Sunny Hills Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of three sampled residents' (Resident 2) low air loss (LAL) mattress pump (a small electric machine that constantly blows air into a medical air bed to prevent a pressure ulcer/injury [localized damage to the skin and/or underlying tissue usually over a bony prominence]) from developing or worsening) was set according to Resident 2's weight. This failure placed Resident 2's current pressure ulcers to worsen and had the potential to develop further pressure injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medicine was not left at the resident's bedside and ensure one of three sampled residents (Resident 2), drunk the scheduled medication. This failure resulted in the medication not being taken timely.

Inspectors wroteBased on interview and record review, the facility failed to ensure the prescribed therapeutic diet of one of three sampled residents (Resident 1) was followed. This failure placed Resident 1 at risk for elevated blood sugar levels.

Inspectors wroteBased on interview and record review, the facility failed to notify one of three sampled residents' (Resident 1) primary care physician (PCP), when the resident did not receive prescribed Buprenorphine (a controlled [regulated] pain medication for the management of severe, persistent, and chronic pain) and Ozempic (medication to lower blood sugar). This failure placed the resident at risk for potential complications such as increased need of pain medication, poor pain management, and complications from diabetes such as diabetic ketoacidosis (a life-threatening complication that can occur if blood glucose levels are high) leading to hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1), pain level was reassessed timely, after the pain medication was administered. This failure placed Resident 1's pain level unresolved and the potential to affect in maintaining the resident's highest practicable physical, mental and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), medications was available, and were administered to the resident, and, ensure the medication brought to the facility by a family member (FM) was verified, order obtained to administer, according to its policy and procedure (P&P) titled, Medication Ordering and Receiving From Pharmacy. These failures placed Resident 1 at risk for complications when medications were received or not received as ordered, which could lead to hospitalizations.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the at risk for fall care plan for 1 of 3 residents, (Resident 1), who was non-compliant (uncooperative) in maintaining the height of bed to its lowest position, was revised, as indicated in its policy and procedure (P&P) titled Fall Prevention Program. This failure placed the resident at risk for falls, severe injuries, including hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach and/or not a proper call light for five of 18 sampled residents (Resident 31, Resident 44, Resident 95, Resident 48 and Resident 99). This deficient practice had the potential to negatively impact Residents 31, 44, 95, 48, and 99's psychosocial well-being and result in delayed provision of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's consent for the administration of a psychotropic medication (drugs that affects behavior, mood, thoughts, or perception) was obtained from and verified with the resident's representative party (RP) for one out of two sampled residents (Resident 3). This deficient practice had the potential to place Resident 3 at risk for receiving psychotropic medications without the proper authorization and education regarding the risks and the benefits of the prescribed psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify one of one sampled resident's (Resident 138) physician of scattered ecchymosis (bruising) on both of his arms upon his admission to the facility. This deficient practice resulted in Resident 138's ecchymosis being unmonitored and had the potential for worsening bruising and delay in care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS, a resident assessment tool) assessment for one of six sampled residents (Resident 50) oral and/or dental status. This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS, a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program) regarding Resident 50's missing natural teeth, and had the potential to negatively affect Resident 50s' plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level I screening was completed for one of eight sampled residents (Resident 11). This deficient practice resulted in Resident 11 not receiving a PASARR Level II evaluation, and had the potential to result in Resident 11 not receiving the specialized services needed to address serious mental illness while residing in the nursing facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for two of 12 sampled residents (Resident 50 and Resident 31), by failing to:1. Develop a care plan to address Resident 50's oral status and lack of teeth. 2. Implement interventions related to Resident 31's indwelling catheter (a flexible tube inserted into the bladder to drain urine into a bag), including monitoring and documenting urinary output. These deficient practices placed Residents 50 and 31 at risk for delayed care, nutrition risks and needs, continuity of care, and overall health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the comprehensive fall prevention care plan following a resident's fourth fall for one out of six sampled residents (Resident 74). This deficient practice had the potential to result in additional falls and bodily injury for Resident 74.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided necessary assistance with activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) for one of eight sampled residents (Resident 22), who required assistance with transfers (help from one or more staff members to safely move a resident between two positions, such as from a bed to a chair, a chair to a wheelchair, or standing up) and dressing. This deficient practice had the potential to result in decline in mobility (ability to move freely), muscle weakness, development of pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and decreased psychosocial well-being from remaining in bed for prolonged periods.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the placement of bilateral (pertaining to both) floor mats and padded siderails for two of eight sampled residents (Residents 44 and 37), who were on fall and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions. These deficient practices had the potential to result in Resident 44 sustaining an injury from a fall, and Resident 37 sustaining an injury during seizure activity.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services related to urinary Foley catheter (a flexible tube inserted through the urethra [a hollow tube that lets urine leave the body] into the bladder to drain urine into a collection bag) management were provided for one of six sampled residents (Resident 39), who had sediment (matter that settles to the bottom of a liquid), cloudiness and blood in the urine. This deficient practice had the potential to result in urinary catheter obstruction, urinary tract infection (UTI- an infection in the bladder/urinary tract) and a decline in Resident 39's health status. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to change one of one sampled resident's (Resident 138) peripherally inserted central catheter (PICC, a thin, flexible tube inserted into the vein in the upper arm and guided into a large vein near the heart) line dressing and securement device (a sterile tool to hold the PICC in place on the skin) in accordance with the physician's orders. These deficient practices resulted in Resident 138's PICC line dressing and securement device remaining unchanged for 11 days which had the potential to result in avoidable bloodstream infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide oxygen (a medical gas used to help with breathing) therapy in accordance with the facility policy and physician orders for one of three sampled residents (Resident 137). This deficient practice had the potential to result in hyperoxygenation (too much oxygen) which could result in respiratory failure (sudden onset condition where the lungs cannot bring enough oxygen into the blood).

Inspectors wroteBased on interview and record review, the facility failed to effectively manage one of two sampled residents' (Resident 30) pain, after Resident 30 complained of severe pain (pain rated seven to ten on a 10-point scale). Resident 30 was administered Norco (an opioid medication used to treat pain), which was ordered for moderate pain (pain rated four to six on a 10-point scale). This deficient practice resulted in Resident 30's pain being mismanaged which left Resident 30 feeling frustrated with his pain management regimen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the hemodialysis (treatment to cleanse the blood of waste and extra fluid artificially through a machine when the kidney(s) have failed) emergency kit ([E-kit]- a readily set of supplies for immediate use in the event of dialysis-related complications) was at the bedside for one of two sampled residents (Resident 45), who was receiving hemodialysis treatment. This deficient practice had the potential to result in lack of necessary treatment and services in the event of an emergency, such as bleeding for Resident 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Registered Nurse (RN) 2 was competent regarding peripherally inserted central catheter (PICC, a thin, flexible tube inserted into the vein in the upper arm and guided into a large vein near the heart) line dressing changes for one of one sampled resident (Resident 138). This deficient practice resulted in Resident 138's PICC line dressing not being changed upon admission and placed Resident 138 at risk for avoidable bloodstream infection. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor signs and symptoms of bleeding for one of five sampled residents (Resident 138), who was receiving heparin (anticoagulant medication used to treat blood clots from forming in the blood vessels and the heart). This deficient practice had the potential to result in undetected bleeding and had the potential to result in delay in care.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six sampled residents (Residents 3 and 4) were free from significant medication error (one which caused the resident discomfort or jeopardizes his or her health and safety) when:1. Resident 4 was administered midodrine (medication used to treat low blood pressure) outside of the ordered parameter (specific instructions that dictate whether the medication is safe to administer) 17 times in January 2026 and 19 times in February 2026.2. Resident 3 was administered metoprolol (medication used to treat high blood pressure) outside of the ordered parameters on 1/10/2026, 2/16/2026, 2/19/2026, and 2/21/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses accurately and completely documented the administration of intravenous (IV) antibiotics (medications administered directly into the blood stream to treat an infection), and the peripherally inserted central catheter (PICC- a thin, flexible tube that delivers medications through a vein) line dressing change for two out of three sampled residents (Resident 78 and Resident 138). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection (the invasion and multiplication of microorganisms[like bacteria, viruses] in body tissues, potentially causing illness or harm) control practices for one of six residents (Resident 7), when Resident 7's indwelling catheter (a flexible tube inserted into the bladder to drain urine into a bag) drainage bag was observed touching the floor. This deficient practice placed Resident 7 at risk for infection and had the potential to spread bacteria through cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment).

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and Responsible Party (RP) of a change of condition (COC) for one of five sampled residents (Resident 1), who had a [NAME] Blood Cell ([WBC]-part of the body's immune system that protects the body from infection) count of 15,200 (normal reference range 4,000-10,000 cells per microliter [cells/ L]). This deficient practice had the potential to result in Resident 1 not receiving necessary medical care and placed the resident at risk of sepsis (a life threatening blood infection).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper infection control practices were followed during wound care for one of five sampled residents (Resident 2), who was admitted to the facility with a stage 4 pressure injury (full-thickness loss of skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the sacrococcygeal region (consists of the sacrum and coccyx [tailbone]). This deficient practice placed Resident 2 at risk for poor wound healing, infection, and deterioration of the resident's existing pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper nutritional assistance for one of five sampled residents (Resident 5), who is at risk for malnutrition (which occurs when a person receives too few nutrients, resulting in health problems). The facility failed to:Assist Resident 5 with eating as indicated in the resident's nutritional problem/potential nutritional problem care plan. Ensure timely meal support, as Resident 5's food tray was left open in front of the resident for 20 minutes before the resident assisted eating. These deficient practices placed Resident 5 at risk for weight loss and potential hospitalization related to malnutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean, comfortable and home-like environment two of six sampled residents (Resident 3 and Resident 4) by failing to ensure there were enough linen, incontinent pads (used to absorb leakage, reduce odors and control bacteria,) towels and blankets available to change for the residents. This failure had the potential to result in skin breakdown and negatively affect the psychosocial well-being of Residents 3 and 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and treat one of two sampled residents (Resident 1) after being exposed to scabies (a highly contagious skin infection caused by the microscopic mite), by failing to ensure staff: 1. Performed a skin assessment and tested Resident 1 for scabies after Resident 1's roommate tested positive for scabies. 2. Treated Resident 1 for scabies. These deficient practices resulted in Resident 1 expressing feelings of discomfort from constant itchiness and scratching and had the increased risk of scabies transmission to residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure the nutritional supplement ordered by the physician for one of three sampled residents' (Resident 1), were monitored and documented. This failure had the potential to result in delayed identification of low or poor intake and interventions, causing further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) did not receive medication that is greater than the recommended dose by the manufacturer's label, and accepted standards of practice for a resident ' s condition. This deficient practice had potential to cause adverse reactions and medical complications for Resident 1. Findings During a review of Resident 1 ' s admission Record dated 5/20/2025, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to one of two sampled residents (Resident 1) identified as an elopement (the act of leaving a facility unsupervised and without prior authorization) risk by failing to: 1. Follow its policy and procedures (P&P) titled Accidents and Supervision, which indicated the facility will implement interventions to prevent injury to residents. 2. Follow its P&P titled Elopements and Wandering Residents, which indicated residents with a risk for elopement would receive supervision to prevent accidents. 3. Utilize a systematic approach to monitoring and managing Resident 1 to prevent the resident from leaving the facility unsupervised. 4. Ensure door locks/alarms were in place to prevent Resident 1 from eloping. 5. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, and home like environment to the 8 of 9 residents living in the affected rooms. These failures had the potential to result in unsanitary living conditions and accidental falls and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, one of four sampled residents (Resident 3), swallowed scheduled stool softener medications during medication administration. This failure resulted in Resident 3 missing a dose and placed the resident at risk for constipation.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was initiated for one of three sampled residents (Resident 2) who had a history of falls. This failure had the potential for unidentified nursing interventions (actions), repeated falls and injuries for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) orders, in accordance with facility policy, for four (4) of 4 sampled residents (Resident 56, Resident 41, Resident 35, and Resident 81) when: A. Resident 56 received GT feeding Glucerna (a nutrition supplement designed for people with Diabetes Mellitus [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing] or abnormal sugar) 1.2 instead of Glucerna 1.5 as ordered. B. Residents 81, 41 and 35 were administered medications via GT without flushing the GT line with prescribed amount of water before and after medication administration for Resident 41; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%). Eight medication errors out of 31 total opportunities contributed to an overall medication error rate of 25.81% for two of six residents (Resident 81 and Resident 41) observed during medication administration (MedPass). The facility failed to ensure: (Cross Reference F693) A. Resident 81's gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition and/or medication directly to the stomach) was flushed after each medication administration and the resident was administered the full dosages of each medication as ordered on 10/29/2024 for the scheduled 9 AM administration. B. Resident 41's GT was flushed before administering medication and again upon completion of medication administration as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of six sampled residents' medication regimen was free from significant medication errors (Resident 36 and Resident 55). This deficient practice jeopardized Resident 36 and Resident 55's health and safety by failing to administer necessary medications in accordance with the physician order, manufacturer's specification, and notifying physician when medication was not administered as prescribed to meet the needs of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were properly stored and labeled for five of five residents (Resident 15, Resident 42, Resident 2, Resident 17, and Resident 92). The facility failed to: A. Ensure one unopened, unused vial of Insulin Lispro was refrigerated until opened or labeled with the date first stored at room temperature inside of Medication Cart (MedCart) 2 labeled for Resident 2 B. Ensure one vial of expired Humulin R was removed and discarded and not stored available for use in MedCart 2 labeled for Resident 17 C. Ensure controlled [high abuse potential] medications, Lorazepam Oral Solution (a psychotropic medication which act on the brain and nerves to produce a calming effect) requiring refrigeration were stored according to the manufacturer's requirements affecting Resident 15 and Resident 42. D. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary food storage practice was upheld in the kitchen when: 1. The temperature for Refrigerator 1 was not logged for two days. 2. A container of grated cheese was not labeled with the item name, open date, and the use by date. 3. An open bag of tortillas was ripped and was not placed in a tight-lidded container after opening. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (unintentional transfer of harmful bacteria) that could lead to foodborne illness in residents that received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control practices for six of six residents (Resident 5, 54, 76, 281, 8, and 92) when the following occurred: 1. Licensed nurses did not wear appropriate personal protective equipment (PPE, equipment worn for protection against infectious materials, e.g. gown and gloves) during the handling of a gastrostomy tube (G-tube, tube inserted through the abdomen that delivers nutrition, hydration, and/or medication directly to the stomach) and during direct resident contact during medication administration to Resident 81. 2. Resident 54's nasal cannula tubing (a plastic medical device to provide supplemental oxygen therapy to people who had lower oxygen levels, device goes directly into the nostrils) was touching the floor. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's responsible party (RP) was informed in advance, of the risks and benefits of the use of bedrails (adjustable metal or rigid plastic bars that attach to the bed) for one of eight sampled residents (Resident 331). This deficient practice resulted in the violation of Resident 331's RP's right to make an informed decision regarding the use of bedrails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled resident's (Resident 5) call light was within reach. This deficient practice prevented Resident 5 from communicating with staff and had the potential to delay appropriate care, treatment, and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to remove the identifiable health information (any information that could be used to identify the individual, such as the full name, date of birth , etc.) on the intravenous (IV, within the vein) medication bag prior to disposition in the trash can for one of nine sampled residents (Resident 30). This deficient practice had the potential to result in unauthorized disclosure of Resident 30's personal information to unauthorized users.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for three of eight sampled residents (Residents 46, 94, and 100) who shared a room and had old, yellow stains on the celling and an unfinished painted wall of their room. This deficient practice resulted in Residents 46, 94, and 100 being unhappy with the quality of their living space.

Inspectors wroteBased on interview and record review, the facility failed to conduct background criminal checks for four of four randomly selected employees prior to hire and upon completion of orientation (a process that introduced new hires to their job, company, and coworkers) in accordance with the facility's policy. This deficient practice had the potential to place residents at risk for abuse which could lead to serious harm and/or injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) for two of 16 sampled residents' (Residents 66 and 331) by failing to: 1. Develop a care plan for Resident 331's use of bedrails. 2. Develop a care plan for Resident 66 whose predominant language was Korean. These failures had the potential to negatively affect Residents 331 and 66's physical and mental, and psychosocial and potentially delay delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality of care for three out of 16 sampled residents (Resident 14, 30, and 49) when the following occurred: 1. Licensed nurses failed to follow the physician's order for bilevel positive airway pressure ([BIPAP], noninvasive ventilation mask that helps a person breathe, a treatment to provide oxygen and get rid of carbon dioxide) therapy for Resident 14. 2. Licensed nurses falsified on the Medication Administration Record (MAR) that BIPAP application was carried out as ordered for Resident 14. 3. Licensed nurses failed to provide medications, treatments, and monitoring as ordered on multiple shifts for Residents 30 and 49. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff used a communication board, device, and/or interpreter services for two of 16 sampled residents (Resident 66 and 92) who did not speak the dominant language of the facility (English). This deficient practice had the potential to negatively affect Resident 66 and 92's physical, mental, and psychosocial needs by preventing the residents from communicating with staff and potentially causing missed or delayed care and/or treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up on a mammogram (imaging of the breast that is used to detect and diagnose breast disease in women) appointment for one of eight sampled residents (Resident 32). This deficient practice resulted in Resident 32 feeling frustrated with her healthcare team and this failure had the potential to result in a delay in treatment based on the result from Resident 32's mammogram results.

Inspectors wrote2. During a review of Resident 331's admission Record (Face Sheet), the admission record indicated Resident 331 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 331's diagnoses included sepsis (a life-threatening blood infection), dementia (a progressive state of decline in mental abilities), and chronic obstructive pulmonary disease ([COPD], a chronic lung disease causing difficulty in breathing). During a review of Resident 331's MDS, dated [DATE], the MDS indicated Resident 331's cognition was severely impaired. The MDS indicated Resident 331 was dependent on staff for assistance with oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated Resident 331 utilized a pressure reducing device for a bed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement safe oxygen administration practices, for three of 16 sampled residents (Residents 14, 54, and 99), by failing to ensure: 1. Resident 14's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was dated with an open date. 2. Precautionary (warning) sign was posted outside of Resident 14, Resident 54, and Resident 99's room, who were using oxygen. 3. Resident 14 and Resident 54's nasal cannula was not touching the floor. These deficient practices had the potential to Residents 14 and 54 to acquire respiratory infection and placed Residents 14, 54 and 99, at risk for injuries due to fire hazard.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper use of bedrails (adjustable metal or rigid plastic bars that attach to the bed) for one of eight sampled residents (Resident 331) as indicated in the facility's policy and procedure (P&P) by failing to: 1. Assess Resident 331's risk for entrapment (the state of being caught in or as in a trap). 2. Assess Resident 331's need for bedrails. 3. Conduct monitoring specific to Resident 331's use of bedrails. These deficient practices had the potential to result in an accident such as a body part being caught between the bedrails, entrapment, and/or a fall if Resident 331 were to attempt to climb over, around, between, or through the bedrails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses were trained on the use of a bilevel positive airway pressure ([BIPAP], noninvasive ventilation mask that helps a person breathe, a treatment to provide oxygen and get rid of carbon dioxide) machine for one out of eight sampled residents (Resident 14). This deficient practice prevented Resident 14 from receiving the benefits of BIPAP therapy and placed Resident 14 at risk for respiratory complications during her sleep.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to administering Seroquel (a medication used to treat several kinds of mental health conditions) to Resident 118 at bedtime on 10/29/2024. This deficient practice had the potential to result in Resident 118 and his responsible party's (RP) unawareness of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug might have) related to the medication therapy and may cause impairment or decline in mental, physical condition, functional, and/or psychosocial status of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer alternative food choices and provide an alternative menu for two of eight sampled residents (Residents 24 and 77). This deficient practice had the potential to impact Resident's 24 and 77 nutritional status, quality of life and result in food dissatisfaction leading to insufficient food intake.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Nursing staff completed the following for one of six sampled resident's (Resident 1): 1 Reconciled (process of reviewing resident medications to identify the most accurate list of all medications and resolve any discrepancies) the medication list correctly upon admission to the facility. 2. Administered Sucralfate (a drug used to decrease bleeding associated with radiation-induced proctitis) twice a day as ordered by the physician. 3. Accurately documented the administration of Sucralfate in the medical record. These deficient practices had the potential to result in medication errors, worsening of symptoms and condition, which could lead to hospitalization and complications for Resident 1.

Inspectors wroteBased on interview and record review, the facility staff failed to protect one resident (Resident 1) from abuse by failing to: 1. Ensure Resident 1 was free from verbal abuse. 2. Ensure a contracted Xray provider (Xray Provider 1, a healthcare professional who uses X-rays [a type of radiation that produces an image of the inside of the body to help diagnose and treat diseases] and other imaging techniques to create images of a patient's body) did not verbally abuse Resident 1 by using profanity towards Resident 1. 3. Ensure Xray Provider 1 treated Resident 1 with dignity and respect. These deficient practices had the potential to affect Resident 1's emotional state and negatively affect Resident 1 ' s experience during the Xray process.

Inspectors wroteBased on observation, interview, and record review, the facility failed implement infection control practices according to professional standards by failing to: 1. Place Resident 1 on Novel Respiratory Precautions (a transmission-based precaution to prevent the spread of respiratory illnesses) on 7/9/2024 when Resident 1was reported being exposed to COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) by the Infection Preventionist Nurse (IPN). 2. Fit test (a test required for healthcare providers to ensure they have tight-fitting respirator mask to prevent infection or the spread of respiratory diseases) Certified Nursing Assistant (CNA1) and CNA 2 who was working with and came into direct contact with Resident 1, who was a positive COVID-19 resident. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate post fall reassessment was conducted for one of three sampled residents (Resident 1). This failure had the potential that the causes of repeated fall will not be identified timely, individualized care plan interventions not modified and placing Resident 1 for recurring falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan for two out of three sampled residents (Resident 2 and Resident 3) after an altercation in Activity Room A. This failure had the potential to result in another altercation between Resident 2 and Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to closely monitor one out of four sampled residents (Resident 1) with a history of attempted elopement (to leave unnoticed). Resident 1 eloped from the facility and was later found at a nearby restaurant and reported to have eaten an entire meal two hours after being last seen by facility staff. This failure resulted in the potential for Resident 1 to endure bodily injury and a fall while outside of the facility's premises without supervision from staff.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow their infection prevention and control policy and procedure (P&P) by failing to report the facility's Coronavirus Disease ([Covid-19], a highly contagious respiratory infection caused by a virus that could easily spread from person to person) outbreak (at least one confirmed Covid-19 resident case who had resided in the facility for at least 7 days) to the California Department of Public Health (CDPH) District Office. This deficient practice had the potential to result in a delay of the District Office' response to the facility's Covid-19 outbreak and cause the spread of the COVID-19 infection to other residents, staff and visitors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services for 6 of 24 sampled residents by failing to: 1. Check Resident 268's blood glucose level (amount of sugar in the blood stream, the normal value between 70 milligrams [mg, unit of measurement] per (/) deciliter [dL, unit of measurement] and 100 mg/dL) prior to administering Insulin Glulisine (a fast-acting medication to lower high blood sugar). 2. Accurately transcribe (copy from one place to another) Resident 268's discharge medication order for Insulin Glargine (a long-acting medication to lower high blood sugar) when readmitted to the facility on [DATE] from a long-term acute care hospital (LTACH). 3. Administer Milk of Magnesia (medication to treat constipation) to Resident 3 who did not have a bowel movement for three days and then for five days. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure residents' call lights (a device used by patients to call and alert nurses or other nursing personnel to assist a patient when in need) were placed within reach for four of ten sampled residents (Resident 79, Resident 22, Resident 41, and Resident 13). 2. Ensure one of ten sampled residents (Resident 16) did not wait for the call light to be answered for almost an hour when Resident 16 needed pain medication. These failures had the potential to affect the prompt and quality care provided to the residents and the inability to maintain the highest practicable physical, mental, and psychosocial well-being of the residents under the facility's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for three of six sampled residents, (Residents 5, 73, and 100), by failing to: 1. Ensure Resident 5 had both siderails padded to prevent injury during seizure activity (involuntary jerking, shaking, uncontrolled movement), and ensure the abdominal binder was applied to prevent the gastrostomy tube (g-tube, a tube surgically inserted into the stomach to administer nutrition and medications) from being accidentally pulled out by the resident. 2. Ensure Resident 73 had a padded siderails to prevent injury due to his seizure disorder. 3. Ensure Resident 100, who had history of seizure disorder, had padded siderails, fall mats at the bedside, and the bed kept at the lowest position for safety and to prevent injury. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure enteral feeding (a special liquid food mixture containing protein, carbohydrates, fats, vitamins, and minerals) was administered as ordered for three of seven sampled residents (Resident 73, 169, and 115). This failure created the potential for Resident 73, 169, and 115 to not meet their nutritional requirements, placing them at risk for avoidable weight loss, malnutrition, and skin breakdown or worsening of existing wounds.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing for 123 of 123 residents when the Infection Preventionist Nurse (IPN) and the Case Manger (CM) were taken out of their primary roles to pass medications to the residents. This failure had the potential to result in the delay in care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Record the medication refrigerator temperature for one of one inspected medication rooms (Medication Room Station 1). 2. Account for one dose of controlled medication ([CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Resident 6 in one of two inspected medication carts (Medication Cart 1C). 3. Document one dose of CM in the [DATE] Medication Administration Record ([MAR] - a record of mediations administered to residents) for Resident 6 in one of two inspected medication carts (Medication Cart 1C). 4. Document the monitoring of signs and symptoms of bleeding for 21 shifts to one of five residents observed for medication administration (Resident 76). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%) due to four (4) errors observed out of 25 total opportunities (error rate of 16 %). The medication errors were as follows: 1. Resident 76 and 418 received a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) that was different than the one ordered by Resident 76's and 418's physician. 2. Resident 418 received a dose ascorbic acid (a medication used to improve the immune system) that was not ordered by Resident 418's physician. 3. Resident 418 did not receive duloxetine (medication used to treat depression) as ordered by Resident 418's physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. To administer duloxetine (a medication used to treat depression [ persistent sadness]) as ordered to one of five residents (Residents 418) observed for medication administration. 2. Not administered expired insulin (a medication used to regulate blood sugar levels) to one of five residents (Resident 218) observed for medication availability. As a result, Residents 218 received a total of four (4) doses of expired insulin, and Resident 418 did not receive three (3) consecutive doses of duloxetine. These failure had the potential to cause Residents 218 and 418 to experience serious health complications due to increased depressive behaviors and uncontrolled blood sugar levels, possibly resulting in hospitalization or death. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. Remove and discard from use one expired eye drop bottle for Resident 39 in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart 1C). b. Label two inhalation aerosol (form of medication that is inhaled through the mouth) devices for Resident 72 and 113, with an open date in accordance with the manufacturer's requirements in one of two inspected medication carts (Medication Cart 1C). c. Remove and discard from use one expired insulin (medication used to regulate blood sugar levels) kwikpen (an injection device containing insulin) for Resident 218, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart 2A). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility was equipped with a nourishment refrigerator to ensure proper sanitation and food handling practices to prevent the potential outbreak of foodborne illness for 1 (Resident 61) out of 122 residents within the facility. This failure had the potential to spread food borne illness to Resident 61.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures were implemented or maintained when the following occurred: 1. While providing care to Resident 168, facility staff failed to: a. Ensure signage for the required transmission-based precautions (TBP, precautions implemented to prevent or control the spread of infection) was posted outside of Resident 168's room. b. Wash their hands with soap and water after providing direct care to Resident 168. c. Disinfect shared medical equipment with the appropriate disinfectant following use on Resident 168, who had a transmissible (contagious) infection. 2. Facility staff failed to date and store oxygen delivery equipment per facility policy and procedure for Resident 78. 3. Facility staff failed to store and handle clean linens in a sanitary environment. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, sanitary, and home like environment when Room A, Room C, Room D, Room E, Room F, Room I and Room G were observed with dry stool on the toilet seats, Room A and Room C's toilet was leaking and observed with a white towel at the base of the toilet, Room I had clutter on the floor, the privacy curtains were dirty, and two resident pillows were observed on the floor, an extension cord was observed with multiple plugs were coiled around Resident 79's metal side rail, and Station 2's shower room was dirty, had a strong smell of feces (technical word for poop, stool), water observed coming from the door toward the hallway, a wet floor with dirty masks and feces observed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a privacy cover for one of three sampled resident's (Resident 168) indwelling urinary catheter (flexible tube inserted and left in the bladder to empty urine) drainage bag. This failure had the potential to negatively affect Resident 168's sense of dignity and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 7 sampled residents (Resident 169) who was receiving enteral feeding (a way of delivering nutrition directly to the resident's stomach), was provided care and services to prevent aspiration (food or liquid entering the airway or lungs) by failing to ensure the resident's head of the bed was elevated. This failure had the potential to cause aspiration and complications including choking, difficulty breathing, lung infection and hospitalization for Resident 169.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was admitted to the facility with no pressure ulcers and/or injuries (damaged skin caused by staying in one position for too long), was turned and repositioned every 2 hours to prevent the development of an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough [yellow/white material consisting of dead cells that accumulate in the wound, contributing to delayed wound healing or eschar [collection of dry, dead tissue within a wound]). This failure resulted in Resident 1 developing an unstageable pressure ulcer on the sacrococcygeal (tail bone) area.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat one of four sampled residents (Resident 3) with dignity and respected her preference when Resident 4 ' s family members pulled the curtain of Resident 3 open multiple times (on 9/1/2023 by Family Member 1 and on 9/6/2023 by Family Member 2) against Resident 3 ' s preference and comfort. On 9/6/2023, when Resident 3 re-opened the privacy curtain separating Resident 3 ' s and Resident 4 ' s beds after being closed by Family Member 2, Family Member 2 pointed a back scratcher stick and saying, No, No, No! towards Residents 3 while standing in front of Resident 3 ' s foot of the bed on 9/6/2023. This failure resulted in Resident 3 feeling disrespected, threatened, and stressed outduring and after the incident on 9/6/2023.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly report one of four sampled residents' (Resident 3) verbal grievance to the facility's Executive Director (ED, Administrator) for resolution. Resident 3 notified Licensed Vocational Nurse (LVN 3) on 9/3/2023 regarding the incident that happened on 9/1/2023 with her roommate's (Resident 4) family member (Family Member 1) pulling Resident 3's privacy curtain closed aggressively, against her preference and without her permission while she was asleep and woken up. This failure resulted in Resident 3 feeling disrespected. Resident 3's grievance was unresolved from 9/3/2023 until a second incident happened with another family member of Resident 4 (Family Member 2) on 9/6/2023. (Cross Reference F557)