a negative impact on the Resident 1's self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who has severe impaired cognition (ability to think and make decisions), with a wander-guard (a device designed to activate alarms when a resident gets closer to entries and exit points) in place as ordered by the physician was kept free from accidents and hazards by failing to monitor and provide supervision to Resident 1. This deficient practice resulted in Resident 1 leaving the facility on 2/8/2024 at 2:35 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement comprehensive person-centered care plans (a document designed to facilitate communication among members of the care team that summarizes a resident ' s health conditions, specific care needs, and current treatments) for five of six sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 6), who were identified as a risk for elopement (an act or instance of a patient or person in care leaving a hospital, care facility, or safe area independently without notifying anyone). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1, Resident 2, Resident 3, Resident 4, and Resident 6.

Inspectors wroteBased on 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) by Resident 2 for one of five sampled residents (Resident 1); when on 12/21/2023 Resident 2 pulled Resident 1 out of bed causing Resident 1 to fall to the floor. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 2 pulled Resident 1 out of his bed causing Resident 1 to fall onto the floor, to cry, scream, and shake. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the right of three of seven sampled residents (Resident 1, Resident 2, and Resident 3) were respected by not allowing Residents 1, 2, 3 to attend and participate in their care plan meetings. This deficient practice resulted in the residents and their representatives not having ongoing participation in their care planning process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information of licensed and unlicensed nursing staff at the beginning of each shift was posted and updated daily. This deficient practice resulted in the residents and visitors not having accurate and current nurse staffing information of the total number of staff and the actual hours worked by the staff each shift.

Inspectors wroteBased on interview and record review, the facility failed to ensure notification of the attending physician when there was a change in the residents ' skin condition for two of seven sampled residents (Resident 2 and Resident 3). This deficient practice resulted in delay of medical care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician completed for three of seven sampled residents (Resident 1, Resident 2, and Resident 4) their History and Physical (H&P) examination timely and ensure all the conditions of the residents were identified and treated as needed. This deficient practice had the potential for not meeting the residents ' care needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure foods are distributed in a safe manner by using an open mobile meal cart and left the resident ' s meal tray unattended in hallway for one of three sampled residents (Resident 7). This deficient practice placed the resident at risk for foodborne illnesses (caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of four sampled residents (Resident 1), who was identified with episodes of refusing Activities of Daily Living (ADL - activities related to personal care such as bed mobility, transfers or getting in and out of bed or a chair, dressing, using the toilet, personal hygiene, bathing or showering) care. This deficient practice had the potential to result in a delay in or lack of delivery of care and services. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 106) maintained acceptable parameters of nutritional status (desirable body weight) and did not experience unplanned severe weight loss (a body weight loss of greater than five [5] percent [%-unit of measure] of weight in one months' time) by: 1. Failing to ensure Resident 106 received their gastrostomy tube (G-tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) feedings at the rate of 70 milliliters (ml-unit of measure) per hour (hr- unit of time) as ordered by the physician, the g-tube feeding rate was observed set at 60 ml per hour on 10/17/2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights (the primary method of patient-nurse communication in a healthcare setting) were within residents' reach for three of three sampled residents (Residents 270, 34, and 29) investigated for accommodation of needs. This deficient practice had the potential to cause a delay in resident care and for the residents' needs to remain unmet.

Inspectors wrote1.d. A review of Resident 48's Face Sheet indicated the facility admitted the resident on 1/24/2020 and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure). A review of Resident 48's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/8/2023, indicated the resident had intact cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 48 required one-person total limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs) with transfer, dressing, and personal hygiene. [...]

Inspectors wrote2.a. A review of Resident 58's Face Sheet indicated that the facility admitted the resident on 7/21/2023, with diagnoses that included heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), hypertension (high blood pressure), and atrial fibrillation (an irregular and often very rapid heart rhythm). A review of Resident 58's MDS dated [DATE], indicated that Resident 58's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making was intact. The MDS also indicated the resident required extensive assistance on staff for bed mobility, dressing, toilet use, personal hygiene, and bathing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's environment remained free of accident hazards and residents received adequate supervision for two of seven sampled residents (Resident 27 and 41) investigated under the Accidents Care Area by failing to: 1. Ensure Resident 27, who is at high risk for falls, was not left unattended by staff with the bed in the raised position. This deficient practice had the potential to result in Resident 27 sustaining an injury from a fall. 2. Provide monitoring for a high risk for elopement (when a patient or resident who is incapable of adequately protecting themself, and who departs the health care facility unsupervised and undetected) resident's whereabouts as ordered by the physician for Resident 41. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sample residents (Resident 100) who was admitted to the facility with an indwelling urinary catheter (tube inserted into the bladder to drain urine) received appropriate care and services, by failing to assess and monitor Resident 100's indwelling urinary catheter for the month of 9/2023. This deficient practice had the potential for Resident 100 to have a delay in identifying and treating a possible urinary tract infection (UTI- an infection in any part of the urinary system).

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) for three of five sampled residents (Resident 14, 46, 103). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). 2. Ensure to hold the administration of Lantus (long-acting insulin [hormone that lowers the level of sugar in the blood]) when a resident's blood sugar was below 100 milligram per deciliter (mg/dl- a unit of measurement) as specified in the physician's order for one of one sampled resident (Resident 7). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) was acted upon for three of five sampled residents (Resident 4, 267, and 7) investigated under the care area of unnecessary medications by failing to: 1. Notify the physician of the pharmacist's recommendation to re-evaluate a resident's rivaroxaban (anticoagulant - helps to prevent blood clots) and escitalopram (used to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest] and generalized anxiety disorder [intense, excessive, and persistent worry and fear about everyday situations]) for Resident 4. This deficient practice had the potential to place Resident 4 at increased risk of bleeding and unwanted side effects of the medication. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that three of nine sampled residents (Resident 39, Resident 51 and Resident 58) were free from significant medication errors (when a medication is administered to a resident not as prescribed and has the potential to jeopardize the health and safety of the resident) by: 1. Failing to ensure Licensed Vocational Nurse 6 (LVN 6) checked Resident 51's heart rate (HR- the number of times the heart beats per minute [bpm], normal range is 60-100 bpm) prior to administering carvedilol (a medication to treat high blood pressure [when the force of the blood pushing on the blood vessel walls is too high]) with a physician's ordered parameter (a set of defined, measurable limits) to hold (do not give) the medication if the HR is less than 55 bpm. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship program by failing to conduct infection surveillance and complete the infection control reporting form once signs and symptoms of infection were identified and antibiotics were initiated for three of five sampled residents (Residents 66, 105, and 106). This deficient practice had the potential for Residents 66, 105, and 106 to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections.

Inspectors wroteBased on interview and record review the facility failed to educate about risks and benefits of and offer the pneumococcal (PNA, pneumococcal disease is an infection caused by a type of bacteria called streptococcus pneumoniae) vaccination for four of five sampled residents (Resident 34, 99, 100, and 317). These deficient practices had the potential to result in increased risk for residents developing complications from pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were not standing over residents while assisting with feeding for two of two sampled residents (Resident 106 and 49) investigated for dignity. This deficient practice had the potential to negatively affect the resident's sense of self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to obtain a consent and inform the resident in advance of the risks and benefits of the psychotropic (medications capable of affecting the mind, emotions, and behavior) medication clozapine (medication that treats schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly] for one of five sampled residents (Resident 69). This deficient practice resulted in Resident 69 not being informed regarding the use of a psychotropic medication.

Inspectors wroteBased on interview and record review, the licensed nursing staff failed to meet professional standards of quality of care by failing to ensure a resident had an order for surgical wound dressing changes upon admission for one of three sampled residents (Resident 317). This deficient practice had delayed service and treatment of Resident 317's surgical wound and placed Resident 317 at risk for developing infection of the wound.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 317) with a peripherally inserted central catheter line (PICC line-a long flexible catheter [thin tube] that is put into a vein) was provided with a PICC line dressing as ordered by the physician on 10/14/2023. This deficient practice had the potential to place Resident 317 at risk for complications and infection from a central line-associated blood stream infection (CLABSI-a serious infection that occurs when germs enter the bloodstream through the central line).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure licensed nurses monitored a specific behavior for a resident on olanzapine (medication used to treat mental disorders including schizophrenia [severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others] and bipolar disorder [mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks]) for one out of five sample residents (Resident 87) investigated for unnecessary medications. This deficient practice had the potential to result in adverse reaction or impairment in the resident's mental or physical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety for 107 of 117 residents who are served food from the kitchen by failing to ensure a container of mixed vegetables inside the walk-in refrigerator was labeled with a use by date or the date it was opened. This deficient practice had the potential to place the residents at increased risk of experiencing a foodborne illness (an illness that comes from eating contaminated food).

Inspectors wroteBased on observation, interview and record review the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by failing to ensure Licensed Vocational Nurse 6 (LVN 6) did not willfully falsify entries in the Medication Administration Record (MAR- a flow sheet where nursing documents medications provided to a resident daily) for one of four sampled residents (Resident 51) investigated during medication administration. LVN 6 documented a heart rate (HR, the number of times the heart beats per minute [bpm]) of 85 bpm on 10/18/2023 that LVN 6 stated was determined by guessing the rate. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically submit staffing information based on payroll data on a quarterly schedule to the Centers for Medicare & Medicaid Services (CMS) for one of four fiscal quarters (4th quarter of 2022 [7/1/2022 to 9/30/2022]). The deficient practice prevented the provision of complete and accurate direct care staffing information to the public.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label a resident's wash basin found inside a bathroom shared by four residents with a resident identifier for four (Residents 270, 44, 71, and 34) out of four sampled residents investigated for infection control. This deficient practice had the potential to place the residents at increased risk of cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and developing an infection.

Inspectors wroteBased on interview and record review, the facility failed to draw (obtain) laboratory (lab) tests as ordered by the physician for one of three sampled residents (Resident 1). This deficient practice had the potential to delay necessary care and services.