Sunny Village Care Center

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary supervision and assistive devices to prevent accidents for three (3) of four (4) sample residents (Resident 10, Resident 89, and Resident 8) reviewed for fall by failing to:and 2. Provide floor mattress (a protective, cushioned device placed on the floor beside a bed or in high-risk areas to reduce the severity of injuries-such as fractures or bruises-if a resident falls or rolls out of bed) for Residents 10 and 89 in accordance with the resident's care plan and the facility's policy and procedure(P&P) titled, Safety of Residents. 3. Monitor Resident 8's needs more frequently in accordance with the resident's care plan for Risk for Fall and Injury. These deficient practices placed Resident 10, 89 and 8 at risk for a fall that may result in serious injury and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of three (3) sampled Residents (Residents 13 and 52) reviewed for tube feeding received appropriate gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (GT) care and treatment in accordance with the facility policy by failing to:1. Properly label Resident 13's GT dressing with a date to indicate dressing change was provided as indicated in the physician's order and care plan. This failure had the potential to result in infection, deterioration of Resident 13's wound, and a lack of continuity of care. 2. Provide Resident 52 with enteral feeding as indicated on the physician's order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) by:Failing to ensure food items were properly labeled with the item name, date opened and/ or use by date. Failing to ensure a scoop device was not placed on top of the rice. These deficient practices had the potential to result in food born illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) to 84 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three garbage containers (dumpster) lids remained closed as indicated in the facility's policy and procedure (P&P) policy titled, Garbage and Trash. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents.

Inspectors wroteBased on interview and record review, facility failed to ensure the arbitration agreement included information that provided for the use of a neutral arbitrator (an impartial, or unbiased third-party decision maker, contracted with, and agreed to by both parties to resolve their dispute) and the selection of a venue that is convenient to both parties (facility and residents) for two (2) of three (3) residents (Residents 51 and 87) as indicated on the facility's policy. This failure had the potential to prevent Residents 51 and 87 from fully understanding and participating in the arbitration process, which could limit informed consent and adversely affect the outcome of any dispute.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures for three (3) of 22 sampled residents (Resident 3, 60, and 85) as indicated on the facility policy by failing to ensure:1.a. Certified Nursing Assistant 1 (CNA 1) and CNA 2 changed gloves and performed hand hygiene after incontinent care and before continuing care for Resident 3.1.b. Proper infection control practices were followed during catheter care when Treatment Nurse used paper towels that had contacted a contaminated sink surface containing hair and brown particles. 2. CNA 3 changed gloves and performed hand hygiene after incontinence care and before continuing care for Resident 60. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an accurate assessment of the resident's hearing ability in the resident's Minimum Data Set (MDS - a resident assessment tool) for 1 of 22 sampled residents (Resident 37). This deficient practice had the potential for the facility to not develop and implement a resident centered care plan for Resident 37 to receive care and services to maximize and/ or improve Resident 37's functional ability in hearing.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions for one (1) of 22 sampled residents (Resident 37) when Resident 37's Responsible Party (RP) refused the resident to have a consult with an Ears, Nose and Throat doctor (ENT doctor). This deficient practice has the potential to delay in the necessary care and services for Resident 37's impaired hearing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of (2) sampled residents (Resident 8), reviewed for language/communication, had a communication board (a sheet of symbols, pictures or photos that the resident can point to, to communicate with the staff) in a language that the resident can understand when the resident is in need of assistance. This deficient practice had the potential for a delay in the necessary care and services for Resident 8.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pain medication Norco (a combination medication that contains hydrocodone [an opioid] and acetaminophen [a pain medication] was administered for one (1) of two (2) sampled residents (Resident 106), reviewed for pain, as indicated in the physician's order and facility's policy. This failure had the potential for Resident 106's pain to be inadequately managed and to negatively impact the resident's physical, mental and/or psychosocial (the interaction between an individual's psychological factors [thoughts, emotions, behaviors] and their social environment [relationships, culture, society]) well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed) access site and access site dressings (a sterile, protective covering applied to an insertion site to prevent infection, stabilize and/or protect) for one (1) of three (3) sampled Residents (Resident 87) reviewed for dialysis were assessed and documented on the Nurses Dialysis Communication Record prior to dialysis as indicated on the physician's order and in the facility's policy and procedure (P&P). This failure placed Resident 87 at risk for a delay in detecting any complications to the dialysis access site including redness, swelling and/or draining and necessary communications to the Resident 87's health care providers including the dialysis staff for timely treatment as needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to verify the identify for one (1) of 5 (five) sampled residents (Resident 20) observed for medication administration, prior to administering resident's medications as indicated on the facility's policy. This deficient practice had the potential of a medication error which could result to harm hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation of the Medication Administration Record (MAR - a document used to record the administration of prescribed medications) was accurate for one (1) of 1 sampled resident (Resident 85), reviewed for respiratory. Resident 85's MAR did not indicate oxygen therapy (medical treatment that provides additional oxygen to individuals who cannot get enough oxygen on their own due to conditions like lung disease or acute respiratory distress) was provided for 11 days in 3/2026. This failure had the potential for Resident 85's interdisciplinary team (IDT - a coordinated group of experts from several different fields) to conclude Resident 85 did not receive or need oxygen therapy, which could lead to inappropriate care planning, delayed interventions, and an increased risk of respiratory decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Residents' Rights information was posted in a prominent and accessible location within the facility, as indicated in the facility's policy. This deficient practice had the potential to prevent residents from being aware of, and understanding how to exercise, their rights, advocate for their needs, or report concerns regarding their care.

Inspectors wroteBased on interviews and record review, the facility to provide documented evidence that the Heating, Ventilation, and Air Conditioning (HVAC, is a mechanical system that regulates the temperature, humidity, and air quality in indoor environments to provide thermal comfort and remove contaminants which is essential for maintaining environmental temperatures within safe and acceptable ranges) system was maintained by outside HVAC maintenance services contractors and the HVAC is in safe and in good working condition. This deficient practice had the potential to cause unverified preventative maintenance by outside HVAC maintenance services contractors that could result in HVAC system failure affecting the health and comfort of 99 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain ethical standards of practice (guidelines that govern behavior and prioritize resident dignity, autonomy [independence], safety, and guided by principles of beneficence [acting in the patient's best interest], non-maleficence [do no harm], justice, and respect for rights) for one of two sampled residents (Resident 2) by purchasing a prescribed Brand 1 sensor (a small, wearable continuous blood glucose [sugar] monitor sensor that measures blood glucose levels in real-time beneath the skin) from Resident 1 on 10/13/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a psychiatrist (a medical doctor who diagnoses and treats mental, emotional, and behavioral disorders) /psychologist (a person who specializes in the study of mind and behavior) consult was provided timely for an acute change in condition as ordered for one of two sampled residents (Resident 1) in accordance with the Physician's order, care plan, and facility policy. This failure resulted in no psychiatric consultation (evaluation) for 25 days, with the potential for Resident 1 to experience a decline in mental and/or psychosocial (having to do with the mental, emotional, social, and spiritual) wellbeing and/or a lack of services/treatments to maintain or attain Resident 1's highest practicable mental and psychosocial wellbeing.

Inspectors wroteBased on interview, and record review, the facility failed to ensure licensing staffs are competent with the knowledge of use of continuous Brand 1 glucose (blood sugar) monitoring systems, [(CGM), a continuous glucose monitoring system helps adults and children ages 2 years and older living with diabetes (a condition that happens when your blood sugar is too high), keep track of their glucose levels in real-time without finger sticks, (a quick, at-home method to get a small capillary blood sample by pricking a fingertip with a sterile lancet for tests of blood sugar)] for one (1) of one (1) sampled resident (Resident 1) This deficient practice had the potential to result in failure of monitoring of Resident 1's blood sugar, this can cause abnormal blood sugar ranging level, with the possibility of damage nerves, blood vessels, and vital organs due to persistently high blood sugar [...]

Inspectors wroteBased on interview the facility failed to notify California Department of Public Health (CDPH) about COVID-19 (COVID-19 - a highly contagious respiratory disease caused by the SARS-CoV-2 virus) outbreak in the facility, in accordance with the facility's policies and procedures (P&P) titled Outbreak of Communicable Diseases. This deficient practice prevented CDPH being aware of outbreak and to ensure proper guidelines are followed to control the COVID-19 outbreak, prevent further spread and lead to irreversible health issues to the residents in the facility. During an interview on 8/28/25 at 11:31 AM with the facility's Infection Preventionist (IP), the IP stated that he did not report the facility's current COVID-19 outbreak to CDPH. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Care Plan (a document that outlines how a resident will receive support and care to meet their needs) was resident centered (treating each resident as an individual with unique preferences and requirements) for one (1) of two (2) sampled residents (Resident 1) by failing to include Resident 1 requires a 2-person assistance with Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily). These deficient practices have the potential for Residents 1 not to receive care and interventions specific to the resident's needs which could affect the resident's overall wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for three (3) of 18 residents (Residents 10, 244, and 58) as indicated on the facility's policy when facility staff labeled Residents 10, 244, and 58 as feeders during dining observation on 1/27/2025. This deficient practice had the potential to affect Resident Residents 10, 244, and 58's sense of self-worth and self-esteem which could result in problems with emotional and mental well-being.

Inspectors wroteBased on observation and interview, the facility failed to maintain a comfortable and safe environment for four (4) of 18 sampled residents (Resident 187, Resident 18, Resident 54, and Resident 69) by failing to: 1. 2. And 3. Failing to maintain the residents' room temperature level between 71- and 81-degree Fahrenheit ( degrees F) of Resident 187, Resident 18, and Resident 54). This deficient practice resulted in the residents' increased level of discomfort which can negatively impact the residents' quality of life, increase the residents' risk of dehydration (excessive loss of body water), hypothermia (a condition where the body's core temperature drops below 95 degrees F), and/or hyperthermia (condition where the body's core temperature is higher than 98 degrees F). 4. ensure Resident 69's belongings were safe and missing items were addressed. [...]

Inspectors wrote3. During a review of Resident 73's admission Record, the admission record indicated Resident 73 was admitted to the facility on [DATE], with diagnoses of hypotension (low blood pressure) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people). During a review of Resident 73's MDS, dated [DATE], the record indicated Resident 73's cognitive skills for daily decision making were moderate impaired. The MDS indicated Resident 73 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for toileting hygiene, shower/bathe self, lower body dressing, sit to lying, and sit to stand. The MDS indicated Resident 73 was on oxygen therapy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: 1. Label food in the preparation area, refrigerators, and freezers in the kitchen with item name, and date opened. 2. Ensure kitchen equipment and kitchen surfaces were clean and free of food debris. 3. Ensure trash bins were not placed next to the clean serving trays. 4. Ensure dietary staff (Cook 1 and [NAME] 2) perform hand hygiene (is the act of cleaning the hands with soap or handwash and water to remove viruses/bacteria/microorganisms, dirt, grease, or other harmful and unwanted substances stuck to the hands) and change gloves during cooking and tray line assembly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident or resident's representative was informed in advance of the treatment risks and benefits, options, and alternatives by a physician or other practitioner or professional for the use of antipsychotic medication (a class of drugs used to treat mental health conditions characterized by psychosis [mental health condition characterized by a loss of contact with reality], such as schizophrenia [a mental illness that is characterized by disturbances in thought ] and bipolar disorder [extreme mood swings that include mania {emotional highs} and depression { mood disorder that causes a persistent feeling of sadness and loss of interest } which may lead to impaired functioning]) for one of five sampled residents (Resident 14). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate assessment of the Minimum Data Set (MDS, a resident assessment tool) for one (1) of three (3) sampled residents (Resident 84) by failing to include the resident's correct discharge status. This failure resulted in the facility's inaccurate MDS and care screening tool reporting to the Centers for Medicare & Medicaid Services (CMS).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the completion and implementation of the baseline care plan within 48 hours of the resident's admission for one of one sampled resident (Resident 14). This failure had the potential to affect Resident 14's health and safety by not promoting continuity of care and communication among the nursing home staff regarding the initial plan for delivery of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of 18 sampled residents (Resident 15 and 73) were provided and were using a communication board (a sheet of symbols, pictures or photos that the resident can point to, to communicate with the staff) when the resident needed assistance. This deficient practice had the potential for a delay in the necessary care and services for Resident 15 and 73.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 44) was provided care and services to maintain good grooming and personal hygiene. This deficient practice had the potential to result in a negative impact on Resident 44 's self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure the low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for one (1) of 1 sampled residents (Residents 15), in accordance with the facility's Pressure Injury (painful wound caused as a result of pressure or friction) policy and procedure (P&P). This deficient practice had the potential for Resident 15 to have worsening stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) which can negatively affect resident's overall well-being.)

Inspectors wroteBased on observation, interview and record review, the facility failed to keep the foley catheter bag (bag that collects urine that drains through the urinary catheter [a hollow tube inserted into the bladder to drain or collect urine]) below the level of the bladder for one of two sampled residents (Resident 15), in accordance with the facility's policy. This deficient practice had the potential for Resident 15 to develop urinary tract infection (UTI - an infection in the bladder/urinary tract) due to urine back flow.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer Metformin hydrochloride (medication used to treat high blood sugar levels that are caused by DM type 2 [a disorder characterized by difficulty in blood sugar control and wound healing]) within one hour of the prescribed time in accordance with the physician's order for one (Resident 23) of three (3) sampled residents. This deficient practice had the potential to result in ineffectively managing Resident 23's medical condition, which could result to harm, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure laboratory orders were done for one of 18 sampled residents (Resident 14). This failure had the potential to result in Resident 14's delayed treatment and increased risk of complications, such as another heart attacks or strokes if high cholesterol remains undetected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food that accommodated resident's preference was provided for one of 18 sampled residents (Resident 9). This deficient practice had the potential for resident's poor meal intake which could lead to weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure meal trays were served timely for two (2) of 2 sampled residents (Residents 287 and 38) when Resident 287 and Resident 38 were served lunch at 12:45 PM and 12:47 PM respectively. This deficient practice resulted in residents receiving meals late and had the potential to negatively affect the psychosocial wellbeing of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the nurses were documenting the complete orthostatic blood pressure (the measurement of blood pressure when a person stands up from a sitting or lying position) for the lying position for one of 18 sampled residents (Resident 14). This failure had the potential to result in Resident 14's orthostatic BP lying a risk for fall incident from hypotension (a medical condition characterized by abnormally low blood pressure) or from dizziness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff doff (take off) Personal Protective Equipment (PPE; protective clothing, goggles, or other garments to prevent or minimize exposure to and spread of infection or illness) and perform hand hygiene (cleaning hands to prevent germs) after providing peri-care (cleaning the genitals and anal area) for one of 18 sampled residents (Resident 15), in accordance with the policy. This deficient practice has the potential to spread infection to staff and residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment by failing to ensure there was no water leak in the kitchen ceiling from 1/26/2025 to 1/27/2025. This deficient practice had the potential to result in unsafe and non-functional kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep accurate documentation in the medical records for 1 of 2 sampled residents by having a Certified Nursing Assistant (CNA) administer a topical cream and a Licensed Vocational Nurse (LVN) documenting the administered topical cream in the Treatment Administration Record (TAR - is a report detailing the treatments administered to a resident by a licensed professional). This deficient practice had the potential to negatively impact the delivery of services.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure proper disposal of medication for one (1) of two (2) sampled residents (Resident 1). As a result, Resident 1's medication that was still in use have been disposed.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold (a resident's right to keep a bed vacant and available for seven days after their transfer to the hospital in anticipation of their return to the facility) policy during the resident's transfer to the General Acute Care Hospital (GACH) on 9/29/2024 for one of one sampled resident (Resident 1) in accordance with the facility's policy and procedure. This deficient practice violated the resident to make informed decisions and receive information of their rights to have the bed hold and return to the facility from the GACH or therapeutic leave.

Inspectors wroteBased on observation, interview, and record review, the facility: 1. Failed to have a process in place and include in their policy and procedure for Medications Brought to the Facility by the Resident/Family (dated April 2007) and Bedside storage of medications (dated September 2010) the handling and management of Resident 1's Ozempic (an injectable medication used to help manage type 2 diabetes mellitus [high blood sugar]) brought in by the Resident 1's family, being stored at bedside and administered by the facility's nursing staff. 2. Failed to ensure licensed nurse documented the injection site for 1 of 4 Ozempic injections (administered on 8/14/2024) that Resident 1 received on August 2024. 3. Failed to ensure two (2) expired medications and discontinued medications of discharged residents would be stored and discarded as per facility's policy. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to log or take inventory of Resident 1's personal and current medications brought in by Resident 1. This failure had a potential for misappropriation of resident properties.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) 1 was competent and skilled to administer medication via injection to one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure. As a result, RN 1 instructed Resident 1 to administer his own medication, Humalog (insulin, medication that helps treat diabetes) and had the potential for Resident 1 to not receive the medication properly.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure one of three sampled residents (Resident 1) did not self- administer his Humalog (medication for diabetes [a group of diseases that result in too much sugar in the blood]) injection. As a result, Resident 1 administered his own medication and had the potential for Resident 1 to not receive the medication properly.

Inspectors wroteBased on interview and record review, the facility failed to provide one of three sampled residents (Resident 1) or Resident 1's Representative, a copy of the resident's medical records upon request and within two working days from notice in accordance with the facility's policy. This deficient practice violated Resident 1's /Resident 1's representative right to have access to resident's personal and medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free of accident hazards for two out of three sampled residents (Residents 43 and 22) for the accidents care area: a. Certified Nurse Assistant 1 (CNA 1) did not lower the height of Resident 43's bed prior to exiting resident's room. b. Ensure Resident 22's sensor pad alarm (an alarm used to detect motion and are designed to notify caregivers if the resident is getting out of the bed or wheelchair or moving about and need assistance) worked at all times. These deficient practices had the potential to result in Resident 43 and 22 sustaining an injury such as a fall (an unintentional coming to rest on the ground) and complications that could occur because of a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure on storage and disposal of medication as evidenced by: 1. Opened probiotic (widely regarded as live microorganisms that, when administered in sufficient amounts, confer a health benefit) bottle was not stored in the refrigerator, as per manufacturer's instructions medication cart 1 (MC1). This deficient practice had the potential for residents to be exposed to adverse side effects such as allergic reaction, like rash, itching, severe dizziness and trouble breathing in the event a resident ingests the unrefrigerated probiotic. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was performed under sanitary conditions for ninety-eight (98) residents of the facility according to the policy and procedure by not labeling food and perishables to indicate the received, opened, use by, and expiration dates. This deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose food waste products into a covered trash bin located under the food preparation (prep) table as indicated on the facility policy. This failure had the potential to attract and spread vermin (animals that are believed to be harmful or that carry disease, e.g., rodents, parasitic worms, or insects) that could potentially infiltrate the facility, affect the resident care areas, and pose a disease threat to residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove the lint from the dryer lint catcher for two (2) of three (3) dryers as indicated in the facility's Maintenance and Cleaning Laundry policy, This deficient practice had the potential to cause fire in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' clinical record were updated with a copy of the resident's advance directives (a written statement of a resident's wishes regarding medical treatment made to ensure those wishes are carried out should the resident be unable to communicate them to a physician) for two (2) of eight (8) sampled residents (Residents 74 and 79) for advance directives care area, in accordance with the facility Advance Directives policy. This deficient practice had the potential to cause conflict in carrying out the resident's wishes for medical treatment and health care decisions.

Inspectors wroteBased on interview and record review, the facility failed to inform two of 22 sampled residents (Residents 47 and 80) of their potential financial liability (the state of being responsible for something) after exhausting their Medicare Part A (insurance which covers inpatient hospital care, skilled nursing facility [SNF], hospice [focuses on the care, comfort, and quality of life of a resident with serious illness, who is approaching the end of life], lab tests, surgery, home health care [wide range of health care services that can be given in the resident's home for an illness or injury]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a resident-centered comprehensive care plan (a care plan developed and implemented to meet his or her preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs) for one (1) of 22 sampled residents (Resident 80) after the resident was hospitalized for gastrostomy tube (g- tube, a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration) dislodgement. This deficient practice had the potential to result in future g-tube dislodgement and had the potential to result in a lack of or delay in delivery of necessary care and services for Resident 80.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 22 sampled residents (Resident 52) was free from an unnecessary drug (any drug when used without adequate indications for its use) in accordance with the facility policy by failing to have the accurate indication for the use of propranolol (medication to treat high blood pressure and also used to treat certain types of tremors) 10 milligrams (mg, a unit of measurement) by mouth once a day. This deficient practice had the potential to place Resident 52 at risk for significant adverse (harmful) consequences from the use of unnecessary drug.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate and complete vital signs (measurements of the body's most basic functions that include body temperature, blood pressure, pulse rate, breaths per minute, and the amount of oxygen circulating in blood, also known as oxygen saturation [level of oxygen in the blood]) were taken for one out of 22 sampled residents (Resident 51) as indicated in the resident's care plan (a form that summarizes and addresses a patient's health care needs and interventions to meet those needs). This failure had the potential for Resident 51 to not have received required medication leading to decline in resident's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of 22 sampled residents, (Resident 62) had their call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within the resident's reach (an arm's length). This failure had the potential for Resident 62's needs to be met in a safe and timely manner.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of two registered nurse (RN 1) was competent with the administration of Ozempic (a weekly injection that helps lower blood sugar) in accordance with the facility's policy and procedure. This deficient practice had the potential for Resident 3 to not receive the prescribed medication which can result to uncontrolled blood sugar level and adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment by failing to ensure Housekeeping (HKP) Staff doff (remove) personal protective equipment (PPE- gowns, gloves, N95 masks [respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles], and face shields worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) before leaving Resident 4 and Resident 5's room. This deficient practice had the potential to result in the spread of Coronavirus (COVID-19, a respiratory illness caused by a virus that can spread from person to person) to residents and staff that could cause respiratory illness, hospitalization, and death.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to one of two sampled residents (Resident 1) when: a. License Vocational Nurse (LVN1) administered Ozempic (a weekly injection that helps lower blood sugar) pen to Resident 1 with cap on. b. Registered Nurse Supervisor (RN Sup) and Physician Assistant (PA) attempted to give Resident 1's a medication that is not labeled with patient's name. c. Charge Nurse (CN) left insulin syringe (a device used to inject solutions into the body) on Resident 1 roommates' food tray. These deficient practices had the placed Resident 1 at risk for side effects of skipping a medication dose and potentially result in uncontrolled blood sugars or weight gain. In addition, it places Resident 1 at risk for receiving the wrong medication if medication was not verified by residents' name. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of two sampled residents (Resident 1) with meals that accommodated the resident's food preferences by failing to ensure no watermelon is included in Resident 1's food tray. The deficient practice had the potential to alter Residents 1's nutritional status.